"Sometimes Our Mob Don't Really Take It Serious Until It's Serious": The Experiences of Western Australian Aboriginal Adolescents Living With Type 2 Diabetes, Their Parents, and Their Family Members.

OBJECTIVES: In Australia, Aboriginal children experience disproportionate rates of type 2 diabetes (T2D) compared with non-Aboriginal children. The aim of this qualitative study was to explore the experiences of Aboriginal adolescents with T2D and their family members to better understand the influences of T2D on self-management, with findings used to inform an enhanced service model of care. METHODS: Semistructured interviews were conducted with purposively selected Western Australian Aboriginal adolescents with T2D and their parents and guardians. Interviews were transcribed verbatim and analyzed with NVivo software using interpretative thematic analysis; overarching themes were generated. RESULTS: Interviews with 24 participants, including 8 adolescents aged 11 to 16 years, were conducted across 4 regions of Western Australia. A high proportion of these adolescents were diagnosed with T2D during an unrelated hospitalization or medical appointment. Most did not fully understand or were unaware of the long-term impact of T2D. Discussions about diabetes within families did not typically occur, and shame and concealment of the diagnosis was a common finding. The parents of the adolescents described the diagnosis of T2D as compounding an already challenging set of circumstances for the family; this impacted their capacity to promote self-management activities and attend hospital and outpatient appointments. CONCLUSIONS: This study privileges the voices of Aboriginal adolescents and family members and offers insight into their personal narrative of living with T2D. Building family and community capacity to normalize preventive activities and manage T2D postdiagnosis is recommended to improve health outcomes.

Monogenic diabetes due to an INSR mutation in a child with severe insulin resistance.

SUMMARY: We report a case of an 11-year-old girl presenting with a new diagnosis of diabetes associated with a heterozygous missense mutation in the insulin receptor (INSR) gene. This case highlights that INSR gene variants can be a cause for monogenic diabetes in children and adolescents and the need for genetic evaluation in atypical presentations of diabetes. We also describe the possible role of metformin in treating individuals with type A insulin resistance syndrome due to INSR gene variants. LEARNING POINTS: Insulin receptor (INSR) gene variants can be a cause of monogenic diabetes in children and adolescents. Genetic evaluation should be considered in children and adolescents with type 2 diabetes (T2D), particularly where there is an atypical presentation and/or positive family history. Metformin may have a role in the treatment of type A insulin resistance syndrome due to heterozygous mutation of the INSR gene.

Simple scoring tool to estimate risk of hospitalization and mortality in ambulatory and emergency department patients with COVID-19.

BACKGROUND: Accurate methods of identifying patients with COVID-19 who are at high risk of poor outcomes has become especially important with the advent of limited-availability therapies such as monoclonal antibodies. Here we describe development and validation of a simple but accurate scoring tool to classify risk of hospitalization and mortality. METHODS: All consecutive patients testing positive for SARS-CoV-2 from March 25-October 1, 2020 within the Intermountain Healthcare system were included. The cohort was randomly divided into 70% derivation and 30% validation cohorts. A multivariable logistic regression model was fitted for 14-day hospitalization. The optimal model was then adapted to a simple, probabilistic score and applied to the validation cohort and evaluated for prediction of hospitalization and 28-day mortality. RESULTS: 22,816 patients were included; mean age was 40 years, 50.1% were female and 44% identified as non-white race or Hispanic/Latinx ethnicity. 6.2% required hospitalization and 0.4% died. Criteria in the simple model included: age (0.5 points per decade); high-risk comorbidities (2 points each): diabetes mellitus, severe immunocompromised status and obesity (body mass index≥30); non-white race/Hispanic or Latinx ethnicity (2 points), and 1 point each for: male sex, dyspnea, hypertension, coronary artery disease, cardiac arrythmia, congestive heart failure, chronic kidney disease, chronic pulmonary disease, chronic liver disease, cerebrovascular disease, and chronic neurologic disease. In the derivation cohort (n = 16,030) area under the receiver-operator characteristic curve (AUROC) was 0.82 (95% CI 0.81-0.84) for hospitalization and 0.91 (0.83-0.94) for 28-day mortality; in the validation cohort (n = 6,786) AUROC for hospitalization was 0.8 (CI 0.78-0.82) and for mortality 0.8 (CI 0.69-0.9). CONCLUSION: A prediction score based on widely available patient attributes accurately risk stratifies patients with COVID-19 at the time of testing. Applications include patient selection for therapies targeted at preventing disease progression in non-hospitalized patients, including monoclonal antibodies. External validation in independent healthcare environments is needed.

Endothelial function and carotid intima-medial thickness in adolescents with type 2 diabetes mellitus.

OBJECTIVE: We assessed the effect of type 2 diabetes mellitus and obesity on flow-mediated dilation (FMD) and endothelial-dependent vasodilation and carotid intima-medial thickness (cIMT) in young people. STUDY DESIGN: Adolescents were recruited in 3 groups: subjects with type 2 diabetes mellitus (n = 15), subjects who were obese and non-insulin resistant (n = 13), and lean control subjects (n = 13). Body mass index was similar in subjects with obesity and subjects with type 2 diabetes mellitus, but higher compared with that of lean control subjects (both P < .001). Brachial artery FMD and cIMT were assessed by using Duplex ultrasound scanning imaging. RESULTS: There were no significant differences in brachial or common carotid arterial diameters in the groups. cIMT was significantly greater in the group with type 2 diabetes mellitus (0.54 ± 0.01mm) compared with both the lean control (0.46 ± 0.02 mm, P < .001) and obese control (0.46 ± 0.02 mm, P < .01) groups. FMD was significantly decreased in the group with type 2 diabetes mellitus (7.98% ± 0.54%) compared with the lean group (10.40% ± 1.00%, P < .05). CONCLUSIONS: Measures of vascular health were impaired in adolescents with type 2 diabetes mellitus compared with lean and obese adolescents who were not insulin resistant. Measures of arterial function and structure may provide pre-clinical measures of cardiovascular disease in young people at elevated risk.

Developing statewide remdesivir use criteria.

PURPOSE: This report describes our process of 4 health systems coming together to agree on standard use criteria for remdesivir as a coronavirus disease 2019 (COVID-19) treatment for patients in Utah. We hope our process provides a framework for remdesivir use in other states and insights on future use of other therapeutic agents that may also be in short supply, such as vaccines and monoclonal antibodies. SUMMARY: Emergency use authorization (EUA) criteria for COVID-19 treatments often allow for broad use of a treatment relative to limited supplies. Without national criteria, each health system must develop further rationing criteria. Health systems in Utah worked together as part of the state's crisis standards of care workgroup to develop a framework for how to limit the EUA criteria for remdesivir to match available supplies. The 4 largest health systems were represented by infectious diseases specialists, chief medical officers, and pharmacists. The group met several times online and communicated via email over a 9-day period to develop the criteria. The clinicians agreed to use this framework to develop criteria for future therapeutics such as monoclonal antibodies. CONCLUSION: The unique collaboration of the 4 health systems in Utah led to statewide criteria for use of remdesivir for patients with COVID-19, ensuring similar access to this limited resource for all patients in Utah.

Real-world Effectiveness and Tolerability of Monoclonal Antibody Therapy for Ambulatory Patients With Early COVID-19.

BACKGROUND: Neutralizing monoclonal antibodies (MAbs) are a promising therapy for early coronavirus disease 2019 (COVID-19), but their effectiveness has not been confirmed in a real-world setting. METHODS: In this quasi-experimental pre-/postimplementation study, we estimated the effectiveness of MAb treatment within 7 days of symptom onset in high-risk ambulatory adults with COVID-19. The primary outcome was a composite of emergency department visits or hospitalizations within 14 days of positive test. Secondary outcomes included adverse events and 14-day mortality. The average treatment effect in the treated for MAb therapy was estimated using inverse probability of treatment weighting and the impact of MAb implementation using propensity-weighted interrupted time series analysis. RESULTS: Pre-implementation (July-November 2020), 7404 qualifying patients were identified. Postimplementation (December 2020-January 2021), 594 patients received MAb treatment and 5536 did not. The primary outcome occurred in 75 (12.6%) MAb recipients, 1018 (18.4%) contemporaneous controls, and 1525 (20.6%) historical controls. MAb treatment was associated with decreased likelihood of emergency care or hospitalization (odds ratio, 0.69; 95% CI, 0.60-0.79). After implementation, the weighted probability that a given patient would require an emergency department visit or hospitalization decreased significantly (0.7% per day; 95% CI, 0.03%-0.10%). Mortality was 0.2% (n = 1) in the MAb group compared with 1.0% (n = 71) and 1.0% (n = 57) in pre- and postimplementation controls, respectively. Adverse events occurred in 7 (1.2%); 2 (0.3%) were considered serious. CONCLUSIONS: MAb treatment of high-risk ambulatory patients with early COVID-19 was well tolerated and likely effective at preventing the need for subsequent emergency department or hospital care.

Responding to disasters: academic medical centers' responsibilities and opportunities.

Disaster preparedness and disaster response should be a capability of all academic health centers. The authors explore the potential role and impact of academic medical centers (AMC)s in disaster response. The National Disaster Medical System and the evolution of disaster medical assistance teams (DMAT) are described, and the experience at one AMC with DMAT is reviewed. The recent deployment of a DMAT sponsored by an AMC to the Hurricane Katrina disaster is described, and the experience is used to illustrate the opportunities and challenges of future disaster medical training, research, and practice at AMCs. AMCs are encouraged to identify an appropriate academic unit to house and nurture disaster-preparedness activities, participate in education programs for health professionals and the public, and perform research on disaster epidemiology and response. Networks of AMCs offer the potential of acting as a critical resource for those AMCs stricken by a disaster and for communities needing the infusion of highly trained and motivated health care providers. The Association of American Medical Colleges can play a critical role in assisting and coordinating AMC networks through its relationship with all AMCs and the federal government and by increasing the awareness of medical educators and researchers about this important, emerging area of medical knowledge.

Analysis of patients treated during four Disaster Medical Assistance Team deployments.

To aid disaster planning, a retrospective review of patients seen by New Mexico 1 Disaster Medical Assistance Team (NM-1 DMAT) after four disasters was conducted. Data analyzed included age, gender, past medical history, chief complaint, diagnosis, diagnostic testing, treatment, triage category, disposition, and time to presentation after the disaster. Data were analyzed for differences between patients presenting early vs. late after a disaster and to test if availability of diagnostic testing changed patient disposition. The results showed that the majority of patients presented with upper respiratory tract infection symptoms, wounds, and musculoskeletal pain. The needs of patients were similar whether they presented early or late. The same proportion of patients was transferred to hospitals when diagnostic testing was available vs. not available, despite a higher level of acuity when diagnostic testing was available. In conclusion, DMATs should be prepared to see high volumes of low acuity patients. Patient needs do not change with time. Diagnostic testing may be useful.

Higher venous bicarbonate concentration associated with hypoxemia, not acute mountain sickness, after ascent to moderate altitude.

BACKGROUND: The pathophysiology underlying acute mountain sickness (AMS) and excessive hypoxemia at high altitudes is not fully understood. Previous work by our group has demonstrated a significant association between urinary measures of dehydration and bicarbonate retention in subjects developing excessive hypoxemia and AMS at high altitudes. To further characterize these findings, we returned to our original testing site to examine the hypothesis that subjects with lower levels of oxygen saturation and/or AMS would possess higher levels of venous bicarbonate. METHODS: Medical history inquiry, clinical examination, Lake Louise scoring, and the collection of venous levels of bicarbonate concentration and base excess were performed on 52 lowland-dwelling persons after they completed a religious pilgrimage in the Nepal Himalayas to approximately 4,250 m. RESULTS: Oxygen saturation levels were strongly and inversely correlated with serum levels of venous bicarbonate and base excess, whereas AMS and Lake Louise scores were not associated with these measures of alkalosis. CONCLUSIONS: Our data suggest an association between measures of serum bicarbonate anion retention and decreasing oxygen saturation. Our data do not demonstrate an association between AMS or Lake Louise scores and measures of serum bicarbonate level. We propose that excessive hypoxemia at high altitudes may be associated with a compromised ability of the kidney to metabolically compensate for an altitude-induced hypocapnic alkalosis.

Effective healthcare system response to consecutive Florida hurricanes.

In September 2004, two consecutive hurricanes (Hurricane Frances and Hurricane Jeanne) made landfall in Stuart, FL, and created healthcare needs that overtaxed the capacity of the local healthcare system. To determine the character and structure of the response to these hurricanes, researchers from the University of New Mexico, Center for Disaster Medicine conducted both a structured written survey of employees and a guided group interview with healthcare system management. The written survey queried staff on topics related to their ability and willingness to get to work and stay at work during the storms. The roundtable interview with leadership resulted in analysis of the preexisting Emergency Operations Plan and its use during the storms, including preparation and execution of plans for staffing, facility operation, communication, community resource utilization, and recovery. In addition, the interaction with federally deployed Disaster Medical Assistance Teams was documented and reviewed. In general, prior planning on the part of the healthcare system in Stuart, FL, resulted in a successful response to both hurricanes. Employees were willing and able to provide the necessary care for patients during the hurricanes, overcoming many physical and emotional barriers that arose during the month-long response. These barriers included concern for the safety of family and pets, inoperable or insufficient communication methods, and damage to employees' personal property and homes. Recommendations for healthcare system preparedness and response were formulated by the researchers based on this healthcare system's successful response to back-to-back hurricanes, including recommendations for interacting with disaster medical resources.

Changes in metabolic and hematologic laboratory values with ascent to altitude and the development of acute mountain sickness in Nepalese pilgrims.

OBJECTIVE: During August of each year, thousands of Nepalese religious pilgrims ascend from 2050 m to 4500 m in 1 to 3 days. Our objectives were to evaluate the incidence of acute mountain sickness (AMS) among this large group of native people, to explore changes in serum electrolytes as subjects ascend to high altitude, and to attempt to determine whether decreased effective circulating volume is associated with the development of AMS. METHODS: This was a prospective study with 2 parts. In the first part, demographic, physiologic, and laboratory data were collected from a cohort of 34 pilgrims at both moderate (2050 m) and high altitude (4500 m). Changes that occurred with ascent were compared in subjects who did and did not develop AMS. The second part was a cross sectional study of a different group of 57 pilgrims at the high-altitude site to further determine variables associated with AMS. RESULTS: In the cohort of 34 subjects, Lake Louise score, heart rate, respiratory rate, blood urea nitrogen (BUN), BUN:creatinine ratio, and pH increased at high altitude, whereas oxygen saturation, bicarbonate, creatinine, and PCO2 decreased. Sixteen of these 34 subjects (42%) were diagnosed with AMS; these patients had a statistically significantly lower hematocrit, oxygen saturation, and self-reported water consumption than those without AMS. Of the 57 subjects enrolled in the cross sectional study, 31 (54%) were diagnosed with AMS. These pilgrims had higher heart rates and BUNs than did their non-AMS counterparts. CONCLUSIONS: Fifty-two percent of the subjects developed AMS. With ascent to altitude, subjects showed some evidence of decreased effective circulating volume, though there were no clinically significant changes. The data did not show whether decreased circulating volume is a significant risk factor in the development of AMS at high altitude.