Excess Hospital Burden Among Young People in Contact With Homelessness Services in South Australia: A Prospective Linked Data Study.

PURPOSE: Youth homelessness remains an ongoing public health issue worldwide. We aimed to describe the burden of emergency department (ED) presentations and hospitalizations among a South Australian population of young people in contact with specialist homelessness services (SHS). METHODS: This whole-of-population study used de-identified, linked administrative data from the Better Evidence Better Outcomes Linked Data (BEBOLD) platform on all individuals born between 1996 and 1998 (N = 57,509). The Homelessness2Home data collection was used to identify 2,269 young people in contact with SHS at ages 16-17 years. We followed these 57,509 individuals to age 18-19 years and compared ED presentations and hospital separations related to mental health, self-harm, drug and alcohol, injury, oral health, respiratory conditions, diabetes, pregnancy, and potentially preventable hospitalizations between those in contact and not in contact with SHS. RESULTS: Four percent of young people had contact with SHS at ages 16-17 years. Young people who had contact with SHS were 2 and 3 times more likely to have presented to an ED and hospital respectively, compared to those who did not contact SHS. This accounted for 13% of all ED presentations and 16% of all hospitalizations in this age group. Excess burden causes included mental health, self-harm, drug and alcohol, diabetes, and pregnancy. On average, young people in contact with SHS experienced an increased length of stay in ED (+0.6 hours) and hospital (+0.7 days) per presentation, and were more likely to not wait for treatment in ED and to self-discharge from hospital. DISCUSSION: The 4% of young people who contacted SHS at ages 16-17 years accounted for 13% and 16% of all ED presentations and hospitalizations respectively at age 18-19 years. Prioritizing access to stable housing and primary health-care services for adolescents in contact with SHS in Australia could improve health outcomes and reduce health-care costs.

Is guided self-help family-based treatment for parents of adolescents with anorexia nervosa on treatment waitlists feasible? A pilot trial.

OBJECTIVE: The aim of the study was to assess the feasibility (recruitment and retention) of an online 12-session guided self-help family-based treatment (GSH-FBT) for families on the waitlist for face-to-face FBT utilizing trainee psychologists to assist carers of children with anorexia nervosa (AN) or atypical AN. METHOD: The primary outcomes were feasibility of GSH-FBT for families on the waitlist and secondary exploratory outcomes examined improvement of child and parental function. RESULTS: Of 187 eligible families on the waitlist, 24 (13%) expressed interest in the study; 16 (67%) of these families completed baseline, 13 (54%) completed GSH-FBT over a 6-month recruitment period. Children (mean age = 13.92, SD = .86; mean body mass index [BMI] centile = 29.47, SD = 24.80) had an average weight gain of 6 kg (BMI centile effect size = 2.61, 95% CI: 1.77-3.44) and a decrease in eating disorder behaviors (effect size = 1.11, 95% CI: .27-1.95). Improvements also occurred for general mood and behaviors in the child, and the impact of eating disorder symptoms on their functioning. Parents reported improvements in knowledge, skills, and confidence in managing AN. DISCUSSION: Use of this low-cost intervention while families are on the waitlist for FBT is engaging and useful but strategies to improve initial recruitment are needed. PUBLIC SIGNIFICANCE STATEMENT: Although most eligible families did not enroll in an online 12-session guided self-help family-based treatment for families on the waitlist for face-to-face FBT for anorexia nervosa, families who participated found it engaging. The children experienced improvements in BMI centile, eating and behavior. Parents reported increased confidence, knowledge, and skills. We need to examine how families can be encouraged to participate on online training when on waitlists for treatment.

Adherence to metformin is reduced during school holidays and weekends in children with type 1 diabetes participating in a randomised controlled trial.

BACKGROUND: Non-adherence to treatment in childhood chronic illness has serious consequences for health and healthcare costs. Accurate detailed objective data on adherence are minimal in this age group. OBJECTIVE: To evaluate medication adherence using electronic monitoring systems in children with type 1 diabetes (T1D). DESIGN: A cohort study of 90 T1D children (aged 13.6±2.5 years, 41 males) from two paediatric diabetes clinics, participated in a 12-month double-blind, randomised, placebo-controlled trial (1:1 allocation). This cohort provided 28 336 days of study observations; 7138 school holiday and 8875 weekend/public holiday days. METHOD: Adherence to intervention (metformin (n=45) or placebo (n=45)) was measured objectively by Medication Event Monitoring Systems (MEMS) including proportion of medication doses taken and daily adherence patterns and by tablet count at 3, 6 and 12 months. The trial was completed in June 2015. RESULTS: There was an average (SD) of 363.3 (42) days of MEMS observations available for each study participant (94.1 (12.6) school holiday days and 117.1 (13.4) weekend/public holiday days). Adherence reduced during school holidays (adjusted OR (aOR) 0.81; 95% CI 0.72 to 0.91; p<0.001) and during weekends/public holidays (aOR 0.74; 95% CI 0.69 to 0.80; p<0.001). Adverse effects to the intervention did not affect overall adherence (aOR 0.77; 95% CI 0.3 to 2.01; p=0.6). Age, gender, body mass index, diabetes duration, insulin dose, HbA1c (Haemoglobin A1c) or socioeconomic status did not predict adherence. CONCLUSION: Medication adherence was reduced during school holidays and on weekends in children with T1D. Clinical characteristics including socioeconomic status and the presence of adverse effects did not predict adherence. TRIAL REGISTRATION NUMBER: ACTRN12611000148976.

Australian children with type 1 diabetes consume high sodium and high saturated fat diets: Comparison with national and international guidelines.

AIM: We aimed to evaluate the diets of children with type 1 diabetes (T1D) against recommended Australian dietary intakes and international T1D guidelines and compare them to children without T1D. METHODS: A cross-sectional analysis in 143 children (103 children aged 8-18 years with T1D and 40 age- and gender-matched controls) and longitudinal analysis at 0, 3, 6 and 12 months in 90 T1D children were conducted. Diet was assessed using an Australian validated food frequency questionnaire. Diet quality was assessed against recommended servings and nutrient intakes from Australian Dietary Guidelines and International Society for Pediatric and Adolescent Diabetes (ISPAD) Nutritional Guidelines. RESULTS: Diet was evaluated in 478 questionnaires. Diet composition did not differ between T1D and controls, and both groups did not meet the majority of the Australian Dietary Guidelines, except for fruit intake. The majority of T1D children and controls (80-83%) were overconsuming sodium (2837 ± 848 mg/day), discretionary foods (5.9 ± 2.5 serves/day) and saturated fat and trans fatty acids (13.1 ± 2.7% of total daily energy intake) in comparison with Australian and ISPAD guidelines. A total of 84% of T1D children and controls achieved the recommended intake of fibre (34.4 ± 11.0 g/day). Longitudinal analysis in children with T1D showed that total daily energy, macronutrient, micronutrient and food group servings intake did not change over the 12 months. Overconsumption of sodium, discretionary foods and saturated fat persisted over the 12-month study period. CONCLUSIONS: The majority of Australian children, with and without T1D, is not meeting recommended dietary guidelines. Significant overconsumption of sodium, saturated fat and discretionary foods attracts the most concern.

Early atherosclerosis is associated with retinal microvascular changes in adolescents with type 1 diabetes.

BACKGROUND/OBJECTIVE: Adolescents with type 1 diabetes have early macrovascular changes (increased intima-media thickness [IMT]) and early retinal changes that predict clinical disease in adulthood. We hypothesized that early changes in the macrovascular and retinal microvascular beds develop in parallel before retinopathy develops. We therefore aimed to investigate the relationship between changes in atherosclerosis (carotid and aortic IMT) and retinal vascular geometry cross-sectionally and longitudinally in adolescents with type 1 diabetes. METHODS: Ninety adolescents with type 1 diabetes (41 boys, aged 13.6 ± 3.5 years) who were enrolled in a randomized controlled trial had evaluations at baseline; 41 randomized to placebo were also investigated at 12 months for carotid and aortic IMT using ultrasound and retinal vascular geometry was measured from retinal photographs. RESULTS: There were significant associations between thicker mean/maximum carotid IMT and wider retinal arteriolar and venular calibers; for every 0.1 mm increase in mean carotid IMT, retinal arteriolar caliber increased by 7.90 µm (95% confidence interval [CI] 4.50, 11.30, P < 0.0001) and venular caliber by 9.61 µm (95% CI 4.16, 15.06, P = 0.0008). Increased mean aortic IMT was associated with increased arteriolar tortuosity (2.61, 95% CI 0.50, 4.71, P = 0.02). CONCLUSIONS: The early changes of atherosclerosis are associated with retinal microvascular changes in adolescents with type 1 diabetes. This supports parallel adverse changes in the macro and microvascular circulations from early adolescence in type 1 diabetes, and highlights the importance of early intervention.

Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review.

CONTEXT: Hormonal interventions are being increasingly used to treat young people with gender dysphoria, but their effects in this population have not been systematically reviewed before. OBJECTIVE: To review evidence for the physical, psychosocial, and cognitive effects of gonadotropin-releasing hormone analogs (GnRHa), gender-affirming hormones, antiandrogens, and progestins on transgender adolescents. DATA SOURCES: We searched Medline, Embase, and PubMed databases from January 1, 1946, to June 10, 2017. STUDY SELECTION: We selected primary studies in which researchers examined the hormonal treatment of transgender adolescents and assessed their psychosocial, cognitive, and/or physical effects. DATA EXTRACTION: Two authors independently screened studies for inclusion and extracted data from eligible articles using a standardized recording form. RESULTS: Thirteen studies met our inclusion criteria, in which researchers examined GnRHas (n = 9), estrogen (n = 3), testosterone (n = 5), antiandrogen (cyproterone acetate) (n = 1), and progestin (lynestrenol) (n = 1). Most treatments successfully achieved their intended physical effects, with GnRHas and cyproterone acetate suppressing sex hormones and estrogen or testosterone causing feminization or masculinization of secondary sex characteristics. GnRHa treatment was associated with improvement across multiple measures of psychological functioning but not gender dysphoria itself, whereas the psychosocial effects of gender-affirming hormones in transgender youth have not yet been adequately assessed. LIMITATIONS: There are few studies in this field and they have all been observational. CONCLUSIONS: Low-quality evidence suggests that hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact are generally lacking. Future research to address these knowledge gaps and improve understanding of the long-term effects of these treatments is required.

Dietary sodium intake relates to vascular health in children with type 1 diabetes.

BACKGROUND AND OBJECTIVE: Children with type 1 diabetes (T1D) have vascular dysfunction and frequently struggle to adhere to dietary recommendations. Limited data exist for the vascular consequences of poor diet quality in children. We aimed to evaluate the association between dietary components and vascular function in children with T1D. METHODS: Cross-sectional study including 90 children (13.6 [3.5] years, 41 boys) with T1D. They had evaluation of dietary micro and macronutrients (Australian Child and Adolescent Eating Survey), vascular endothelial and smooth muscle function (flow-mediated dilatation and glyceryl trinitrate mediated dilatation [GTN], respectively), clinical and biochemical variables. RESULTS: Children had a sodium intake of 3.013 (0.76) (mean [SD]) g/day. Vascular smooth muscle dysfunction, as measured by GTN, related to higher daily sodium intake (r = -0.31, P = .003), independent of the inverse relationships between GTN and total energy (r = -0.30, P = .005) and fat intake (r = -0.28, P = .007). Multiregression model showed that an increase in 1 g of daily sodium intake was independently associated with a deterioration of 3 percentage units in GTN (95% CI -4.3, -0.9; P = .003). There was an association between sodium intake and systolic blood pressure after adjustment for age and gender (regression coefficient 2.4; 95% CI 0.5, 4.3; P = .01). CONCLUSIONS: High dietary sodium intake in children with T1D is common and relates to vascular dysfunction, independently of other dietary intake, blood pressure, and glycemic control.

Children With Type 1 Diabetes Have Delayed Flow-Mediated Dilation.

OBJECTIVES: Children with type 1 diabetes have accelerated atherosclerosis with early endothelial dysfunction as measured by reduced flow-mediated dilation (FMD) at 60 seconds postischemic stress (early FMD). Delayed dilation may also occur in the presence of cardiovascular risk factors and may be a more sensitive marker. No data exist that evaluate FMD beyond 60 seconds (delayed FMD) in children with type 1 diabetes. We aimed to compare early and delayed FMD in children with type 1 diabetes and in healthy children. METHODS: We studied 66 children 13.5±2.8 years of age; 29 were males. Of the 66 children, 38 had type 1 diabetes, and 28 were healthy age- and gender-matched controls. Evaluation of brachial artery FMD was performed at 60 seconds (FMD60s) and 120 seconds (FMD120s) postischemic stress. Early FMD was defined as peak FMD60s and delayed FMD as peak FMD120s. RESULTS: Children with type 1 diabetes had diabetes durations of 5.4±4.6 years and median glycated hemoglobin levels of 8.8 (6.6 to 14)% (73 [49 to 130] mmol/mol). Of the children, 8 with type 1 diabetes and 1 healthy child had delayed FMD; a relationship was seen between the prevalence of early FMD and delayed FMD in children with type 1 diabetes and healthy children, respectively (p=0.019). Children with type 1 diabetes and delayed FMD had lower FMD60s than children without delayed FMD (2.50±3.61 vs. 6.14±3.83 percentage units; p=0.02). Children with type 1 diabetes had lower FMD60s than healthy children (5.38±4.0 percentage units; p=0.03) but not FMD120s (7.56±3.5 percentage units; p=0.47). CONCLUSIONS: Delayed FMD patterns occur in children with type 1 diabetes and detect children who have more severe vascular abnormalities. The standard FMD60s remains the better marker to identify children at increased risk for cardiovascular disease.

Effect of Metformin on Vascular Function in Children With Type 1 Diabetes: A 12-Month Randomized Controlled Trial.

Context: Children with type 1 diabetes have vascular dysfunction preceding atherosclerosis. Early interventions are needed to reduce cardiovascular disease. Objective: To evaluate the effect of metformin on vascular function in children with type 1 diabetes. Design: Twelve-month double-blind, randomized, placebo-controlled trial. Setting: Tertiary pediatric diabetes clinic. Participants: Ninety children (8 to 18 years of age), >50th percentile body mass index (BMI), with type 1 diabetes. Intervention: Metformin (up to 1 g twice a day) or placebo. Main Outcome Measure: Vascular function measured by brachial artery ultrasound [flow-mediated dilatation/glyceryl trinitrate-mediated dilatation (GTN)]. Results: Ninety participants were enrolled [41 boys, 13.6 (2.5) years of age, 45 per group], 10 discontinued intervention, and 1 was lost to follow-up. On metformin, GTN improved, independent of glycosylated hemoglobin (HbA1c), by 3.3 percentage units [95% confidence interval (CI) 0.3, 6.3, P = 0.03] and insulin dose reduced by 0.2 U/kg/d (95% CI 0.1, 0.3, P = 0.001) during 12 months, with effects from 3 months. Metformin had a beneficial effect on HbA1c at 3 months (P = 0.001) and difference in adjusted HbA1c between groups during 12 months was 1.0%; 95% CI 0.4, 1.5 (10.9 mmol/mol; 95% CI 4.4, 16.4), P = 0.001. There were no effects on carotid/aortic intima media thickness, BMI, lipids, blood pressure, or other cardiovascular risk factors. Median (95% CI) adherence, evaluated by electronic monitoring, was 75.5% (65.7, 81.5), without group differences. More gastrointestinal side effects were reported on metformin (incidence rate ratio 1.65, 95% CI 1.08, 2.52, P = 0.02), with no difference in hypoglycemia or diabetic ketoacidosis. Conclusions: Metformin improved vascular smooth muscle function and HbA1c, and lowered insulin dose in type 1 diabetes children. These benefits and good safety profile warrant further consideration of its use.

Lack of evidence for progression of atherosclerosis during puberty in type 1 diabetes.

OBJECTIVES: Children with type 1 diabetes have early changes in vascular structure with increased aortic intima-media thickness (aIMT) or carotid IMT (cIMT). aIMT may be an earlier, more sensitive marker; however, longitudinal data in type 1 diabetes are lacking. This study will aim to evaluate changes in vascular structure (aIMT and cIMT) over 2 yr during puberty in children with type 1 diabetes and compare them with those in healthy children. RESEARCH DESIGN AND METHODS: A total of 110 children (aged 10-18 yr, 55 males) participated in a prospective cohort study, including 77 children with type 1 diabetes and 33 age- and sex-matched healthy children. Ultrasound assessments of aIMT and cIMT; and clinical and biochemical data were collected at baseline and 2 yr later. RESULTS: Mean and maximal aIMT or cIMT did not worsen over time in children with type 1 diabetes compared with healthy children. Longer duration of diabetes related to an increase in aIMT. Improvement in HDL cholesterol and leptin related to a decrease in aIMT. Higher baseline IMT related to an improvement in IMT in children with type 1 diabetes (mean and maximal aIMT: ß = -0.52, p < 0.001; ß = -0.49, p = 0.001, and mean and maximal cIMT: ß = -0.36, p = 0.003; ß = -0.40, p = 0.001), independent of cardiovascular risk factors. CONCLUSIONS: Aortic and carotid IMT does not deteriorate during puberty in children with type 1 diabetes. This has implications for the design of interventional studies in this important age group.

Does metformin improve vascular health in children with type 1 diabetes? Protocol for a one year, double blind, randomised, placebo controlled trial.

BACKGROUND: Cardiovascular disease is the leading cause of mortality in Type 1 diabetes (T1D). Vascular dysfunction is an early and critical event in the development of cardiovascular disease. Children with T1D have vascular dysfunction therefore early interventions to improve vascular health are essential to reduce cardiovascular mortality in T1D. Metformin is an insulin sensitising agent which is known to improve vascular health outcomes in type 2 diabetes (T2D) and other individuals with insulin resistance. It has been used safely in children and adolescents with T2D for over 10 years. This study aims to assess the effect of metformin on vascular health in children with T1D. METHODS/DESIGN: This study is a 12 month, double blind, randomised, placebo controlled trial to determine the effect of metformin on vascular health in children (age 8-18) with T1D. The sample size is 76 with 38 children in the metformin group and 38 children in the placebo group. Vascular health and biochemical markers will be measured at baseline, 3, 6 and 12 months. Vascular function will be measured using flow mediated dilatation and glyceryl trinitrate mediated dilatation of the brachial artery and vascular structure will be measured with carotid and aortic intima media thickness, using standardised protocols. DISCUSSION: This study will be the first to investigate the effect of metformin on vascular health in children with T1D. It will provide important information on a potential intervention to improve cardiovascular morbidity and mortality in this population at high risk from cardiovascular disease. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12611000148976.

Apnoea after the 2-month immunisation in extremely preterm infants: what happens with the 4-month immunisation?

AIM: To describe the outcome of the 4-month immunisation in a cohort of extremely preterm babies who had clinically significant apnoea after their 2-month immunisation. METHOD: A retrospective audit was conducted from January 2001 to January 2011 at Flinders Medical Centre (FMC). Suspected apnoeic reactions to the 2-month immunisation in preterm infants ≤28 weeks + 6 days gestation were identified from the Neonatal Unit database. The medical records of babies with reactions then reviewed. We classified apnoeic reactions using predefined criteria into likely, possible or unlikely. The outcomes for subsequent immunisations were determined either when babies were specifically readmitted to FMC for immunisation and cardiorespiratory monitoring, or from the SA Health Immunisation Unit database. RESULTS: There were 203 extremely preterm babies at FMC over the study period who received their 2-month immunisation as inpatients. Clinically significant apnoea post immunisation occurred in 17 (8.4%) babies (likely in 12 and possible 5). The subsequent (4-month) immunisation was given with inpatient cardiorespiratory monitoring in nine babies (seven with likely and two with possible reactions), and no instability was identified. There were eight babies not readmitted to FMC for the subsequent immunisation. No reported adverse events were recorded on the SA Health Immunisation Unit database for these babies. CONCLUSIONS: Apnoea following the 2-month immunisation in extremely preterm infants is not likely to be repeated with the subsequent immunisation. Prospective surveillance using standardised case definitions and monitoring protocols in this population are required to guide uniform practice.