Conjugated hyperbilirubinemia among infants with hyperinsulinemic hypoglycemia.

From clinical practice, we noted that a subset of neonates with hyperinsulinism develop conjugated hyperbilirubinemia. A relationship between these two conditions has not been previously described. We aimed to assess the incidence of cholestasis in a cohort of neonates with hyperinsulinism and describe their clinical characteristics. In a retrospective cohort of 63 neonates with hyperinsulinism, 48% developed cholestasis (conjugated bilirubin > 17 µmol/L) with a median maximum conjugated bilirubin of 81 [21 to 191] µmol/L. A history of fetal distress (RR 2.3 [1.24-4.45], p < 0.01) and prematurity (RR 2.0 [1.23-3.26], p <0.01) was associated with the development of cholestasis, but not parental nutrition or other pharmacological treatments. An underlying etiology for the cholestasis was only found in 1 patient, and in all cases the cholestasis spontaneously improved.Conclusions: A significant percentage of infants with hyperinsulinism develop idiopathic, spontaneously resolving, conjugated hyperbilirubinemia. The association with a history of fetal distress potentially suggests that intrauterine factors leading to hyperinsulinism may also predispose towards conjugated hyperbilirubinemia. While the presence of neonatal cholestatic jaundice warrants timely investigations to exclude important underling etiologies, if validated, these findings may support a less invasive diagnostic workup of conjugated hyperbilirubinemia in infants with co-existent hyperinsulinism. What is Known: • Hyperinsulinism and conjugated hyperbilirubinemia are two common presentations in neonates. • A clinical association between the two conditions has not been described. What is New: • A significant proportion of infants with hyperinsulinism develop idiopathic, spontaneously resolving conjugated hyperbilirubinemia. • Increased risk for cholestasis in this patient population is associated with fetal distress and prematurity but not parental nutrition.

A student-led curriculum framework for homeless and vulnerably housed populations.

BACKGROUND: Medical student demands for competency based homeless health education is increasing. Indeed, humans living homeless is a treatable health and social emergency. This innovation report outlines the initial development of an education framework for homeless health. METHODS: A medical student task force and educators conducted a mixed method study, including a scoping review of homeless health curriculum and competencies, a cross-country survey of medical students, and unique clinical guidelines. The task force collaborated with persons with lived experience and clinical guideline developers from the Homeless Health Research Network. The students presented at the Toronto Homeless Health Summit and refined the framework with feedback from homeless health experts. RESULTS: The main outcome was an evidence-based Homeless Health Curriculum Framework. It uses seven core competencies; with communication, advocacy, leadership, and upstream approaches playing the strongest roles. The framework integrated the new clinical guideline (housing, income assistance, case management and addiction). In addition, it identified approaches to support mental health care with trauma informed and patient centered care. It identified public health values, clinical objectives, and case studies. The framework aims to inform the design, delivery, service learning and evaluation for medical school curriculum. CONCLUSIONS: This student-led curriculum framework can support the design, implementation, delivery and evaluation of homeless health within the undergraduate medical curriculum. The framework can lay the foundation for new doctors, research and development; support consistency across programs; and support the creation of national learning and evaluation tools.

Clinical Predictors of Transient versus Persistent Neonatal Hyperinsulinism.

INTRODUCTION: Hyperinsulinism (HI), the most common neonatal cause of persistent hypoglycemia, can be associated with prolonged hospitalizations and risk for long-term neurological sequelae. Rapid identification of transient versus persistent forms of HI is crucial to optimize management. OBJECTIVES: The aims of the study were to assess the ability of clinical and biochemical features at presentation to predict transient versus persistent HI, and to evaluate differences in hospital outcomes. METHODS: This study is a retrospective review of 79 infants with HI admitted to the Hospital for Sick Children, Toronto, from 2012 to 2017. Patients were classified into 3 groups: transient and the 2 persistent forms, diazoxide responsive and diazoxide unresponsive (DU). RESULTS: Infants with birth weight >90th percentile had an 8-fold increased risk of having a persistent form of HI (OR 8.8, 95% CI 2.5-30) and a 21-fold increased risk of having a DU form of HI (OR 21.1, 95% CI 4.9-91.8). The majority of children with transient HI and a birth weight >90th percentile were born to mothers with gestational diabetes. There were no other useful clinical or biochemical presenting features that differentiated the groups. There were significant differences in outcome measures, with the DU children more likely to require gastrostomy tube insertion and have an extended length of hospital admission. CONCLUSION: A higher birth weight in the absence of maternal gestational diabetes is highly associated with a persistent form of HI. Given the marked difference in clinical outcomes between groups, expedited genetic testing should be considered in infants with this presentation to inform clinical management.

The quality of clinical practice guidelines for management of pediatric type 2 diabetes mellitus: a systematic review using the AGREE II instrument.

AIMS: Pediatric type 2 diabetes mellitus (T2DM) is a relatively new disease with increasing incidence corresponding to the obesity epidemic among youth. It is important for clinicians to have access to high-quality clinical practice guidelines (CPGs) for appropriate management of pediatric patients with T2DM. The objective of this systematic review was to evaluate overall quality of CPGs for the management of pediatric T2DM using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. METHODS: We searched MEDLINE, Embase, CINAHL, Trip, National Guideline Clearinghouse, and grey literature to identify eligible CPGs. We also searched the webpages of national and international diabetes and pediatric organizations globally. We included CPGs from national and international diabetes and pediatric associations that were published as standalone guidelines for T2DM in children and adolescents (2-18 years of age). We also included pediatric and adult guidelines for type 1 diabetes if they included a section addressing T2DM management in children and adolescents. We retrieved the two most recent guidelines from each organization when available to assess change in quality over time. We excluded individual studies and systematic reviews that made treatment recommendations as well as CPGs that were developed for a single institution. RESULTS: We included 21 unique CPGs in this systematic review. Of the included guidelines, 12 were developed or updated between 2012 and 2014. Five of all included CPGs were specific to pediatric populations. The analysis revealed that "Rigour of Development" (mean 45%, SD 28.68) and "Editorial Independence" (mean 45%, SD 35.19) were the lowest scoring domains on the AGREE II for the majority of guidelines, whereas "Clarity of Presentation" was the highest scoring domain (mean 72%, SD 18.89). CONCLUSIONS: Overall, two thirds of the pediatric T2DM guidelines were moderate to low quality and the remaining third ranked higher in quality. Low quality was especially due to the scores for the "Rigour of Development" domain, which directly measures guideline development methodology. It is important that future guidelines and updates of existing guidelines improve the methodology of development and quality of reporting in order to appropriately guide physicians managing children and adolescents with T2DM. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016034187.

Appraisal of clinical practice guidelines for management of paediatric type 2 diabetes mellitus using the AGREE II instrument: a systematic review protocol.

BACKGROUND: The prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents is increasing. This has spurred the development and publication of clinical practice guidelines (CPGs) for the management of paediatric T2DM. Given the long-term complications of T2DM, optimal management is important to prevent or delay these complications. However, the quality of published CPGs has not yet been empirically evaluated. Our objective is to systematically appraise all published CPGs for the management of T2DM in children and adolescents. METHODS: We will identify all published CPGs that address T2DM in children and adolescents through MEDLINE, Embase, CINAHL, Trip, and the National Guideline Clearinghouse and will screen diabetes and paediatric societies and associations' websites. Search records will be screened in duplicate for inclusion. Grey literature will be covered by systematically searching publications of all relevant diabetes societies and associations and other health organizations for CPGs that meet our inclusion criteria. CPGs deemed eligible for inclusion will be retrieved. Quality assessment will be conducted using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool by a team of four appraisers. Scaled scores of the AGREE II will be used to gauge the overall quality of CPGs. DISCUSSION: The results of this review will be disseminated through presentations at local, national, and international conferences and publication in a peer-reviewed journal. The results of this review can help improve the reporting of future guidelines, inform decisions of policy-makers to endorse CPGs, and affect the choice of guideline use in clinical practice. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016034187.