Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial.

Objective: To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data. Results: Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low. Conclusions: Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial.

BACKGROUND: African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care. INTRODUCTION: The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits. MATERIALS AND METHODS: Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion. RESULTS: Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control. DISCUSSION AND CONCLUSIONS: Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

Development and Validation of a Pediatric Endocrine Knowledge Assessment Questionnaire: Impact of ac Pediatric Endocrine Knowledge Assessment Questionnaire Intervention Study.

OBJECTIVE: While there is general agreement that patient education is essential for compliance, no objective tools exist to assess knowledge in children and parents of children with endocrine disorders. We aimed to design and validate a Pediatric Endocrine Knowledge Assessment Questionnaire (PEKAQ) for congenital hypothyroidism, Hashimoto's thyroiditis, isolated growth hormone deficiency, Graves' disease, and congenital adrenal hyperplasia. We evaluated baseline knowledge of children and parents of children with these disorders and assessed impact of educational intervention. METHODS: At baseline, 77 children (12-18 years) and 162 parents of children 1-18 years participated in this prospective intervention study. Educational handouts for five targeted disorders were designed. Following one-on-one educational intervention, 55 children and 123 parents participated. Baseline and post-intervention knowledge scores were compared using McNemar's test. RESULTS: Adequate multi-rater Kappa measure of agreement was achieved for children's (0.70) and parent's (0.75) PEKAQs. Flesch Reading Ease Score for both PEKAQs (15 questions each) was 65. Post-intervention, significantly higher proportion of parents and children answered majority of questions correctly (p<0.05). Sixteen percent more parents and 22% more children knew their diagnosis correctly (p<0.05). Significant improvement was noted among all participants regarding reason for treatment, steps to take in a situation of missed dose, exercise and diet with these disorders, and long-term prognosis. Parent's knowledge score was an independent predictor of child's score. CONCLUSIONS: To our knowledge, this is the first validated PEKAQ that can be used widely in pediatric endocrinology clinics. We noted significant improvement in knowledge of children and parents of children with endocrine disorders.

Use of Gonadotropin-Releasing Hormone for Intractable Seizures in a Girl with Precocious Puberty without Hypothalamic Hamartoma.

The use of gonadotropin-releasing hormone analogs has been reported in the treatment of gelastic seizures and precocious puberty associated with hypothalamic hamartomas, but not in other seizure types without hypothalamic hamartoma. We describe a 7.5 year-old girl whose seizures subsided after gonadotropin-releasing hormone analog implant, administered for precocious puberty.

Effects of socio-demographic factors on parental monitoring, and regimen adherence among adolescents with type 1 diabetes: A moderation analysis.

Parental monitoring of adolescent diabetes care is an important predictor of adolescent regimen adherence. To date, no studies have investigated whether socio-demographic factors are associated with low levels of parental monitoring or differences in parental monitoring styles, and their moderating effects in families of adolescents with type 1 diabetes. The purpose of this cross-sectional study was to determine whether youth and family socio-demographic factors moderated the relationship between monitoring and youth regimen adherence (i.e., mean frequency of blood glucose testing [BGT]). Data were collected from 267 adolescents with type 1 diabetes and their parents. Hierarchical multiple regression analyses were employed. Socio-demographic factors accounted for 17.1% of the variance in adherence. After parental monitoring scales were entered, R2 in all eight equations increased and R2 change score in six of eight equations were significant. All models were significant after the interaction terms were entered. In the adolescent report models, parent age and family structure were both independently associated with adherence and also moderated the association between adolescent-report parental monitoring and adherence to diabetes care, in particular, adolescent report of parental direct observation/presence during diabetes care. In the parent report models, income was moderated the association between parent-report youth disclosure and adherence. Research should focus on identifying additional modifiable factors that place families at risk for low levels of parental monitoring of diabetes care. Future clinical research is needed to help identify risk factors for low levels of parental monitoring and develop interventions to promote optimal parenting skills that can support youth diabetes care.

Improving screening for diabetes in cystic fibrosis.

PURPOSE: Annual screening for cystic fibrosis-related-diabetes (CFRD) using oral glucose tolerance test (OGTT) is recommended, but national testing rates are low. The purpose of this paper is to implement the quality improvement (QI) initiative to improve cystic fibrosis (CF) annual screening rates among patients at one CF center. DESIGN/METHODOLOGY/APPROACH: To improve screening for CFRD at the CF Center, the authors used the Dartmouth Microsystem Improvement Ramp method and formed a collaborative working group. A process map was created to outline the steps and a fishbone analysis was performed to identify barriers and to utilize resources for implementing new interventions. FINDINGS: Prior to these interventions, 21 percent of eligible patients had completed annual screening and after the intervention, it rose to 72 percent. The initial completion rate with the first prescription was only 50 percent, but it improved steadily to 54/75 (72 percent) in response to reminder letters sent six weeks after the initial script was given. PRACTICAL IMPLICATIONS: Close tracking and reminder letters can improve adherence with annual OGTT screening for CFRD among CF patients, with special emphasis on high-risk patients. ORIGINALITY/VALUE: There should be a special emphasis on screening for CFRD in high-risk CF patients (those with low BMI or higher age). This QI initiative brought about several operational changes in the annual OGTT screening process that have now become the standard operating procedure at the center.

Multisystemic Therapy Improves the Patient-Provider Relationship in Families of Adolescents with Poorly Controlled Insulin Dependent Diabetes.

The purpose of this study was to determine if multisystemic therapy (MST), an intensive, home and community-based family treatment, significantly improved patient-provider relationships in families where youth had chronic poor glycemic control. One hundred forty-six adolescents with type 1 or 2 diabetes in chronic poor glycemic control (HbA1c ≥8 %) and their primary caregivers were randomly assigned to MST or a telephone support condition. Caregiver perceptions of their relationship with the diabetes multidisciplinary medical team were assessed at baseline and treatment termination with the Measure of Process of Care-20. At treatment termination, MST families reported significant improvement on the Coordinated and Comprehensive Care scale and marginally significant improvement on the Respectful and Supportive Care scale. Improvements on the Enabling and Partnership and Providing Specific Information scales were not significant. Results suggest MST improves the ability of the families and the diabetes treatment providers to work together.

Pituitary abscess in an adolescent girl: a case report and review of the literature.

We report the case of a 15-year-old girl who presented with a history of recurrent bitemporal headaches for the last 2 months. In the prior few days, she complained of neck pain, emesis, phonophobia and photophobia, but no fever. Additional symptoms included polydipsia, polyuria and weight gain in the last year. Magnetic resonance imaging (MRI) of the brain demonstrated a cystic sellar and suprasellar mass with peripheral enhancement. Cerebrospinal fluid studies showed pleocytosis. Serum hormone levels were consistent with panhypopituitarism. Transnasal sphenoidotomy was performed, and 2 mL of purulent material was drained, confirming the diagnosis of pituitary abscess. The patient completed 6 weeks of parenteral antibiotics. She improved but continued to require home hormonal replacement therapy. A repeated MRI 3 months later showed abscess resolution. In addition to tumors, pituitary abscess should be considered in children who present with headache and panhypopituitarism, particularly in those who present with signs of meningeal inflammation. Prolonged parenteral antibiotics and surgical drainage are effective.

Enhancing parental motivation to monitor african american adolescents' diabetes care: development and Beta test of a brief computer-delivered intervention.

BACKGROUND: African American youth are at increased risk for poor diabetes management. Parenting behaviors such as parental monitoring are significant predictors of youth diabetes management and metabolic control, but no intervention has targeted parental monitoring of daily diabetes care. OBJECTIVE: The purpose of the present study was to develop and pilot test a three-session computer-delivered intervention to enhance parental motivation to monitor African American pre-adolescents' diabetes management. METHODS: The 3 Ms (Medication, Meter, and Meals) intervention was based on the Information-Motivation-Behavioral Skills (IMB) model of health behavior change and Motivational Interviewing approaches. Five caregivers of African American youth aged 10-13 years diagnosed with type 1 diabetes for a minimum of one year (ie, the target population) reviewed the intervention and provided feedback via semi-structured interviews. Interviews were transcribed and analyzed using thematic analysis. RESULTS: Caregivers' responses to interview questions suggest that The 3 Ms was helpful (minimum rating was 8 out of 10) and they would recommend the program to another parent of a child with diabetes (minimum rating was 9 out of 10). Three of five reported that The 3 Ms program increased the likelihood that they would talk to their child about diabetes. Thematic analysis suggested two primary themes: caregivers found the intervention to be a useful reminder of the importance of supervising their child's diabetes care and that it evoked a feeling of shared experience with other parents. CONCLUSIONS: The 3 Ms computer-delivered intervention for increasing parental monitoring of African-American youth with type 1 diabetes was well-received and highly rated by a small sample of representative caregivers. TRIAL REGISTRATION: ClinicalTrials.gov NCT01515930; http://clinicaltrials.gov/ct2/show/NCT01515930 (Archived by WebCite at http://www.webcitation.org/6Rm0vq9pn).

Neonatal thyrotoxicosis presenting as persistent pulmonary hypertension.

Neonatal hyperthyroidism is a rare condition caused either by transplacental passage of thyroid-stimulating immunoglobulins from a mother with Graves' disease or by activating mutations of the thyrotropin receptors and α-subunit of G-protein. The clinical features may vary. We report a case of neonatal thyrotoxicosis in an infant born to a mother with Graves' disease, who presented with cardiorespiratory failure and persistent pulmonary hypertension (PPHN). PPHN resolved with specific antithyroid treatment and extracorporeal membrane oxygenation was not required.

Multisystemic therapy compared to telephone support for youth with poorly controlled diabetes: findings from a randomized controlled trial.

BACKGROUND: Few interventions have effectively improved health outcomes among youth with diabetes in chronic poor metabolic control. PURPOSE: This study aims to determine whether multisystemic therapy (MST), an intensive, home-based, tailored family treatment, was superior to weekly telephone support for improving regimen adherence and metabolic control among adolescents with chronic poor metabolic control. METHODS: A randomized controlled trial was conducted with 146 adolescents with types 1 or 2 diabetes. Data were collected at baseline, 7 months (treatment termination), and 12 months (6 months follow-up). RESULTS: Adolescents receiving MST had significantly improved metabolic control at 7 (1.01 % decrease) and 12 months (0.74 % decrease) compared to adolescents in telephone support. Parents of adolescents receiving MST reported significant improvements in adolescent adherence. However, adolescent-reported adherence was unchanged. CONCLUSIONS: MST improved health outcomes among adolescents with chronic poor metabolic control when compared to telephone support. Home-based approaches may provide a viable means to improve access to behavioral interventions for such youth.

Psychometric properties of the revised Parental Monitoring of Diabetes Care questionnaire in adolescents with type 1 diabetes.

PURPOSE: We evaluated the psychometric properties of a revised version of the Parental Monitoring of Diabetes Care questionnaire (PMDC-R) designed to evaluate parental supervision and monitoring of adolescent diabetes care behaviors. The revised measure was intended to capture a broad range of ways used by parents to gather information about youth adherence to diabetes care. METHODS: Two hundred sixty-seven caregivers of 12-18-year-old adolescents with type 1 diabetes completed the PMDC-R. Measures of parental knowledge of youth illness management, illness management behavior, and metabolic control were also obtained. RESULTS: The PMDC-R demonstrated good internal consistency (alpha coefficient = .91) and test-retest reliability (r = .79, p < .001). Supporting the instrument's construct validity, a bifactor model with one primary factor and three secondary factors had an acceptable fit to the data (comparative fit index = .92, root mean square error of approximation = .06). Concurrent validity was also supported. In structural equation models, parental monitoring, as assessed by the PMDC-R, had a significant direct effect on parental knowledge of adolescent diabetes management and, through knowledge, an indirect effect on adolescent diabetes management and metabolic control. CONCLUSIONS: The PMDC-R displayed strong psychometric properties and represents an important next step in refining the measurement of parental monitoring for youth with chronic illnesses.

The parental monitoring of diabetes care scale: development, reliability and validity of a scale to evaluate parental supervision of adolescent illness management.

PURPOSE: Monitoring of adolescents' behavior and whereabouts has been repeatedly identified as an important predictor of adolescent behavioral outcomes. However, to date, measures of parental supervision and monitoring are lacking in the chronic illness literature. The present study describes development and initial evaluation of a measure of parental monitoring of the illness management of adolescents with diabetes: the Parental Monitoring of Diabetes Care scale (PMDC). METHODS: Ninety-nine parents of 12-18-year-old children with type 1 diabetes completed the PMDC. Measures of illness management and metabolic control were also obtained. RESULTS: The PMDC demonstrated good internal consistency (alpha coefficient = .81) and test-rest reliability (ICC = .80). Supporting the instrument's construct validity, confirmatory factor analysis indicated that a five subdomain structure had an acceptable fit to the data, [chi(2) (181.65)/df (126) = 1.44, Bollen-Stine chi(2) = 165.03, p = .32, comparative fit index (CFI) = .91, and root-mean-square error of approximation = .07]. In structural equation models, parental monitoring as assessed by the PMDC had a significant direct effect on adolescent diabetes management, accounting for 38% of the variance. Parental monitoring also had a significant indirect effect on metabolic control. CONCLUSIONS: The PMDC represents an important first step in the development of measures of parental monitoring for use with adolescents with chronic medical conditions.

The role of parental monitoring in adolescent health outcomes: impact on regimen adherence in youth with type 1 diabetes.

OBJECTIVE: To determine if parental monitoring of adolescent behavior was related to regimen adherence and metabolic control among adolescents with type 1 diabetes. An additional objective was to compare the relative importance of instrumental parenting behaviors such as monitoring to affective behaviors such as parental support as predictors of regimen adherence. METHOD: Ninety-nine adolescents aged 12-18 years and their primary caregiver completed self-report questionnaires. Path analysis was used to test a model where diabetes-specific parental monitoring and support were predicted to have direct effects on regimen adherence and indirect effects on metabolic control via regimen adherence and an alternative model where parental support moderated the effects of monitoring on adherence. RESULTS: Diabetes-specific, but not general, monitoring was found to be associated with regimen adherence based on both parent and youth report. Monitoring had an indirect effect on metabolic control through regimen adherence. Although adolescent-reported parental support was significantly associated with regimen adherence in bivariate analyses, multivariate analyses indicated that parental support was not a significant independent predictor of health outcomes when parental monitoring was considered simultaneously. Modest support was also found for parental support as a moderator of the relationship between monitoring and adherence. CONCLUSIONS: Close parental monitoring of care completion can contribute to better adherence in adolescents with diabetes. General warmth and support in the absence of careful parental supervision may be insufficient to help youth achieve adequate levels of adherence.

Education and multidisciplinary team care concepts for pediatric and adolescent diabetes mellitus.

The DCCT scientifically established the basis for optimizing blood glucose control in type 1 diabetes mellitus around the world using a multidisciplinary team approach and patient-centered adjustments of food and insulin based upon blood glucose data generated by the patient. Pediatric diabetologists no longer believe that it is prudent to allow higher blood glucose levels in prepubertal children but much educational emphasis must be placed upon minimizing serious episodes of hypoglycemia. Individualized treatment should be determined by a close working relationship between highly trained diabetes nurses, educators and dieticians with the patient as the focus of self-care decisions, and a pediatric diabetologist ideally setting the philosophical and medical goals. Rather than the diabetes health care team being the only ones to initiate treatment, patient and parents should be empowered to analyze their own data, identify patterns, solve problems with food and activity, and do so based upon actual blood glucose results. This empowerment paradigm helps decrease care frustrations and improve treatment outcomes. Survival education followed by in-depth problem solving education and organized follow-up education are all needed steps for successful diabetes management. Identification of psychosocial barriers and energy diverting behavioral and family issues just as knowledge about learning styles play key roles in this process. Dogma should be avoided. More physiological utilization of insulin analogs, greater insulin dosing flexibility with a multidose insulin regimen coupled with adaptation of insulin to food and activity, should allow maximum benefit. Four major types of learning styles are reviewed: concrete sequential learners, abstract sequential learners, abstract random learners and concrete random learners. Health Belief Models, Locus of Control constructs, and Self-Efficacy models all provide sophisticated ways to help identify and overcome learning and self-care barriers. Parental, child, adolescent and young adult responsibility for care also needs to be addressed and placed in the context of family functioning and glycemic goals. Age and developmental stages as well as parental and societal roles play important roles in the care needed to live well with a chronic illness. The role of the health care professionals who are part of the diabetes care team involves not only setting the stage and providing guidance but also supervising appropriate short- as well as long-term complications monitoring for early detection and treatment of microangiopathy. Applying not only telephone but also fax, e-mail and computers in modern diabetes care should facilitate applications of these psychological, educational and medical models to improve short-term and long-term diabetes treatment outcomes.