Emerging Adults With Type 2 Diabetes: Understanding Illness Experience and Transition to Adult Care.

PURPOSE: Youth-onset type 2 diabetes (T2D) is increasingly common and is often diagnosed shortly before transition from pediatric to adult care. Little is known about the experience of emerging adults (EAs) with T2D and the readiness, barriers, and facilitators to transition. This study sought to describe the illness experience of EAs with T2D and perceptions about transition, and explore themes by "transition readiness," measured by the Transition Readiness Assessment Questionnaire (TRAQ). METHODS: In this mixed-methods study, we conducted semi-structured interviews with EAs with T2D using a guide grounded in the health belief model, administered the TRAQ, and collected disease metrics from the electronic medical record. We developed a coding scheme using a directed content-analysis approach and triangulated qualitative and quantitative data to compare themes stratified by mean TRAQ score. RESULTS: Participants described modifying factors like adjusting to life with a chronic illness and coping with mental health issues as critical elements of the illness experience that influence transition. Individual beliefs emerged including the perceived risk of disease complications being informed by experience of family members, self-efficacy in diabetes care hinging on the ability to be highly organized, and transition as a daunting obstacle with numerous emotional and logistical barriers. Participants emphasized the need for support from caregivers and providers throughout transition. Themes did not vary significantly by TRAQ score. DISCUSSION: Experiences of EAs with T2D suggest more assistance is needed in the transition period to address factors such as mental health, organizational skills, and identifying support people to facilitate care.

Adolescent Preferences for a Pediatric Primary Care-based Sexually Transmitted Infection and HIV Prevention Intervention.

PURPOSE: We sought to elicit perspectives on HIV and sexually transmitted infection (STI) prevention among adolescents with recent STIs in primary care to optimize acceptability and effectiveness in designing a novel HIV/STI prevention intervention. METHODS: We enrolled 13-19 year-olds with recent gonorrhea, chlamydia, trichomonas, and/or syphilis in a multimethods cross-sectional study at two primary care clinics. Participants completed surveys and interviews. We used an integrated analytic approach deductively coding data using the Integrated Behavioral Model, then inductively coding to identify themes not represented in the Integrated Behavioral Model. RESULTS: Participants (n = 35) were 85% cisgender female, 14% cisgender male, 1% transgender female; 25% identified as lesbian, bisexual, or queer. Most (97%) identified as non-Latinx Black. None used condoms consistently, 26% were aware of pre-exposure prophylaxis (PrEP), and 31% were never HIV tested. Five key themes emerged. 1) Mental health was central to HIV prevention behavior uptake and coping with STI diagnosis. 2) Youth desired prevention counseling that allowed decisional autonomy and individualized goal setting. 3) Negative social norms around condoms and absent norms around HIV testing and PrEP limited method uptake. 4) Both confidence and concrete skills were needed to initiate prevention methods. 5) Youth desired education at the time of STI diagnosis to improve subsequent prevention decision making. DISCUSSION: Key intervention design considerations included 1) integrating mental health assessment and referral to services, 2) promoting individualized goal setting, 4) building communication skills, 4) providing navigation and material support for PrEP uptake and HIV testing, and 5) augmenting comprehensive STI and HIV prevention education.

A Social Network Analysis of a Multi-sector Service System for Intimate Partner Violence in a Large US City.

About one in four women in the US report having experienced some form of intimate partner violence (IPV) during their lifetime and an estimated 15.5 million children live in families in which IPV occurred in the past year. Families of young children with IPV experiences often face complex needs and require well-coordinated efforts among service providers across social and health sectors. One promising partnership aims to support pregnant and parenting IPV survivors through coordination between IPV agencies and community-based maternal and early childhood home visiting programs. This study used social network analysis (SNA) to understand the interconnectedness of the system of IPV prevention and intervention for families with young children in a large US city. The SNA included 43 agencies serving this population across various service domains spanning IPV, legal, maternal and child health, and public benefit programs. An SNA survey collected data on four forms of collaboration between agencies, including formal administrative relationship, referral reciprocity, case consultation, and shared activities in community committees/organizing bodies. Density and centrality were the primary outcomes of interest. A community detection analysis was performed as a secondary analysis. The overall level of interconnectedness between the 43 responding agencies was low. Making referrals to each other was the most common form of collaboration, with a network density of 30%. IPV agencies had the highest average number of connections in the networks. There was a high level of variation in external collaborations among home visiting agencies, with several home visiting agencies having very few connections in the community but one home visiting program endorsing collaborative relationships with upwards of 38 partner agencies in the network. In serving families at risk for IPV, home visiting agencies were most likely to have referral relationships with mental health provider agencies and substance use disorder service agencies. A community detection analysis identified distinct communities within the network and demonstrated that certain agency types were more connected to one another while others were typically siloed within the network. Notably, the IPV and home visiting communities infrequently overlapped. Sensitivity analyses showed that survey participants' knowledge of their agencies' external collaborations varied by their work roles and agencies overall had low levels of consensus about their connectedness to one another. We identified a heterogeneous service system available to families of young children at-risk for or experiencing IPV. Overall inter-agency connectedness was low, with many siloed agencies and a lack of shared knowledge of community resources. Understanding current collaborations, silos, and centrality of agencies is an effective public health tool for allocating scarce resources across diverse service sectors to efficiently improve the system serving families experiencing IPV.

Eligibility, Utilization, and Effectiveness of 17-Alpha Hydroxyprogesterone Caproate in a Statewide Population-Based Cohort of Medicaid Enrollees.

OBJECTIVE: The primary objective was to estimate the initiation and adherence rates of 17 α-hydroxyprogesterone caproate (17OHPC) among eligible mothers in a statewide population-based cohort of Medicaid enrollees. The secondary objectives were to (1) determine the association of maternal sociodemographic and clinical characteristics with 17OHPC utilization and (2) assess the real-world effectiveness of 17OHPC on recurrent preterm birth prevention and admission to neonatal intensive care unit (NICU). STUDY DESIGN: This is a retrospective cohort study using a linked, longitudinal administrative dataset of birth certificates and medical assistance claims. Medicaid-enrolled mothers in Pennsylvania were included in this study if they had at least one singleton live birth from 2014 to 2016 following at least one spontaneous preterm birth. Maternal Medicaid claims were used to ascertain the use of 17OHPC from various manufacturers, including compounded formulations. Propensity score matching was used to create a covariate balance between 17OHPC treatment and comparison groups. RESULTS: We identified 4,781 Medicaid-covered 17OHPC-eligible pregnancies from 2014 to 2016 in Pennsylvania, 3.4% of all Medicaid-covered singleton live births. The population-based initiation rate was 28.5% among eligible pregnancies. Among initiators, 50% received ≥16 doses as recommended, while 10% received a single dose only. The severity of previous spontaneous preterm birth was the strongest predictor for the initiation and adherence of 17OHPC. In the matched treatment (n = 1,210) and comparison groups (n = 1,210), we found no evidence of 17OHPC effectiveness. The risks of recurrent preterm birth (relative risk [RR] 1.10, 95% confidence interval [CI] 0.97-1.24) and births admitted to NICU (RR 1.00, 95% CI 0.84-1.18) were similar in treated and comparison mothers. CONCLUSION: The 17OHPC-eligible population represented 3.4% of singleton live births. Less than one-third of eligible mothers initiated treatment. Among initiators, 50% were treatment adherent. We found no difference in the risk of recurrent preterm birth or admission to NICU between treatment and comparison groups. KEY POINTS: · About 3.4% of singleton live births were eligible for 17OHPC.. · About 30% of eligible mothers initiated treatment.. · We found no association of 17OHPC with recurrent preterm birth..

A Qualitative Study of Resident Experiences With Clinical Event Debriefing.

OBJECTIVES: The facilitated discussion of events through clinical event debriefing (CED) can promote learning and wellbeing, but resident involvement is often limited. Although the graduate medical education field supports CED, interventions to promote resident involvement are limited by poor insight into how residents experience CED. The objective of this study was to characterize pediatric resident experiences with CED, with a specific focus on practice barriers and facilitators. METHODS: We conducted this qualitative study between November and December 2020 at a large, free-standing children's hospital. We recruited pediatric residents from postgraduate years 1 to 4 to participate in virtual focus groups. Focus groups were digitally recorded, deidentified, and transcribed. Transcripts were entered into coding software for analysis. We analyzed the data using a modified grounded theory approach to identify major themes. RESULTS: We conducted 4 mixed-level focus groups with 26 residents. Our analysis identified multiple barriers and facilitators of resident involvement in CED. Several barriers were logistical in nature, but the most salient barriers were derived from unique features of the resident role. For example, residents described the transience of their role as a barrier to both participating and engaging in CED. However, they described advancing professional experience and the desire for reflective learning as facilitators. CONCLUSIONS: Residents in this study highlighted many factors affecting their participation and engagement in CED, including barriers related to the unique features of their role. On the basis of resident experiences, we propose several recommendations for CED practice that graduate medical education programs and hospitals should consider for supporting resident involvement in CED.

Low-income parents' perceptions of a sweetened beverage tax in Philadelphia.

Objective: To characterise perceptions of the Philadelphia Beverage Tax among low-income parents. Design: We conducted semi-structured interviews and administered demographic questions via telephone. We based the interview guide and initial codebook on a conceptual model illustrating perceived fairness and effectiveness as essential for successfully adopting food policies. We performed thematic analysis using NVivo 12. Setting: We recruited from a primary care paediatrics clinic in Philadelphia, Pennsylvania from July to August 2020. Participants: Philadelphia parents/caregivers of 2- to 11-year-old children with Medicaid insurance. Results: Participants were predominantly African American (97 %), female (100 %), and had annual household incomes <$50 000 (80 %). Participants were 26- to 72-years old, with an average aged child of 5 years (range 7 months to 20 years). Themes emerged regarding tax perceptions, revenue use and behaviour change due to the tax. Using revenue for highly valued programmes and accountability of city government to use revenue as promised were critical elements in perceptions of tax fairness. Some parents avoided the tax through cross-border shopping and buying drink powders or concentrates, influencing perceptions of tax effectiveness. The tax signalled the health dangers of sweetened beverage consumption to most parents. Conclusion: Our findings bring to light four key takeaways for policymakers designing sweetened beverage taxes. (1) Dedication of tax revenue to programmes highly valued by parents and (2) transparency in revenue spending may improve acceptability. (3) State or national taxes may be more effective at decreasing consumption due to cross-border shopping. (4) Pairing taxes with health promotion campaigns may enhance behaviour change.

A Rare Case of Non-IUD-Related Chronic Endometritis caused by Actinomyces Bacteria in a Postmenopausal Woman: A Case Report.

Pelvic actinomycosis is a rare condition, usually associated with intrauterine device (IUD) use. Its clinical presentation may vary from being asymptomatic to the mimicking of pelvic malignancy; it has been described as one of the most misdiagnosed diseases. A 78-year-old woman without a history of IUD use, arrived at our clinic complaining of chronic and intermittent postmenopausal bleeding associated with lower pelvic pain. An endometrial curettage was performed, and endometritis (caused by Actinomyces) identified. Treatment with intravenous piperacillin and tazobactam for 7 days, followed by 6 weeks of oral ampicillin, daily, decreased the bleeding and the pain. Although rare, it is important to consider Actinomyces-related endometritis as a differential diagnosis in cases of elderly woman with postmenopausal bleeding and without a history of IUD use.

From the Frontlines: A Qualitative Study of Staff Experiences With Clinical Event Debriefing.

OBJECTIVES: Clinical event debriefing (CED) can improve patient care and outcomes, but little is known about CED across inpatient settings, and participant experiences have not been well described. In this qualitative study, we sought to characterize and compare staff experiences with CED in 2 hospital units, with a goal of generating recommendations for a hospital-wide debriefing program. METHODS: We conducted 32 semistructured interviews with clinical staff who attended a CED in the previous week. We explored experiences with CED, with a focus on barriers and facilitators. We used content analysis with constant comparative coding to understand priorities identified by participants. We used inductive reasoning to develop a set of CED practice recommendations to match participant priorities. RESULTS: Three primary themes emerged related to CED barriers and facilitators. (1) Factors affecting attendance: most respondents voiced a need for frontline staff inclusion in CED, but they also cited competing clinical duties and scheduling conflicts as barriers. (2) Factors affecting participant engagement: respondents described factors that influence participant engagement in reflective discussion. They described that the CED leader must cultivate a psychologically safe environment in which participants feel empowered to speak up, free from judgment. (3) Factors affecting learning and systems improvement: respondents emphasized that the CED group should generate a plan for improvement with accountable stakeholders. Collectively, these priorities propose several recommendations for CED practice, including frontline staff inclusion. CONCLUSIONS: In this study, we propose recommendations for CED that are derived from first-hand participant experiences. Future study will explore implementation of CED practice recommendations.

Patient and Provider Perspectives on Acceptability, Access, and Adherence to 17-Alpha-Hydroxyprogesterone Caproate for Preterm Birth Prevention.

Background: Preterm birth (PTB) is a pressing maternal and child health issue with long-standing racial inequities in outcomes and care provision. 17-Alpha-hydroxyprogesterone caproate (17OHPC) has been one of few clinical interventions for recurrent PTB prevention. Little is known about the factors influencing successful administration and receipt of 17OHPC among mothers in the Medicaid program. Materials and Methods: We conducted individual semistructured interviews with 17OHPC-eligible pregnant women and obstetric providers from two academic medical centers in Philadelphia, PA. Patient participants were publicly insured, eligible for 17OHPC treatment, and purposively sampled as either (1) actively receiving treatment or (2) declining/discontinuing treatment. Providers had experience providing care to Medicaid-enrolled patients. Interview transcripts were coded and analyzed to identify themes related to treatment acceptability, access, and adherence. Results: Of the 17 patient participants, the mean age was 30 years. Ten providers (MDs, nurse practitioners, and registered nurses) were also interviewed. Factors facilitating 17OHPC uptake and adherence among patients included severity of prior PTB, provider counseling, and coordination among the clinic, pharmacy, and insurance. Pain was cited as the most significant barrier to 17OHPC for patients, while providers perceived social adversity and beliefs about patients' commitment to treatment to be primary patient barriers. For providers, clinical experience and practice guidelines contributed to their use of 17OHPC. Administrative complexity and coordination of services were the primary provider barrier to 17OHPC administration. Conclusions: Patient-provider communication is a primary driver of 17OHPC acceptability and adherence. Comprehensive patient-centered consultation may improve uptake of clinical therapies among pregnant women at high risk for PTB.

Insulin actions on hypothalamic glucose-sensing neurones.

Subsequent to the discovery of insulin 100 years ago, great strides have been made in understanding its function, especially in the brain. It is now clear that insulin is a critical regulator of the neuronal circuitry controlling energy balance and glucose homeostasis. This review focuses on the effects of insulin and diabetes on the activity and glucose sensitivity of hypothalamic glucose-sensing neurones. We highlight the role of electrophysiological data in understanding how insulin regulates glucose-sensing neurones. A brief introduction describing the benefits and limitations of the major electrophysiological techniques used to investigate glucose-sensing neurones is provided. The mechanisms by which hypothalamic neurones sense glucose are discussed with an emphasis on those glucose-sensing neurones already shown to be modulated by insulin. Next, the literature pertaining to how insulin alters the activity and glucose sensitivity of these hypothalamic glucose-sensing neurones is described. In addition, the effects of impaired insulin signalling during diabetes and the ramifications of insulin-induced hypoglycaemia on hypothalamic glucose-sensing neurones are covered. To the extent that it is known, we present hypotheses concerning the mechanisms underlying the effects of these insulin-related pathologies. To conclude, electrophysiological data from the hippocampus are evaluated aiming to provide clues regarding how insulin might influence neuronal plasticity in glucose-sensing neurones. Although much has been accomplished subsequent to the discovery of insulin, the work described in our review suggests that the regulation of central glucose sensing by this hormone is both important and understudied.

d-Glyceric aciduria does not cause nonketotic hyperglycinemia: A historic co-occurrence.

Historically, d-glyceric aciduria was thought to cause an uncharacterized blockage to the glycine cleavage enzyme system (GCS) causing nonketotic hyperglycinemia (NKH) as a secondary phenomenon. This inference was reached based on the clinical and biochemical results from the first d-glyceric aciduria patient reported in 1974. Along with elevated glyceric acid excretion, this patient exhibited severe neurological symptoms of myoclonic epilepsy and absent development, and had elevated glycine levels and decreased glycine cleavage system enzyme activity. Mutations in the GLYCTK gene (encoding d-glycerate kinase) causing glyceric aciduria were previously noted. Since glycine changes were not observed in almost all of the subsequently reported cases of d-glyceric aciduria, this theory of NKH as a secondary syndrome of d-glyceric aciduria was revisited in this work. We showed that this historic patient harbored a homozygous missense mutation in AMT c.350C>T, p.Ser117Leu, and enzymatic assay of the expressed mutation confirmed the pathogeneity of the p.Ser117Leu mutation. We conclude that the original d-glyceric aciduria patient also had classic NKH and that this co-occurrence of two inborn errors of metabolism explains the original presentation. We conclude that no evidence remains that d-glyceric aciduria would cause NKH.