Association of stigma, diabetes distress and self-efficacy with quality of life in adolescents with type 1 diabetes preparing to transition to adult care.

AIMS: In type 1 diabetes (T1D), psychosocial factors may impact quality of life (QOL) and clinical outcomes, but remain understudied, particularly during late adolescence. Our aim was to determine whether stigma, diabetes distress and self-efficacy are associated with QOL in adolescents with T1D as they are preparing to transition to adult care. METHODS: We conducted a cross-sectional study of adolescents (ages 16-17 years) with T1D participating in the Group Education Trial to Improve Transition (GET-IT) in Montreal, Canada. Participants completed validated questionnaires on stigma using the Barriers to Diabetes Adherence (BDA) stigma subscale, self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1-10), diabetes distress (Diabetes Distress Scale for Adults with type 1 diabetes) and QOL (Pediatric Quality of Life Inventory [PedsQL] 4.0 Generic Core Scale and PedsQL 3.2 Diabetes Module). We examined associations of stigma, diabetes distress and self-efficacy with QOL using multivariate linear regression models adjusted for sex, diabetes duration, socioeconomic status and HbA1c. RESULTS: Of 128 adolescents with T1D, 76 (59%) self-reported having the diabetes-related stigma and 29 (22.7%) reported experiencing diabetes distress. Those with stigma had lower diabetes-specific and general QOL scores compared with those without stigma, and stigma and diabetes distress were both associated with lower diabetes-specific QOL and lower general QOL. Self-efficacy was associated with higher diabetes-specific and general QOL. CONCLUSIONS: Stigma and diabetes distress are associated with lower QOL, whereas self-efficacy is associated with higher QOL in adolescents with T1D preparing to transfer to adult care.

Diabetes duration, perceived comfort with self-management and glycaemic control in adolescents with type 1 diabetes: A cross-sectional study.

AIMS: Evidence is lacking on whether diabetes duration is associated with type 1 diabetes (T1D) self-management during late adolescence before transfer from paediatric to adult care. We examined associations of diabetes duration with dimensions of perceived comfort with diabetes self-management (self-efficacy, transition readiness, diabetes distress) and glycaemic control in late adolescence. METHODS: Using a cross-sectional design, we conducted a secondary analysis of baseline data of adolescents (ages 16-17 years) with T1D followed at paediatric diabetes academic hospitals in Montreal and enrolled in the Group Education Trial to Improve Transition (GET-IT-T1D). Participants completed validated questionnaires on self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1 to 10), diabetes distress and transition readiness, as well as a haemoglobin (HbA1c) capillary blood test. Our primary outcome was self-efficacy. We examined associations of diabetes duration with self-efficacy, diabetes distress, transition readiness and HbA1c using linear and logistic regression models adjusted for sex, socioeconomic status, insulin pump use, glucose sensor use and psychiatric comorbidity. RESULTS: Of 203 adolescents with T1D, mean diabetes duration (SD) was 7.57 (4.44) years. Mean SEDM score was 6.83 (SD 1.62). Diabetes duration was not associated with self-efficacy, diabetes distress or transition readiness. Each additional year of diabetes duration was associated with 0.11% (95% CI, 0.05 to 0.16) higher HbA1c. CONCLUSIONS: Although diabetes duration is not associated with dimensions of perceived comfort with diabetes self-management, adolescents with longer diabetes duration are at risk for higher HbA1c and may need additional support to improve glycaemic control before transition to adult care.

Qualitative study exploring the perspectives of emerging adults with type 1 diabetes after transfer to adult care from a paediatric diabetes centre in Montreal, Canada.

INTRODUCTION: Among youth living with type 1 diabetes (T1D), the increasing demands to diabetes self-care and medical follow-up during the transition from paediatric to adult care has been associated with greater morbidity and mortality. Inadequate healthcare support for youth during the transition care period could exacerbate psychosocial risks and difficulties that are common during emerging adulthood. The current investigation sought to explore the post-transfer perceptions of emerging adults living with T1D relating to their transition to adult care. RESEARCH DESIGN AND METHODS: Thirty-three emerging adults living with T1D were recruited during paediatric care and contacted for a semistructured interview post-transfer to adult care (16.2±4.2 months post-transfer) in Montreal, Canada. We analysed data using thematic analysis. RESULTS: We identified four key themes: (1) varied perceptions of the transition process from being quick and abrupt with minimal advice or information from paediatric healthcare providers (HCP) to more positive including a greater motivation for self-management and the transition being concurrent with the developmental period; (2) facilitators to the transition process included informational and tangible social support from HCPs and family or friends, a positive relationship with adult HCP and a greater ease in communicating with the adult care clinic or adult HCP; (3) barriers to adequate transition included lack of advice or information from paediatric HCPs, loss of support from HCPs and friends or family, the separation of healthcare services and greater difficulty in making appointments with adult clinic or HCP and (4) participants recommendations for improving the transition included increasing the length and frequency of appointments in adult care, having access to educational information, and better transition preparation from paediatric HCPs. CONCLUSIONS: The experiences and perceptions of emerging adults are invaluable to guide the ongoing development and improvement of transition programmes for childhood-onset chronic illnesses.

Text message-based intervention, Keeping in Touch (KiT), to support youth as they transition to adult type 1 diabetes care: a protocol for a multisite randomised controlled superiority trial.

INTRODUCTION: Transition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial. METHODS AND ANALYSIS: We will randomise 183 adolescents with T1D aged 17-18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes. ETHICS AND DISSEMINATION: The study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05434754.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care.

OBJECTIVES: As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care. METHODS: We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity. RESULTS: One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted ß=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted ß=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted ß=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted ß=-0.01; 95% CI, -0.03 to -0.00). CONCLUSION: Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.

Association of accelerometry-derived social jetlag and sleep with temperament in children less than 6 years of age.

STUDY OBJECTIVES: Social jetlag (SJL) measures the discrepancy between circadian and social clocks. Using accelerometry-derived data, our objective was to assess the prevalence of SJL in young healthy children and determine the association of SJL and sleep with temperament. METHODS: Of 117 children participating in TARGet Kids!, a Canadian cohort of healthy preschool-aged children, 78 children (39 girls; 50%; mean age [SD]: 35.1 [20.5] months) were included. Sleep was measured objectively using accelerometry. Temperament dimensions (surgency, negative affectivity, and effortful control) were assessed with the very short forms of Rothbart's child and infant behavior questionnaires. We examined associations of SJL and sleep with temperament using multivariable linear regression models adjusted for sex, age, ethnicity, and preschool/daycare attendance. RESULTS: 20 out of 78 (25.6%) experienced SJL of greater than 30 minutes. SJL was greater in children who attended preschool/daycare compared with children who did not (26.3[18.8] minutes vs 17.6 [14.8] minutes; P < .05). There was no evidence of an association between SJL and any temperament dimension. We found evidence of an association between increased sleep duration and increased negative affectivity scores (longer 24-hour sleep; ß: 0.347; 95% confidence interval: 0.182, 0.512; P < .0001; and longer nighttime sleep duration: ß: 0.413; 95% confidence interval: 0.163, 0.663; P = .002). CONCLUSIONS: In our cohort, 1 in 4 preschool-aged children experienced SJL. Increased sleep duration was associated with increased negative affect, which could have implications for children developing internalizing behavior such as depression or low self-esteem. We found that sleep duration, but not SJL, was associated with temperament and may impact daytime behavior of young children. CITATION: Giannoumis M, Mok E, Borkhoff CM, et al. Association of accelerometry-derived social jetlag and sleep with temperament in children less than 6 years of age. J Clin Sleep Med. 2022;18(8):1993-1999.

Increasing Incidence of Type 1 and Type 2 Diabetes Among Canadian Children.

BACKGROUND: Diabetes mellitus is one of the most common pediatric chronic illnesses. Although a rising incidence of childhood type 1 diabetes (T1D) has frequently been documented, an almost 400-fold variation in incidence has been seen worldwide. We aimed to describe the trends in incidence of diabetes (type 1, type 2, all types) among children and adolescents living in the Greater Montréal area of Québec, Canada. METHODS: Using health administrative data (Québec Integrated Chronic Disease Surveillance System) and medical records from the 3 major pediatric diabetes centres in the Greater Montréal area, we conducted serial cross-sectional studies of children aged 1 to 15 years during the period from 2002 to 2010. We conducted a trend analysis of diabetes incidence over time using multivariate Poisson regression models. RESULTS: We identified 696 new cases of diabetes between 2002 and 2010. The age-standardized incidence of diabetes (all types) increased from 16.3 (95% confidence interval [CI], 12.4 to 21.2) to 27.8 (95% CI, 22.5 to 34.0) per 100,000, with annual incidence increasing, on average, by 5.2% per year (adjusted rate ratio [aRR], 1.052; 95% CI, 1.022 to 1.083). This was driven predominantly by the T1D annual increase of 5.4% (aRR, 1.054; 95% CI, 1.023 to 1.086). A low number of incident cases of type 2 diabetes limited trend analysis in this group. There were no significant interactions between year and sex or age. CONCLUSIONS: The annual incidence of T1D is increasing in Québec children and does not vary by sex or age. Further research into etiologic factors is indicated.

Association of Self-Efficacy, Transition Readiness and Diabetes Distress With Glycemic Control in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care.

OBJECTIVES: Adolescence and emerging adulthood are associated with inadequate medical follow up, suboptimal glycemic control and higher risk for adverse outcomes. Our aim in this study was to determine whether self-efficacy, transition readiness or diabetes distress is associated with glycemic control (glycated hemoglobin [A1C]) among adolescents with type 1 diabetes (T1D) preparing to transition to adult care. METHODS: We conducted a cross-sectional study of adolescents (age 17 years) with T1D followed at the Montreal Children's Hospital Diabetes Clinic 1 year before transferring to adult care. Participants completed validated questionnaires on self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1 to 10), transition readiness (Am I ON TRAC? For Adult Care questionnaire [TRAC], score ≥8 indicates readiness) and diabetes distress (Diabetes Distress Scale for Adults with Type 1 Diabetes [T1-DDS], score ≥3 indicates distress). The primary outcome was A1C (%) 1 year before transfer. We examined associations of self-efficacy, transition readiness and diabetes distress with A1C using multivariate linear and logistic regression models adjusted for sex, age at diagnosis and socioeconomic status. RESULTS: Of 74 adolescents with T1D (29 males, 39.1%), 27 (36.4%) had suboptimal glycemic control (A1C ≥9.0%). Less than half were transition-ready (TRAC questionnaire score ≥8) and 14% had diabetes distress (T1-DDS score ≥3). SEDM was not associated with A1C. Adolescents considered ready for transition were less likely to have suboptimal glycemic control (odds ratio, 0.30; 95% confidence interval, 0.09 to 0.99), whereas adolescents with diabetes distress were more likely to have suboptimal glycemic control (odds ratio, 6.24; 95% confidence interval, 1.06 to 36.75). CONCLUSIONS: Improving health-care transition within pediatric care should focus on both transition readiness and diabetes distress to help improve adolescents' glycemic control and prepare them for adult care.

Group education for adolescents with type 1 diabetes during transition from paediatric to adult care: study protocol for a multisite, randomised controlled, superiority trial (GET-IT-T1D).

INTRODUCTION: Transition from paediatric to adult care is challenging for adolescents and emerging adults (ages 18 to 30 years) with type 1 diabetes (T1D). This transition is characterised by a deterioration in glycaemic control (haemoglobin A1c (HbA1c)), decreased clinical attendance, poor self-management and increased acute T1D-related complications. However, evidence to guide delivery of transition care is lacking. Given the effectiveness of group education in adult diabetes glycaemic control and improvements in qualitative measures in paediatric diabetes, group education is a potentially feasible and cost-effective alternative for the delivery of transition care. In emerging adults with T1D, we aim to assess the effectiveness of group education visits compared with usual care on HbA1c, T1D-related complications, psychosocial measures and cost-effectiveness after the transfer to adult care. METHODS AND ANALYSIS: In a multisite, assessor-blinded, randomised, two-arm, parallel-group, superiority trial, 212 adolescents with T1D (ages 17 years) are randomised to 12 months group education versus usual T1D care before transfer to adult care. Visits in the active arm consist of group education sessions followed by usual T1D care visits every 3 months. Primary outcome is change in HbA1c measured at 24 months. Secondary outcomes are delays in establishing adult diabetes care, T1D-related hospitalisations and emergency department visits, severe hypoglycaemia, stigma, self-efficacy, diabetes knowledge, transition readiness, diabetes distress, quality of life and cost-effectiveness at 12 and 24 months follow-up. Analysis will be by intention-to-treat. Change in HbA1c will be calculated and compared between arms using differences (95% CI), along with cost-effectiveness analysis. A similar approach will be conducted to examine between-arm differences in secondary outcomes. ETHICS AND DISSEMINATION: The study was approved by McGill University Health Centre Research Ethics Board (GET-IT/MP-37-2019-4434, version 'Final 1.0 from November 2018). Study results will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03703440.

A systematic review and meta-analysis of the prevalence of sleep problems in children with cerebral palsy: how do children with cerebral palsy differ from each other and from typically developing children?

BACKGROUND: Up to 85% of children with neurodevelopmental disorders have sleep problems, compared with 25% of typically developing children. Children with cerebral palsy (CP)may have risk factors (brain injury, physical disability, and comorbidities) that make them more likely to have sleep problems compared with typically developing children. OBJECTIVE: To determine prevalence of sleep problems in children with CP. METHODS: We conducted a systematic review and meta-analysis to report on the prevalence of sleep problems in children with CP, within subgroups (age, CP phenotype, presence of impairments [auditory, visual, and cognitive], and presence of epilepsy) and compared with control groups of healthy children. We searched eight relevant electronic databases from their respective start dates until September 2018. RESULTS: 23 full-text articles (n=2,908 children with CP) were included in the review. All studies were cross-sectional and examined caregiver-reported sleep measures. The Sleep Disturbance Scale for Children (SDSC) was the most commonly used questionnaire. No study met all Joanna Briggs Institute quality assessment criteria for prevalence studies; selection, coverage, classification, and/or confounding biases were present in all studies. Using a random effects model with a Freeman-Tukey double arcsine transformation, the pooled prevalence was 23.4% (95% confidence interval [CI] 18.8-28.4%; n=9 studies) for an abnormal total score on the SDSC and 26.9% (95% CI 21.5-32.7%; n=9 studies) for disorders of initiation and maintenance of sleep, the most prevalent sleep problem reported. For the studies that reported prevalence for control groups of healthy children (n=4 studies), sleep problems were generally more prevalent in the CP group. CONCLUSION: The prevalence of sleep problems in children with CP is high. There is notable variability in the prevalence of sleep problems between subgroups of children with CP. Future studies using questionnaires validated in children with CP and objective measures (such as polysomnography or actigraphy) in well-described, large, broadly recruited samples are recommended.

Behavioral difficulties, sleep problems, and nighttime pain in children with cerebral palsy.

BACKGROUND: Children with cerebral palsy (CP) may be at risk of behavioral difficulties. AIMS: 1) Determine the prevalence of behavioral difficulties in preschool- and school-aged children with CP and 2) Assess the association between behavioral difficulties and a) sleep problems, b) nighttime pain and c) child characteristics (age, CP phenotype, comorbidities). METHODS AND PROCEDURES: Caregivers of 113 children with CP aged 4-12 years [mean (SD) age = 7.4 (2.5) years; 61.9% male] completed the Strengths and Difficulties Questionnaire, Sleep Disturbance Scale for Children and a sleep quality questionnaire to assess child behavior, sleep and nighttime pain, respectively. OUTCOMES AND RESULTS: 25.6% of children (17.6% preschool-aged; 29.1% school-aged) had behavioral difficulties. Sleep problems (odds ratio [OR] 9.1, 95% confidence interval [CI] 3.4-24.4) and nighttime pain (OR 4.1, 95% CI 1.5-11.5) were associated with behavioral difficulties. Sleep problems remained significantly associated with behavioral difficulties (adjusted OR 7.5, 95% CI 2.6-21.4) when adjusted for nighttime pain, age and non-ambulatory status. CONCLUSIONS AND IMPLICATIONS: Behavioral difficulties were reported in one in four children with CP and were associated with sleep problems and nighttime pain. Identifying and treating behavioral difficulties, sleep problems or nighttime pain is important in the care of children with CP.

Health-related quality of life in Canadian children with cerebral palsy: what role does sleep play?

OBJECTIVE: To evaluate, in Canadian children with cerebral palsy (CP): (1) health-related quality of life (HRQoL) as well as (2) associations between HRQoL and (a) sleep problems, (b) nighttime pain, and (c) child characteristics (eg, age, CP phenotype, comorbidities). METHODS: Children aged 3-12 years were recruited from neurology clinics and a provincial CP registry. Caregivers completed the Pediatric Quality of Life Inventory (PedsQL) Generic Core and CP Modules as well as the Sleep Disturbance Scale for Children (SDSC) to assess HRQoL and sleep, respectively. Child characteristics were extracted from hospital records and registry data. RESULTS: A total of 146 children with CP (mean age ± standard deviation: 6.9 ± 2.9 years) completed the study. Impaired HRQoL (scores more than 2 SDs below the normative population mean) on the PedsQL Total, Physical and Psychosocial Health scales was found in 33.6%, 38.4% and 17.6% of children, respectively. Non-ambulatory status, sleep problems and significant comorbidity were the strongest predictors of impaired Total HRQoL, with odds ratios (95% confidence intervals) of 30.1 (8.2-110.4), 3.8 (1.1-12.5) and 3.3 (1.2-9.2), respectively, adjusted for young age (5-7 years) and nighttime pain. Non-ambulatory status and sleep problems exclusively increased the risk of impaired physical and psychological health, respectively, with adjusted ORs (95% CIs) of 58.3 (11.9-284.5) and 7.5 (2.5-22.5). More severe sleep problems were associated with worse pain-related HRQoL. CONCLUSIONS: Sleep, non-ambulatory status and presence of comorbidities are important determinants of HRQoL in children with CP. Monitoring sleep, psychosocial functioning and pain is important in this population, as their management should improve HRQoL.

Prevalence of sleep problems and sleep-related characteristics in preschool- and school-aged children with cerebral palsy.

OBJECTIVES: To determine, in preschool- and school-aged children with cerebral palsy (CP): (i) the prevalence of sleep disorders, including disorders of initiation and maintenance of sleep, and (ii) the association between child characteristics and sleep disorders. METHODS: Children with CP aged 3-12 years were recruited from neurology clinics and a provincial CP registry. Caregivers completed the Sleep Disturbance Scale for Children (SDSC) and a questionnaire on sleep-related characteristics. Children's medical information was collected from the registry and hospital records. RESULTS: 150 children with CP (mean age ± standard deviation: 6.9 ± 2.9 years) completed the study (66 preschool-and 84 school-aged children). An abnormal total score on the SDSC was found in 20.7% of children (10.6% and 28.6% of preschool-and school-aged children, respectively). Overall, 44.0% of children had one or more sleep disorder (24.2% and 59.5% in preschool-and school-aged children, respectively), as determined by subscales of the SDSC. The most common sleep problem, disorders of initiation and maintenance of sleep, was found in 26.0% of children (18.2% of preschool- and 32.1% of school-aged children, respectively). Pain was the strongest predictor of having an abnormal total score and disorders of initiation and maintenance of sleep, with odds ratios (95% confidence intervals) of 6.5 (2.2-18.9) and 3.4 (1.3-9.3), respectively, adjusted for age group and degree of motor impairment. CONCLUSIONS: Sleep disorders are prevalent in children with CP, with higher frequencies in school-aged as compared to preschool-aged children. Health care professionals caring for this population should routinely inquire about sleep problems and pain.

Sleep and quality of life of patients with glycogen storage disease on standard and modified uncooked cornstarch.

BACKGROUND: Glycemic control in hepatic glycogen storage diseases (GSDs) relies on specific nutritional recommendations, including strict avoidance of a fasting period. Uncooked cornstarch (UCCS) is an important therapeutic component. A new modified UCCS, Glycosade™, was created with the objective of prolonging euglycemia. We aimed to determine the length of euglycemia on Glycosade™ using a continuous glucose monitor (CGM) and to evaluate whether longer euglycemia and thus less nighttime interruptions would improve sleep and quality of life (QoL) after the introduction of the modified cornstarch. METHODS: We conducted a prospective cohort study to assess quality and quantity of sleep and quality of life (QoL) in patients with GSDs on standard UCCS and after the introduction of Glycosade™. Sleep and QoL evaluation was done for patients using validated questionnaires, a standardized sleep diary and actigraphy. Length of fast and glucose variability were determined with CGM. RESULTS: Nine adults with GSD Ia took part in the study. Glycosade™ introduction was done under close supervision during a hospital admission. Comparison of sleep in 9 patients showed sleep disturbances on standard UCCS that were improved with Glycosade™. QoL was normal both pre and post Glycosade™. The CGM confirmed maintenance of a longer fasting period with Glycosade™ at home. CONCLUSION: Glycosade™ represents an alternative option for GSD patients. We showed possible benefits in terms of sleep quality. We also confirmed the longer length of fast on Glycosade™. SYNOPSIS: A new modified form of uncooked starch for patients with glycogen storage disease represents an alternative option as it showed a longer length of fast and improvements in sleep quality.

Point-of-care lung ultrasound in young children with respiratory tract infections and wheeze.

OBJECTIVE: Characterise lung ultrasound (LUS) findings, diagnostic accuracy and agreement between novice and expert interpretations in young children with respiratory tract infections and wheeze. METHODS: Prospective cross-sectional study in a paediatric ED. Patients ≤2 years with a respiratory tract infection and wheeze at triage were recruited unless in severe respiratory distress. Prior to clinical management, a novice sonologist performed the LUS using a six-zone scanning protocol. The treating physician remained blinded to ultrasound findings; final diagnoses were extracted from the medical record. An expert sonologist, blinded to all clinical information, assessed the ultrasound video clips at study completion. Positive LUS was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. RESULTS: Ninety-four patients were enrolled (median age 11.1 months). LUS was positive in 42% (39/94) of patients (multiple B-lines in 80%, consolidation in 64%, pleural abnormalities in 23%). The proportion of positive LUS, along with their diagnostic accuracy (sensitivity (95% CI), specificity (95% CI)), were as follows for children with bronchiolitis, asthma, pneumonia and asthma/pneumonia: 46% (45.8% (34.0% to 58.0%), 72.7% (49.8% to 89.3%)), 0% (0% (0.0% to 23.3%), 51.3% (39.8% to 62.6%)), 100% (100% (39.8% to 100.0%), 61.1% (50.3% to 71.2%)), 50% (50% (6.8% to 93.2%), 58.9% (48.0% to 69.2%)), respectively. There was good agreement between the novice and expert sonographers for a positive LUS (kappa 0.68 (95% CI 0.54 to 0.82)). CONCLUSIONS: Among children with respiratory tract infections and wheeze, a positive LUS seems to distinguish between clinical syndromes by ruling in pneumonia and ruling out asthma. If confirmed in future studies, LUS may emerge as a point-of-care tool to guide diagnosis and disposition in young children with wheeze.

Accuracy of ultrasonography for determining successful realignment of pediatric forearm fractures.

STUDY OBJECTIVE: The primary objective of this study is to assess the accuracy of point-of-care ultrasonography compared with blinded orthopedic assessment of fluoroscopy in determining successful realignment of pediatric forearm fractures. The secondary objective is to determine the rate of agreement of ultrasonography and fluoroscopy in real-time by the treating physician. METHODS: A cross-sectional study was conducted in children younger than 18 years and presenting to an academic emergency department with forearm fractures requiring realignment of a single bone. Physicians performed closed reductions with ultrasonographic assessment of realignment until the best possible reduction was achieved. Fluoroscopy was then immediately performed and images were saved. A positive test result was defined as an inadequately reduced fracture on fluoroscopy by a blinded pediatric orthopedic surgeon (reference standard) and on ultrasonography (index test) and fluoroscopy in real-time by the treating physician. RESULTS: One hundred patients were enrolled (median age 12.1 years; 74% male patients); the radius was involved in 98%, with 27% involving the growth plate. The sensitivity, specificity, positive predictive value, and negative predictive value were 50% (95% confidence interval [CI] 15.4% to 84.6%), 89.1% (95% CI 82.8% to 95.5%), 28.6% (95% CI 4.9% to 52.2%), and 95.3% (95% CI 90.9% to 99.8%), respectively. The treating physicians' agreement rate of the real-time images was 98%. CONCLUSION: Point-of-care ultrasonography can help emergency physicians determine when pediatric forearm fractures have been adequately realigned, but inadequate reductions should be confirmed by other imaging modalities.

Point tenderness at 1 of 5 locations and limited elbow extension identify significant injury in children with acute elbow trauma: a study of diagnostic accuracy.

OBJECTIVE: Our goal was to determine whether the combination of tenderness at 1 of 5 commonly fractured sites and elbow extension accurately predicts the presence of acute elbow fractures or isolated effusions in children. METHODS: A prospective cohort study was performed using a convenience sample of patients. Children 0 to 18 years old with acute elbow injuries without elbow deformities or radial head subluxations were prospectively enrolled. The treating physicians assessed the injured elbow for the presence of tenderness at 5 locations and for abnormal active extension. The examination was defined as positive if any one component was present and negative if all were absent. The radiologist's report or a structured follow-up phone call was used as an a priori-determined composite reference standard for the diagnosis of (1) fracture or isolated effusion and (2) fracture. RESULTS: A total of 332 patients were enrolled; 183 (55.1%) were diagnosed with a fracture (31.0%) or effusion (24.1%). A negative examination result was present in 33 (9.9%), among whom 6 were diagnosed with a small effusion and 1 with a radial neck fracture. The examination's sensitivity, specificity, and positive and negative predictive values (95% confidence interval) were 96.2% (92.0-98.3), 17.4% (11.9-24.7), 58.4% (52.6-64.2), and 60.3% (47.8-72.9), respectively, for fracture or isolated effusion and 99.0% (97.1-100), 14.0% (9.5-18.5), 34.1% (28.7-39.5), and 97.0% (91.1-100.0), respectively, for fracture. A planned subgroup analysis of children younger than 3 years was performed; the elbow extension test was insensitive (sensitivity, 73.3% [51.0-95.7]) at excluding elbow injuries, albeit, when combined with point tenderness, it identified 100% of elbow fractures or effusions. CONCLUSION: The addition of point tenderness to the elbow extension test is highly sensitive at identifying injuries in children with acute elbow injuries, albeit nonspecific. Although the significance of omitting 10% of radiographs is questionable, a cost-benefit analysis would help clarify its potential savings in terms of expenditure and/or radiation exposure when compared to the risk of missing 2% of children with elbow injuries (albeit mainly small effusions).

Attitudes and knowledge regarding health care policy and systems: a survey of medical students in Ontario and California.

BACKGROUND: Canada and the United States have similar medical education systems, but different health care systems. We surveyed medical students in Ontario and California to assess their knowledge and views about health care policy and systems, with an emphasis on attitudes toward universal care. METHODS: A web-based survey was administered during the 2010-2011 academic year to students in 5 medical schools in Ontario and 4 in California. The survey collected demographic data and evaluated attitudes and knowledge regarding broad health care policy issues and health care systems. An index of support for universal health care was created, and logistic regression models were used to examine potential determinants of such support. RESULTS: Responses were received from 2241 students: 1354 from Ontario and 887 from California, representing 42.9% of eligible respondents. Support for universal health care coverage was higher in Ontario (86.8%) than in California (51.1%), p < 0.001. In California, females, self-described nonconservatives, students with the intent to be involved in health care policy as physicians and students with a primary care orientation were associated with support for universal coverage. In Ontario, self-described liberals and accurate knowledge of the Canadian system were associated with support. A single-payer system for practice was preferred by 35.6% and 67.4% of students in California and Ontario, respectively. The quantity of instruction on health care policy in the curriculum was judged too little by 73.1% and 57.5% of students in California and Ontario, respectively. INTERPRETATION: Medical students in Ontario are substantially more supportive of universal access to health care than their California counterparts. A majority of students in both regions identified substantial curricular deficiencies in health care policy instruction.

Quality assurance evaluation of a simple linear protocol for the treatment of impending status epilepticus in a pediatric emergency department 2 years postimplementation.

OBJECTIVE: To evaluate the efficacy and safety of a simple linear midazolam-based protocol for the management of impending status epilepticus in children up to 18 years of age. METHODS: This is a descriptive, quality assessment, retrospective chart review of children presenting with the chief complaint of seizure disorder in the emergency department (ED) of a tertiary care pediatric hospital and a triage category of resuscitation or urgent from April 1, 2009, to August 31, 2011. In children with at least one seizure episode in the ED treated according to the linear protocol, three main outcomes were assessed: compliance, effectiveness, and complications. RESULTS: Of the 128 children meeting the above study criteria, 68 had at least one seizure episode in the ED, and treatment was required to terminate at least one seizure episode in 46 of 68 patients (67.6%). Fifty-five seizure episodes were treated in the 46 patients: 51 of 55 seizure episodes were treated with midazolam (92.7%) and 4 of 55 with lorazepam or diazepam (7.3%). Of those treated with midazolam, 86.3% (44 of 51) were successfully treated with one or two doses of midazolam. The median seizure duration for all treated patients was 6 minutes. Of the 42 patients treated with midazolam, 7 required either continuous positive airway pressure or intubation, and two patients were treated for hypotension. One patient died of pneumococcal meningitis. CONCLUSION: This simple linear protocol is an effective and safe regimen for the treatment of impending status epilepticus in children.

Effect of glutamine on glucose metabolism in children with Duchenne muscular dystrophy.

BACKGROUND & AIMS: Glutamine is a potent gluconeogenic precursor and stimulates insulin secretion. Glutamine's effect on glucose metabolism in Duchenne muscular dystrophy (DMD) has never been studied. To determine plasma glucose and insulin concentrations measured during and after glutamine administration in DMD boys. We hypothesized that glutamine can modulate whole body glutamine-glucose metabolism in DMD, a genetically determined disease. METHODS: As secondary endpoints of a randomized crossover trial in 30 prepubertal DMD boys, we measured fasting blood glucose, insulin and the Homeostasis Model Assessment (HOMA) index after daily oral glutamine (0.5 g kg(-1) d(-1)) for 4 months versus placebo. In a separate time series trial in 6 prepubertal DMD boys, we measured the same endpoints as well as plasma glutamine and whole body glucose turnover (Ra,glc) (primed continuous i.v. infusion of d-[6,6-(2)D]glucose), while participants received acute oral glutamine (0.5 g kg(-1) d(-1)) continuously for 5 h. RESULTS: In the randomized trial, baseline measurements of HOMA correlated with age (r = 0,51, p = 0.007) and percent fat estimated by bioelectrical impedance analysis (BIA) (r = 0.39, p = 0.047). After 4 months glutamine supplementation, we observed no treatment or order effect on HOMA or insulin. During acute glutamine for 5 h (time series trial), plasma glutamine doubled and was associated with increased plasma insulin concentration (10.42 ± 2.54 vs 7.32 ± 1.86, p = 0.05) with no effect on plasma glucose, HOMA or Ra,glc. CONCLUSIONS: Acute glutamine transiently stimulates insulin secretion in DMD boys, which could be mediated by plasma glutamine concentrations. Fasting insulin concentration and HOMA might provide quantifiable indices of disease progression.