Correlation Between the Glycemia Risk Index and Longitudinal Hemoglobin A1c in Children and Young Adults With Type 1 Diabetes.

BACKGROUND: The glycemia risk index (GRI) is a composite metric developed and used to estimate quality of glycemia in adults with diabetes who use continuous glucose monitor (CGM) devices. In a cohort of youth with type 1 diabetes (T1D), we examined the utility of the GRI for evaluating quality of glycemia between clinic visits by analyzing correlations between the GRI and longitudinal glycated hemoglobin A1c (HbA1c) measures. METHOD: Using electronic health records and CGM data, we conducted a retrospective cohort study to analyze the relationship between the GRI and longitudinal HbA1c measures in youth (T1D duration ≥1 year; ≥50% CGM wear time) receiving care from a Midwest pediatric diabetes clinic network (March 2016 to May 2022). Furthermore, we analyzed correlations between HbA1c and the GRI high and low components, which reflect time spent with high/very high and low/very low glucose, respectively. RESULTS: In this cohort of 719 youth (aged = 2.5-18.0 years [median = 13.4; interquartile range [IQR] = 5.2]; 50.5% male; 83.7% non-Hispanic White; 68.0% commercial insurance), baseline GRI scores positively correlated with HbA1c measures at baseline and 3, 6, 9, and 12 months later (r = 0.68, 0.65, 0.60, 0.57, and 0.52, respectively). At all time points, strong positive correlations existed between HbA1c and time spent in hyperglycemia. Substantially weaker, negative correlations existed between HbA1c and time spent in hypoglycemia. CONCLUSIONS: In youth with T1D, the GRI may be useful for evaluating quality of glycemia between scheduled clinic visits. Additional CGM-derived metrics are needed to quantify risk for hypoglycemia in this population.

The Glycemia Risk Index Predicts Performance of Diabetes Self-Management Habits in Youth With Type 1 Diabetes Mellitus.

BACKGROUND: The Glycemia Risk Index (GRI) was developed in adults with diabetes and is a validated metric of quality of glycemia. Little is known about the relationship between GRI and type 1 diabetes (T1D) self-management habits, a validated assessment of youths' engagement in habits associated with glycemic outcomes. METHOD: We retrospectively examined the relationship between GRI and T1D self-management habits in youth with T1D who received care from a Midwest pediatric diabetes clinic network. The GRI was calculated using seven days of continuous glucose monitor (CGM) data, and T1D self-management habits were assessed ±seven days from the GRI score. A mixed-effects Poisson regression model was used to evaluate the total number of habits youth engaged in with GRI, glycated hemoglobin A1c (HbA1c), age, race, ethnicity, and insurance type as fixed effects and participant ID as a random effect to account for multiple clinic visits per individual. RESULTS: The cohort included 1182 youth aged 2.5 to 18.0 years (mean = 13.8, SD = 3.5) comprising 50.8% male, 84.6% non-Hispanic White, and 64.8% commercial insurance users across a total of 6029 clinic visits. Glycemia Risk Index scores decreased as total number of habits performed increased, suggesting youth who performed more self-management habits achieved a higher quality of glycemia. CONCLUSIONS: In youth using CGMs, GRI may serve as an easily obtainable metric to help identify youth with above target glycemia, and engagement/disengagement in the T1D self-management habits may inform clinicians with suitable interventions for improving glycemic outcomes.

Mealtime Insulin BOLUS Score More Strongly Predicts HbA1c Than the Self-Care Inventory in Youth With Type 1 Diabetes.

BACKGROUND: To meet their glycated hemoglobin (HbA1c) goals, youth with type 1 diabetes (T1D) need to engage with their daily T1D treatment. The mealtime insulin Bolus score (BOLUS) is an objective measure of youth's T1D engagement which we have previously shown to be superior to other objective engagement measures in predicting youth's HbA1c. Here, to further assess the BOLUS score's validity, we compared the strengths of the associations between youth's HbA1c with their mean insulin BOLUS score and a valid, self-report measure of T1D engagement, the Self-Care Inventory (SCI). METHODS: One-hundred and five youth with T1D self-reported their T1D engagement using the SCI. We also collected two weeks of insulin pump data and a concurrent HbA1c level. We scored youth's SCI and calculated their mean insulin BOLUS score using standardized methods. For the analyses, we performed simple correlations, partial correlations, and multiple regression models. RESULTS: Youth had a mean age of 15.03 ± 1.97 years, mean time since diagnosis of 8.11 ± 3.26 years, and a mean HbA1c of 8.78 ± 1.49%. The sample included n = 58 boys (55%) and n = 96 families (91%) self-identified as white. Simple correlations between youth's age, HbA1c, SCI total score, and BOLUS score were all significant. Partial correlation and regression models revealed that youth's insulin BOLUS score was more strongly associated with HbA1c than the SCI. CONCLUSIONS: Youths' BOLUS score has better concurrent validity with HbA1c than the SCI. We should consider reporting the BOLUS score as an outcome metric in insulin pump data reports.

An "All-Data-on-Hand" Deep Learning Model to Predict Hospitalization for Diabetic Ketoacidosis in Youth With Type 1 Diabetes: Development and Validation Study.

BACKGROUND: Although prior research has identified multiple risk factors for diabetic ketoacidosis (DKA), clinicians continue to lack clinic-ready models to predict dangerous and costly episodes of DKA. We asked whether we could apply deep learning, specifically the use of a long short-term memory (LSTM) model, to accurately predict the 180-day risk of DKA-related hospitalization for youth with type 1 diabetes (T1D). OBJECTIVE: We aimed to describe the development of an LSTM model to predict the 180-day risk of DKA-related hospitalization for youth with T1D. METHODS: We used 17 consecutive calendar quarters of clinical data (January 10, 2016, to March 18, 2020) for 1745 youths aged 8 to 18 years with T1D from a pediatric diabetes clinic network in the Midwestern United States. The input data included demographics, discrete clinical observations (laboratory results, vital signs, anthropometric measures, diagnosis, and procedure codes), medications, visit counts by type of encounter, number of historic DKA episodes, number of days since last DKA admission, patient-reported outcomes (answers to clinic intake questions), and data features derived from diabetes- and nondiabetes-related clinical notes via natural language processing. We trained the model using input data from quarters 1 to 7 (n=1377), validated it using input from quarters 3 to 9 in a partial out-of-sample (OOS-P; n=1505) cohort, and further validated it in a full out-of-sample (OOS-F; n=354) cohort with input from quarters 10 to 15. RESULTS: DKA admissions occurred at a rate of 5% per 180-days in both out-of-sample cohorts. In the OOS-P and OOS-F cohorts, the median age was 13.7 (IQR 11.3-15.8) years and 13.1 (IQR 10.7-15.5) years; median glycated hemoglobin levels at enrollment were 8.6% (IQR 7.6%-9.8%) and 8.1% (IQR 6.9%-9.5%); recall was 33% (26/80) and 50% (9/18) for the top-ranked 5% of youth with T1D; and 14.15% (213/1505) and 12.7% (45/354) had prior DKA admissions (after the T1D diagnosis), respectively. For lists rank ordered by the probability of hospitalization, precision increased from 33% to 56% to 100% for positions 1 to 80, 1 to 25, and 1 to 10 in the OOS-P cohort and from 50% to 60% to 80% for positions 1 to 18, 1 to 10, and 1 to 5 in the OOS-F cohort, respectively. CONCLUSIONS: The proposed LSTM model for predicting 180-day DKA-related hospitalization was valid in this sample. Future research should evaluate model validity in multiple populations and settings to account for health inequities that may be present in different segments of the population (eg, racially or socioeconomically diverse cohorts). Rank ordering youth by probability of DKA-related hospitalization will allow clinics to identify the most at-risk youth. The clinical implication of this is that clinics may then create and evaluate novel preventive interventions based on available resources.

International Guideline Adherence in Girls with Turner Syndrome: Multiple Subspecialty Clinics Versus Coordinated Multidisciplinary Clinic.

OBJECTIVE: To evaluate the 2016 Cincinnati International Turner syndrome (TS) consensus guideline adherence within our pediatric tertiary referral center and determine if patients managed in our single-day, coordinated multidisciplinary clinic (MDC) format showed superior adherence rates when compared with those managed outside our MDC format. METHODS: We retrospectively reviewed the charts of patients with TS followed at our center from January 1, 2018, to April 30, 2020. The individual and overall adherence rates of 9 age-appropriate screening recommendations were evaluated along with rates of TS comorbidities within our cohort. RESULTS: A total of 111 girls met the study criteria. Sixty-eight were managed in the MDC and 43 were managed outside the MDC. Only 42% of all the girls met all 9 evaluated age-appropriate screening recommendations, of 47 girls, 33 (70%) were managed in MDC compared with 14 (30%) who were managed in the non-MDC. Girls managed in the MDC had higher screening adherence rates versus non-MDC girls for 7 of the 9 evaluated screenings with especially large differences noted for thyroid stimulating hormone (95% vs 78%, P = .034), auditory evaluation (97% vs 65%, P < .001), and HgA1c levels (82% vs 54%, P = .014). CONCLUSION: Girls managed in the MDC format showed higher rates of screening guideline adherence, both overall and with multiple specific screening tests, than those managed outside the MDC format. Overall guideline adherence remained low (42%), highlighting the need for continued optimization and improvement in guideline adherence in this unique subset of the population.

Situational factors that influence overreaching on a ladder during a gutter clearing task among older adults.

Ladder falls from overreaching are a problem in older adults. Evidence suggests ladder use behavior to be dependent on interfacing user and environmental circumstances (i.e. situational factors). This study investigates the effects of situational factors (remaining debris, ladder position, time into task, hand dominant reach, reaching disposition) on reaching during a gutter clearing task on a ladder in 104 older adults. Reaching was quantified as the maximum lateral center of pressure (COP) displacement from the ladder's center. A reach was classified as an overreach when the COP displaced outside the ladder width, indicative of a ladder tip. Reaching disposition, remaining debris, ladder position, and the interaction of reaching disposition and remaining debris predicted 20% of the reaching variability during the ladder task. Overreaching was observed in 40% of participants accounting for 13% of all extended reaches (beyond ladder). This work can guide interventions on mitigating overreaching and improving ladder safety.

Practices and Procedures in Clinical Pediatric Exercise Laboratories in North America.

Interinstitutional differences in clinical pediatric exercise laboratory (CPEL) practices may affect patient care and efficacy of multicenter research. PURPOSE: To describe current practices/procedures in CPELs and explore differences in CPELs employing exercise physiologists to those that do not. METHODS: A 40-item survey was distributed to CPELs in North America focusing on (1) staffing; (2) exercise stress testing (EST) volumes, reporting, and interpretation; and (3) EST procedures/protocols. RESULTS: Of the 55 responses, 89% were in the United States, 85% were children's hospitals with university affiliation, and 58% were cardiology specific. Exercise physiologists were employed in 56% of CPELs, and 78% had master's degrees or higher. Certifications were required in most CPELs (92% emergency life-support, 27% professional, and 21% clinical). Median volume was 201 to 400 ESTs per year, 80% used treadmill, and 10% used cycle ergometer as primary modalities. Ninety-three percent of CPELs offered metabolic ESTs, 87% offered pulmonary function testing, 20% used institution-specific EST protocols, and 72% offered additional services such as cardiac/pulmonary rehabilitation. CPELS staffing exercise physiologists performed higher volumes of ESTs (P = .004), were more likely to perform metabolic ESTs (P = .028), participated in more research (P < .001), and provided services in addition to ESTs (P = .001). CONCLUSIONS: Heterogeneity in CPELs staffing and operation indicates need for standardization.

Parent and Adolescent Thoughts About Suicide Risk Screening in Pediatric Outpatient Settings.

Suicide rates among adolescents in the United States continue to climb and many at-risk youths are undetected. Screening for suicidal thoughts has become the primary approach to identify those at risk, but no studies have assessed reactions to its deployment in pediatric outpatient settings. This mixed-method study assessed parents' and adolescents' thoughts about suicide risk screening in non-psychiatric, pediatric outpatient specialty settings.As part of a multi-site measurement validation study, adolescents (n = 269; ages 10-21) and parents (n = 246) at pediatric specialty clinics in the Midwest completed a survey regarding thoughts about suicide risk screening. Data were collected on tablet computers and transcribed verbatim. Three study team members independently coded transcripts of open-ended responses to identify major themes, and frequency data were analyzed using StataSE 15.1. Inter-rater agreement was substantial (Fleiss' Kappa ranged 75-86%).Parents (55% 41-50 years of age, 20% male, 80% White) and adolescents (Mean age = 14.3, 50% male, 77% White) agreed medical providers should screen adolescents for suicide risk (93% and 88%, respectively). Majority of parents indicated that the pediatric outpatient setting is appropriate for suicide risk screening. Major themes included the important role of providers in identifying at-risk youth, the potential for screening to prevent suicides, and concerns about iatrogenic risk and misdiagnosis.Most parents and adolescents support screening for suicide risk in pediatric outpatient settings. Nevertheless, some have concerns about the screening process and implications. As suicide risk screening becomes standard practice in adolescent care, it's critical to develop screening processes that maximize comfort and address concerns.

Longitudinal associations between family conflict, parent engagement, and metabolic control in children with recent-onset type 1 diabetes.

INTRODUCTION: We prospectively investigated the associations between diabetes-related family conflict, parent engagement in child type 1 diabetes (T1D) care, and child glycated hemoglobin (HbA1c) in 127 families of school-age children who we recruited within the first year of their T1D diagnosis. RESEARCH DESIGN AND METHODS: Parents completed the Diabetes Family Conflict Scale-Revised (DFCS-R) to assess for diabetes-related family conflict and the Diabetes Self-Management Questionnaire-Brief (DSMQ-Brief) to assess parent engagement in child T1D care at the initial study visit (T1) and at 12 (T2) and 27 (T3) months later. We also collected child HbA1c at these time points. Our analyses included Pearson correlations and repeated measures linear mixed models controlling for child age, sex, and T1D duration at T1. RESULTS: Parents' DFCS-R scores negatively correlated with DSMQ-Brief scores (r=-0.13, p<0.05) and positively correlated with children's HbA1c (r=0.26, p<0.001). In our linear mixed models, parents' DSMQ-Brief scores were unchanged at T2 (ß=-0.71, 95% CI -1.59 to 0.16) and higher at T3 (ß=8.01, 95% CI 6.89 to 9.13) compared with T1, and there was an association between increasing DFCS-R and decreasing DSMQ-Brief scores (ß=-0.14, 95% CI -0.21 to -0.06). Child HbA1c values were significantly higher at T2 (ß=0.66, 95% CI 0.38 to 0.94) and T3 (ß=0.95, 95% CI 0.63 to 1.27) compared with T1, and there was an association between increasing DFCS-R scores and increasing child HbA1c (ß=0.04, 95% CI 0.02 to 0.06). CONCLUSIONS: Increasing diabetes-specific family conflict early in T1D may associate with decreasing parent engagement in child T1D care and increasing child HbA1c, suggesting a need to assess and intervene on diabetes-specific family conflict. Trial registration number NCT03698708.

Effect of Combined Clinical Practice Guideline and Electronic Order Set Implementation on Febrile Infant Evaluation and Management.

OBJECTIVE: Management of febrile infants 60 days and younger for suspected serious infection varies widely. Clinical practice guidelines (CPGs) are intended to improve clinician adherence to evidence-based practices. In 2011, a CPG for managing febrile infants was implemented in an urban children's hospital with simultaneous release of an electronic order set and algorithm to guide clinician decisions for managing infants for suspected serious bacterial infection. The objective of the present study was to determine the association of CPG implementation with order set use, clinical practices, and clinical outcomes. METHODS: Records of febrile infants 60 days and younger from February 1, 2009, to January 31, 2013, were retrospectively reviewed. Clinical documentation, order set use, clinical management practices, and outcomes were compared pre-CPG and post-CPG release. RESULTS: In total, 1037 infants pre-CPG and 930 infants post-CPG implementation were identified. After CPG release, more infants 29 to 60 days old underwent lumbar puncture (56% vs 62%, P = 0.02). Overall antibiotic use and duration of antibiotic use decreased for infants 29 to 60 days (57% vs 51%, P = 0.02). Blood culture and urine culture obtainment remained unchanged for older infants. Diagnosed infections, hospital readmissions, and length of stay were unchanged. Electronic order sets were used in 80% of patient encounters. CONCLUSIONS: Antibiotic use and lumbar puncture performance modestly changed in accordance with CPG recommendations provided in the electronic order set and algorithm, suggesting that the presence of embedded prompts may affect clinician decision-making. Our results highlight the potential usefulness of these decision aids to improve adherence to CPG recommendations.

Variations in Morning Serum Cortisol Levels Based on Sex and Pubertal Status.

INTRODUCTION: Patients with suspected adrenal insufficiency undergo screening with a serum morning cortisol level and confirmatory testing with an adrenocorticotropic hormone (ACTH) stimulation test. However, much of the data collected to determine appropriate values for morning cortisol levels are derived from adult populations and may not accurately represent pediatric physiology. The purpose of this study was to evaluate the mean morning cortisol level in the pediatric population based on pubertal status and sex in order to better understand such influences on laboratory evaluation of adrenal insufficiency. METHODS: A retrospective chart review was conducted using electronic medical records of patients seen at Children's Mercy Kansas City from 11/01/2007 to 11/01/2017. Patients between 2 and 18 years of age who had pubertal staging assessed by a pediatric endocrinologist and confirmed adrenal sufficiency by high-dose ACTH stimulation testing were included. Two-sample Wilcoxon rank sum (Mann-Whitney) tests or t tests were used to compare morning cortisol levels between females and males - both independent of Tanner stage and by Tanner stage. Multivariable regression models were used to evaluate associations among covariates on two outcomes: morning cortisol levels and peak cortisol values with ACTH stimulation. RESULTS: Morning cortisol levels were greater in females than males independent of Tanner staging (p = 0.0054) and also in Tanner stage 1 (p = 0.0042). No differences in mean morning cortisol levels between Tanner stage 2-5 females and males were found (p = 0.4652). Morning cortisol levels were not significantly different between Tanner 1 patients and Tanner 2-5 patients independent of sex (p = 0.0575). Sex was predictive of serum morning cortisol levels (p = 0.015), and morning cortisol levels were predictive of peak cortisol levels during ACTH stimulation testing (p < 0.001). CONCLUSIONS: These data suggest that different normative cortisol values may need to be established for pediatric females and males, and by pubertal status. Larger prospective studies are needed to evaluate the role of sex and pubertal status in identifying adrenal insufficiency in the -pediatric population.

A New Paediatric Diabetes Knowledge Test - M-WIKAD Development and Factor Analysis.

Purpose: The purpose of this study was to develop a measure of type 1 diabetes mellitus (T1DM) knowledge that is aimed at youth and is based on contemporary management standards. Methods: An 88-item test was derived from the American Association of Diabetes Educators 7 Self-Care Behaviors. Results: A multidisciplinary team selected the best 49 items which were piloted in a sample of 119 youths (59 males, aged 12-18, having a mean ± standard deviation glycated haemoglobin (A1C) of 9.9%±1.80 (84.7±19.7 mmol/mol). A minimum absolute point-biserial correlation coefficient of 0.250 was used to choose 49 items from the original 88 questions. Categorical principal component analysis was then used to identify the best factor analytical model that consisted of five factors composed of 19 items. These five factors explained 57% of item variances. Factors were associated with the latent variables: advanced problem-solving, hypoglycaemia prevention and management, taking insulin/medication administration, daily management and healthy active living. Conclusion: A new T1D knowledge test for youth was refined from 88 to 49 questions based on expert opinion and empirical test construction. The instrument was then refined to 19 items based on exploratory factor analysis. Future goals are to validate this factor model with another cohort and confirm concurrent validity based on youth's glycated haemoglobin and adherence behaviours. Our new T1DM knowledge measure initially appears valid and promising as a new clinical and research tool.

Pediatric Orthopaedic Surgeons Dissatisfied in On-Call Practices Despite Improving Call Conditions. The 2015 POSNA Membership Survey Regarding Trauma Care.

BACKGROUND: To examine the current trends in trauma call coverage of pediatric orthopaedic surgeons in North America and to identify predictors of surgeon on-call satisfaction. METHODS: In 2015, ∼1200 active members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding emergency room on-call practices. In total, 410 members completed the survey with a response rate of 35%. Information collected included call frequency, practice setting and satisfaction with call. This information was analyzed and compared with the 2006 and 2010 trauma call surveys of Pediatric Orthopaedic Society of North America membership using 2 sample difference in proportion, χ tests for trend and the Fisher exact tests. Logistic regression analyses were used to identify predictors of call satisfaction among pediatric orthopaedic surgeons. RESULTS: In total, 47% of pediatric orthopaedic surgeons had access to a designated trauma operating room in 2015, up from 39% in 2010 and 24% in 2006. In total, 43% of pediatric orthopaedic surgeons currently receive a stipend for taking call, up from 35% in 2010 and 28% in 2006. Although 83% of pediatric orthopaedic surgeons believe that trauma call is an integral part of their practice, only 53% are satisfied with their call experience. Controlling for covariates, believing that call is integral to one's practice doubles odds of call satisfaction. Having resident or fellow support and being financially compensated for orthopaedic trauma call also increases one's odds of satisfaction. The odds of being satisfied with call decrease by 7% for each year of increase in age of the surgeon. CONCLUSIONS: Access to a designated trauma operating room and financial compensation for call coverage have steadily increased over the past decade. A sizable majority of respondents continue to believe that trauma care is an integral part of being a pediatric orthopedist. Despite this, 47% of respondents remain dissatisfied with their trauma call arrangements. The age and attitude of the individual surgeon and extent of hospital support predict satisfaction of surgeons providing trauma coverage. LEVEL OF EVIDENCE: Level V-economic and decision analysis.

Evaluating the Impact of Implementing a Clinical Practice Guideline for Febrile Infants With Positive Respiratory Syncytial Virus or Enterovirus Testing.

OBJECTIVES: To evaluate clinical practice patterns and patient outcomes among febrile low-risk infants with respiratory syncytial virus (RSV) infection or enterovirus (EV) meningitis after implementing a clinical practice guideline (CPG) that provides recommendations for managing febrile infants with RSV infection and EV meningitis. METHODS: Our institution implemented a CPG for febrile infants, which gives explicit recommendations for managing both RSV-positive and EV-positive infants in 2011. We retrospectively analyzed medical records of febrile infants ≤60 days old from June 2008 to January 2013. Among 134 low-risk RSV-positive infants, we compared the proportion of infants who underwent lumbar puncture (LP), the proportion of infants who received antibiotics, antibiotic hours of therapy (HOT), and length of stay (LOS) pre- and post-CPG implementation. Among 274 low-risk infants with EV meningitis, we compared HOT and LOS pre- and post-CPG implementation. RESULTS: Among low-risk RSV-positive patients, the proportion of infants undergoing LP, the proportion of infants receiving antibiotics, HOT, and LOS were unchanged post-CPG. Among low-risk infants with EV meningitis, HOT (79 hours pre-CPG implementation versus 46 hours post-CPG implementation, P < .001) and LOS (47 hours pre-CPG implementation versus 43 hours post-CPG implementation, P = .01) both decreased post-CPG. CONCLUSIONS: CPG implementation is associated with decreased antibiotic exposure and hospital LOS among low-risk infants with EV meningitis; however, there were no associated changes in the proportion of infants undergoing LP, antibiotic exposure, or LOS among low-risk infants with RSV. Further studies are needed to determine specific barriers and facilitators to effectively incorporate diagnostic viral testing into medical decision-making for these infants.

Mixed pathologies including chronic traumatic encephalopathy account for dementia in retired association football (soccer) players.

In retired professional association football (soccer) players with a past history of repetitive head impacts, chronic traumatic encephalopathy (CTE) is a potential neurodegenerative cause of dementia and motor impairments. From 1980 to 2010, 14 retired footballers with dementia were followed up regularly until death. Their clinical data, playing career, and concussion history were prospectively collected. Next-of-kin provided consent for six to have post-mortem brain examination. Of the 14 male participants, 13 were professional and 1 was a committed amateur. All were skilled headers of the ball and had played football for an average of 26 years. Concussion rate was limited in six cases to one episode each during their careers. All cases developed progressive cognitive impairment with an average age at onset of 63.6 years and disease duration of 10 years. Neuropathological examination revealed septal abnormalities in all six post-mortem cases, supportive of a history of chronic repetitive head impacts. Four cases had pathologically confirmed CTE; concomitant pathologies included Alzheimer's disease (N = 6), TDP-43 (N = 6), cerebral amyloid angiopathy (N = 5), hippocampal sclerosis (N = 2), corticobasal degeneration (N = 1), dementia with Lewy bodies (N = 1), and vascular pathology (N = 1); and all would have contributed synergistically to the clinical manifestations. The pathological diagnosis of CTE was established in four individuals according to the latest consensus diagnostic criteria. This finding is probably related to their past prolonged exposure to repetitive head impacts from head-to-player collisions and heading the ball thousands of time throughout their careers. Alzheimer's disease and TDP-43 pathologies are common concomitant findings in CTE, both of which are increasingly considered as part of the CTE pathological entity in older individuals. Association football is the most popular sport in the world and the potential link between repetitive head impacts from playing football and CTE as indicated from our findings is of considerable public health interest. Clearly, a definitive link cannot be established in this clinico-pathological series, but our findings support the need for further systematic investigation, including large-scale case-control studies to identify at risk groups of footballers which will justify for the implementation of protective strategies.

Association of HbA1c to BOLUS Scores Among Youths with Type 1 Diabetes.

BACKGROUND: Frequency of mealtime insulin bolusing (BOLUS) is a promising new objective assessment of adherence in youths with type 1 diabetes (T1D). As further confirmation of the validity of BOLUS, we compare the associations of glycated hemoglobin (HbA1c) values of T1D youths with the original scoring of BOLUS and two alternative scoring procedures: mean mealtime boluses within a 2-h meal window (2h-BOLUS) and total daily frequency of boluses (TOTAL-BOLUS). In addition, we assess HbA1c associations of these three procedures, including interaction terms for mealtime boluses plus correction boluses. SUBJECTS AND METHODS: Blood glucose meter data, insulin pump records, and HbA1c levels were collected from a combined clinical and research database for a random sample of 100 youths (mean age, 12.7 ± 4.6 years). Youths' pump records were scored using the published methodology and alternative procedures for evaluating insulin use. RESULTS: Youths' BOLUS, TOTAL-BOLUS, and mealtime boluses within a 2-h meal window (2h-BOLUS) scores are independently associated with youths' HbA1c level; all measures demonstrated stronger associations with youths' HbA1c than did frequency of glucose monitoring. The strongest association was between youths' BOLUS score and their HbA1c level. In multiple regression analyses, youths' BOLUS score better explains the variations in HbA1c levels than either youths' 2h-BOLUS or TOTAL-BOLUS scores. When combined with BOLUS in the same relationships, 2h-BOLUS and TOTAL-BOLUS were not found to have statistically significant coefficients. None of the bivariate relationships of HbA1c and interaction terms of mealtime and correction boluses was significant. CONCLUSIONS: The original method for calculating BOLUS appears superior to alternative scoring methods in its association with youths' HbA1c levels.

Developing a risk stratification model for predicting future health care use in asthmatic children.

BACKGROUND: Previous studies have stratified pediatric asthma patients for risk of future exacerbation and/or health care use, but most incorporate multiple clinical parameters. OBJECTIVE: To determine whether historical acute care visits (ACVs) alone could predict risk of future health care use. METHODS: Children seen for asthma in an outpatient visit during a 3-year period were identified. The number of ACVs in the 12 months before and after the outpatient visit was determined. Logistic regression models were used to determine the odds of a future ACV. Models were adjusted for age, sex, race, and insurance status. RESULTS: Of 28,047 outpatient visits, 21,099 (75.2%) had no historical ACVs. The probability of a future ACV increased from 30% with one historical ACV to 87% with 5 or more historical ACVs. Outpatient visits with one historical ACV had significantly higher odds of a future ACV compared with those with no historical ACVs (adjusted odds ratio [OR], 3.60; 95% confidence interval [CI], 3.14-4.12; P < .001). The OR increased with each additional historical ACV to an adjusted OR of 58.71 (95% CI, 24.34-141.61; P < .001) with 5 or more historical ACVs. Outpatient visits with 5 or more historical ACVs represented only 1.1% of the study sample but accounted for a higher mean number of future ACVs. CONCLUSION: The historical count of ACVs was predictive of future ACVs. A significant increase in the probability of future ACVs was observed with each additional historical visit, effectively stratifying risk by the historical visit count. Notably, a small group of patients accounted for a disproportionate number of future ACVs.

High hemoglobin A1c variability is associated with early risk of microalbuminuria in children with T1D.

OBJECTIVE: To test the hypothesis that HbA1c variability, as measured by standard deviation (SD), is associated with increased risk for incident microalbuminuria and persistent microalbuminuria in pediatric type 1 diabetes (T1D). METHODS: A retrospective analysis using data from electronic health records was performed on 1195 patients from a pediatric diabetes clinic network in the Midwest USA from 1993 to 2009 with ≥1 yr of T1D, ≥4 total HbA1c values, ≥2 HbA1c values/yr, ≥1 urine microalbumin. Microalbuminuria, the main outcome was defined as albumin excretion rate ≥20 mcg/min or 2 of 3 consecutive urine microalbumin/creatinine ≥30 mg/gm. Patients who had persistently high microalbumin or who were treated with an angiotensin-converting-enzyme inhibitor within 1 yr were considered to have persistent microalbuminuria. Sex, race, age, diagnosis age, and duration were covariates. RESULTS: Median numbers of per-patient HbA1c and microalbumin results were 14 and 3, respectively. Median intrapersonal mean HbA1c and SD were 8.62% (70.72 mol/mol) and 1.47% (16.07 mmol/mol), respectively. The median interquartile range (IQR) of diagnosis age was 9.4 yr (6.26-12.02) and diabetes duration was 4.97 yr (2.93-7.64). A total of 172 patients (14.4%) developed microalbuminuria; 55 (4.6%) had persistent microalbuminuria. Patients with higher SD of HbA1c had shorter time to microalbuminuria. In time-dependent Cox Proportional Hazard models, updated SD of HbA1c was significantly associated with microalbuminuria [univariate hazard ratio (HR) 1.48 (1.25-1.76); multivariable HR 1.28 (1.04-1.58)], whereas updated mean HbA1c was not [univariate HR 1.08 (0.97-1.22); multivariable HR 1.05 (0.92-1.2)]. Patients with persistent microalbuminuria had similar HRs. CONCLUSIONS: HbA1c variability is independently associated with development of microalbuminuria in children with T1D, highlighting the importance of maintaining stable glycemic control in pediatric patients.