Diminished school-based support for the management of type 1 diabetes in adolescents compared to younger children.

AIMS: To evaluate diabetes management at school in a large cohort of adolescents with type 1 diabetes and to compare the level of support provided to adolescents with that provided to younger children. METHODS: Questionnaires were distributed to adolescents with type 1 diabetes attending nine regional and tertiary paediatric diabetes services in the Republic of Ireland. The data collected included patient demographics, treatment regimen and support provided for self-care management. Results were compared with a similar cohort of primary school children with type 1 diabetes, studied using similar methodology. RESULTS: The study cohort comprised 405 adolescents with a median age of 15 years, of whom 215 (54%) were on multiple daily injections and 128 (32%) were on pump therapy. Eighty-five percent of pump users administered their bolus insulin in classrooms, whereas 76% of those on a multiple daily injection regimen injected outside the classroom. Girls were less likely to administer bolus insulin in an office (10% vs 19%) and more likely to administer it in the bathroom (50% vs 34%; P=0.01). Twenty-five adolescents (12%) on multiple daily injection regimens did not administer bolus insulin at school. Compared to primary school children with type 1 diabetes, adolescents were less likely to use pump therapy, have an emergency treatment plan and have a designated staff member responsible for care needs. CONCLUSIONS: Support provided to adolescents with type 1 diabetes is diminished compared with that provided to younger schoolchildren.

Prevalence and characteristics of paediatric Type 2 diabetes in the Republic of Ireland.

OBJECTIVE: To establish the prevalence of paediatric Type 2 diabetes in the Republic of Ireland and describe patient demographics, initial presentation, management, outcomes, comorbidities and complications. METHODS: Using a standardized proforma we conducted a cross-sectional survey of children and adolescents aged < 16 years with a diagnosis of Type 2 diabetes between October and December 2015 in each of the 19 centres in the Republic of Ireland responsible for the care of children with diabetes. RESULTS: Twelve cases of Type 2 diabetes were identified, giving a prevalence in children aged <16 years of 1.2/100 000 (95% CI 0.6 to 2). Six of these children (50%) were white, two (33%) of whom were members of the travelling community. Four (33%) were of black ethnicity. The prevalence of Type 2 diabetes in traveller children was 16.1/100 000 (95% CI 1.9 to 58.1) and was similar to that in black children, a known high-risk group, which was 13.3/100 000 (95% CI 3.6 to 34.1). The median current HbA1c value was 51 mmol/mol (6.8%) and four (33%) of the children achieved the International Society for Pediatric and Adolescent Diabetes target HbA1c of ≤48 mmol/mol (6.5%). Seven (59%) children were managed on metformin monotherapy, three (25%) were managed on insulin and metformin in combination, and two (16%) were receiving dietary management. CONCLUSION: This was the first national study to estimate the prevalence of childhood Type 2 diabetes in Ireland. Despite their white ethnicity, traveller children appear to be a high-risk group, but this finding requires further study.

Reproducibility of the plasma glucose response to moderate-intensity exercise in adolescents with Type 1 diabetes.

AIMS: The aim of the study was to evaluate the reproducibility of the plasma glucose response to moderate-intensity exercise performed on different days under controlled conditions in adolescents with Type 1 diabetes. METHODS: Eight adolescents with Type 1 diabetes on continuous subcutaneous insulin infusion completed two exercise sessions, each on two separate days, under basal insulin and fasting conditions. On each day, participants cycled twice for 30 min at 55% of their peak rate of oxygen consumption, with each exercise session separated by a 30-min rest. RESULTS: Plasma insulin levels were similar between testing days and exercise sessions. The mean absolute drop in plasma glucose from the commencement to the end of exercise was 1.6 ± 0.5 mmol/l on day 1 and 1.9 ± 0.7 mmol/l on day 2 (P = 0.3). In response to the first exercise session, plasma glucose levels relative to baseline did not change significantly (0.2 ± 0.6 and -0.2 ± 0.5 mmol/l on days 1 and 2). By contrast, the change in plasma glucose during the second exercise session was -1.1 ± 0.7 and -1.3 ± 0.7mmol/l on days 1 and 2, respectively. The mean absolute intra-individual difference in the change in plasma glucose between testing days were 0.7 ± 0.5 [95% confidence interval (CI) 0.4-1.0] and 0.7 ± 0.4 (95% CI 0.4-1.0) mmol/l, at the end of the first and second exercise sessions respectively. CONCLUSIONS: The plasma glucose response to moderate-intensity exercise under similar glycaemic and basal insulin conditions can be reproducible in adolescents with Type 1 diabetes.

Subclinical hypothyroidism in childhood.

Subclinical hypothyroidism (SH) is defined as an elevated thyroid stimulating hormone (TSH) in association with a normal total or free thyroxine (T4) or triiodothyronine (T3). It is frequently encountered in both neonatology and general paediatric practice; however, its clinical significance is widely debated. Currently there is no broad consensus on the investigation and treatment of these patients; specifically who to treat and what cut-off level of TSH should be used. This paper reviews the available evidence regarding investigation, treatments and outcomes reported for childhood SH.

Screening for developmental dysplasia of the hip: current practices in Ireland.

OBJECTIVE: To ascertain the current approach to screen for developmental dysplasia of the hip in the Republic of Ireland. METHODS: Two-pronged prospective and retrospective study. (1) Postal questionnaire to consultant paediatricians responsible for the routine neonatal care of infants in the Irish Republic in June 2006. (2) Retrospective database review to identify infants undergoing radiological follow-up and their outcome. RESULTS: All maternity units surveyed responded. Most units (84%) were dependent on radiographs at 4-6 months for imaging hips, only two units primarily used ultrasound (10.5%). We estimate that neonatal hip examination is performed by an experienced examiner in less than 30% of routine newborn examinations. On retrospective analysis, 94% of radiographs performed were normal. CONCLUSIONS: The most effective interventions, selective ultrasound and examination by an experienced clinician are not widely practiced. There is a need for the development of national guidelines based on available resources.

Management of neonatal abstinence syndrome: a national survey and review of practice.

AIM: To ascertain the present management of neonatal abstinence syndrome (NAS) in neonatal units in the United Kingdom (UK) and Ireland. METHODS: Postal questionnaire to 235 neonatal units, with telephone follow-up of non-respondents. RESULTS: The response rate was 90%, and 96% of respondents had a formal NAS guideline. The median number of infants treated annually for NAS was 6 (range 1-100). The method of Finnegan was the most widely used scoring system (52%). Morphine sulphate was the most commonly used first line agent for both opiate (92%) and polysubstance (69%) withdrawal. Dosing regimens varied widely. Units using a maximum daily morphine dose of <400 microg/kg/day were more likely to require the addition of a second agent (76% vs 58%, p = 0.027). Phenobarbitone was the drug of choice to treat seizures secondary to both opiate and polydrug withdrawal in 73% and 81% of units, respectively. 29% of units allowed infants to be discharged home on medication. 58% of these allowed administration of opiates in the community and in almost half of cases this was managed by a parent. Mothers on methadone whose serology was positive for hepatitis B and/or C were four times more likely to be discouraged from breastfeeding. CONCLUSIONS: The majority of units currently use an opiate as the drug of first choice as recommended. Doses utilised and second agents added vary significantly between units. Many of our findings reflect the lack of high-quality randomised studies regarding management of NAS.

Demographic, health and lifestyle factors associated with dental service attendance by young adults.

BACKGROUND: The aim of this study was to describe the demographic and health and lifestyle factors associated with dental service attendance in the previous 12 months by young Australian adults (18-24 years). METHODS: Population-based data from the 2001 Australian National Health Survey were analysed. Proportions and single associations between variables of interest and dental service attendance were calculated. A logistic regression analysis using significant single association variables was then conducted. RESULTS: Overall, 41 per cent of young adults in this study had visited a dental professional in the previous 12 months. Females, those in cities, those with private insurance, those who spoke languages other than English, those in the highest socioeconomic group and those with healthy behaviours were subgroups most likely to have visited a dental professional. With logistic regression, factors found to be associated with dental services attendance were being female, having private health insurance and low alcohol consumption. CONCLUSIONS: In this study, the proportion of young adults who had visited a dental professional in the previous 12 months was only 41 per cent. It is therefore suggested that oral health policy and promotion activities be encouraged for this group, paying attention to young adults in groups with low attendance.

Edentulism and associated factors in people 60 years and over from urban, rural and remote Western Australia.

BACKGROUND: Edentulism is declining in the aged, in turn increasing demand on dental services. The aim of this study was to describe the pattern of edentulism and associated factors for people 60 years or over in urban, rural and remote Western Australia. METHODS: A cross-sectional telephone interview survey was conducted of 2100 people aged 60 years or over (urban n=800, rural n=800, remote n=500), identified through the State Electoral Roll, who were living in non-institutionalized accommodation in Western Australia and who were able to speak English sufficiently well to be interviewed in English. RESULTS: The main outcome measure was edentulism. The prevalence of edentulism was 25 per cent for people in urban areas, 34 per cent for people in rural areas and 32 per cent for people in remote areas. Respondents aged 60-69 years had less than half the edentulism than respondents aged 80 years or over. Multivariable logistic regression models showed geographic location, age, gender, education and occupation were significantly associated with edentulism. CONCLUSIONS: The percentage of edentulism was highest in rural areas with some clear demographic trends. These future aged cohorts are likely to follow the same patterns of social and geographic disadvantage as found for the current edentate cohort. The results were consistent with other studies while providing state level multivariate results to assist service planning.

Reference values for echocardiographic measurements in urban and rural populations of differing ethnicity: the Strong Heart Study.

Discrepancies in reported reference values for left ventricular (LV) dimensions and mass may be due to imaging errors with early echocardiographic methods or effects of subject characteristics and inclusion criteria. To determine whether contemporary echocardiographic methods provide stable normal limits for left ventricular measurements in different populations, M-mode/2-dimensional echocardiography was applied in 176 American Indian participants in the Strong Heart Study and 237 New York City residents who were clinically normal. No consistent difference in any measure of LV size or function existed between populations. Upper normal limits (98th percentile) for LV mass were 96 g/m(2) in women and 116 g/m(2) in men and 3.27 cm/m for LV chamber diameter normalized for height. Thus contemporary M-mode/2D echocardiography provides reference ranges for LV measurements that approximate necropsy measurements and have acceptable stability in apparently normal white, African-American/Caribbean, and American Indian populations.

Relationship of impaired glucose tolerance to left ventricular structure and function: The Strong Heart Study.

BACKGROUND: We have identified increased left ventricular (LV) mass, wall thickness, relative wall thickness, and reduced systolic function in diabetic individuals after adjusting for blood pressure and body mass index. However, the cardiovascular correlates of impaired glucose tolerance (IGT), a precursor of diabetes, are unknown. METHODS: We compared LV measurements between 457 American Indian participants in the Strong Heart Study with IGT (34% men) by World Health Organization criteria and 888 participants (49% men) with normal glucose tolerance. RESULTS: Participants with IGT were older (60 vs 59 years, P < .01), more overweight (body mass index, 32 +/- 6 vs 29 +/- 5 g/m(2)), and had higher systolic blood pressure (129 +/- 20 vs 124 +/- 18 mm Hg, P < .001) and heart rate (67 +/- 10 vs 66 +/- 11 beats/min, P = .011). In univariate analyses, women but not men with IGT had higher LV mass (mean, 150 vs 138 g, P < .001) and cardiac index (2.6 vs 2.5 L/min/m(2), P < .05). LV wall thicknesses and relative wall thickness were greater in women and men with IGT. Regression analysis, adjusting for multiple covariates in the entire study population, identified independent associations of IGT with higher LV relative wall thicknesses, LV mass/height(2.7), and cardiac output/height(1.83). CONCLUSIONS: IGT is associated with increased LV wall thickness, mass, and cardiac output independent of effects of relevant covariates.

Differences in echocardiographic findings and systemic hemodynamics among non-diabetic American Indians in different regions: The Strong Heart Study.

PURPOSE: This study was undertaken to determine whether differences in left ventricular (LV) and systemic hemodynamic findings exist between American Indians in different regions that might contribute to known differences in cardiovascular morbidity rates among American Indians. METHODS: We compared echocardiography results in 290 non-diabetic Strong Heart Study (SHS) participants in Arizona, 595 in Oklahoma and 572 in North/South Dakota (ND/SD). RESULTS: Participants in the 3 regions were similar in age and gender but those in Arizona had the highest body mass indices and lowest heart rates while those in ND/SD had the lowest diastolic blood pressures (BP). In analyses that adjusted for significant covariates, ND/SD participants had larger aortic (Ao) anular, Ao root, and LV chamber size as well as higher cardiac output and lower peripheral resistance, whereas Arizona participants had increased LV wall thickness and mass and reduced LV myocardial contractility. These findings may contribute to the known high rates of cardiovascular events in ND/SD Indians and to the proportionately higher rate of cardiovascular death than of non-fatal cardiovascular events that has been recently documented in Arizona Indians. CONCLUSIONS: Application of echocardiography to non-diabetic SHS participants reveals that LV chamber and arterial size are larger in ND/SD Indians and that LV wall thicknesses and mass are higher and LV myocardial contractility lower in Arizona Indians, possibly contributing to the higher than expected rates of cardiovascular morbidity and mortality among Indians in Arizona.

Impact of diabetes on cardiac structure and function: the strong heart study.

BACKGROUND: Whether diabetes mellitus (DM) adversely affects left ventricular (LV) structure and function independently of increases in body mass index (BMI) and blood pressure is controversial. METHODS AND RESULTS: Echocardiography was used in the Strong Heart Study, a study of cardiovascular disease in American Indians, to compare LV measurements between 1810 participants with DM and 944 with normal glucose tolerance. Participants with DM were older (mean age, 60 versus 59 years), had higher BMI (32.4 versus 28.9 kg/m(2)) and systolic blood pressure (133 versus 124 mm Hg), and were more likely to be female, to be on antihypertensive treatment, and to live in Arizona (all P<0.001). In analyses adjusted for covariates, women and men with DM had higher LV mass and wall thicknesses and lower LV fractional shortening, midwall shortening, and stress-corrected midwall shortening (all P<0.002). Pulse pressure/stroke volume, a measure of arterial stiffness, was higher in participants with DM (P<0.001 independent of confounders). CONCLUSIONS: Non-insulin-dependent DM has independent adverse cardiac effects, including increased LV mass and wall thicknesses, reduced LV systolic chamber and myocardial function, and increased arterial stiffness. These findings identify adverse cardiovascular effects of DM, independent of associated increases in BMI and arterial pressure, that may contribute to cardiovascular events in diabetic individuals.

Relations of left ventricular mass to fat-free and adipose body mass: the strong heart study. The Strong Heart Study Investigators.

BACKGROUND: It is unclear whether increased left ventricular (LV) mass in overweight individuals is related to their adiposity or to greater fat-free mass (FFM). METHODS AND RESULTS: We compared echocardiographic LV mass to FFM and adipose body mass by bioelectric impedance and to anthropometric measurements in 3107 American Indian participants in the Strong Heart Study. In men and women, the relations of LV mass and FFM (r=0.37 and 0.38, P<0.001) were closer (P<0.05 to <0.001) than they were with adipose mass, waist/hip ratio, body mass index, systolic blood pressure, height, or height2.7. Regression analyses showed that in men LV mass had the strongest independent relation with FFM, followed by systolic blood pressure and age (all P<0.001); in women, LV mass was related to FFM more strongly than it was to systolic blood pressure, age (all P<0. 001), and diabetes (P=0.012). Adipose mass had no independent relation to LV mass. When waist/hip ratio or body mass index were substituted for adipose mass, LV mass was independently related to FFM (P<0.001) and body mass index (P=0.02) but not to waist/hip ratio in men and was independently related to FFM and waist/hip ratio (both P<0.001) but not to body mass index in women. Using 97.5 percentile gender-specific partitions for LV mass/FFM in reference individuals, we found that LV hypertrophy occurred in 20.8% of Strong Heart Study participants with hypertension, overweight, or diabetes compared with 10.5% and 16.7% by LV mass indexed for body surface area or height2.7. CONCLUSIONS: LV mass is more strongly related to FFM than to adipose mass, waist/hip ratio, body mass index, or height-based surrogates for lean body weight; LV mass/FFM criteria may increase sensitivity to detect LV hypertrophy.

Relations of left ventricular mass to demographic and hemodynamic variables in American Indians: the Strong Heart Study.

BACKGROUND: Previous studies have identified associations of left ventricular (LV) mass with demographic (body habitus and sex) and hemodynamic variables (blood pressure, stroke volume [SV], and myocardial contractility), but the relative strength and independence of these associations remain unknown. METHODS AND RESULTS: We examined the relations of echocardiographically determined LV mass to demographic variables, blood pressure, Doppler SV, and measures of contractility (end-systolic stress [ESS]/end-systolic volume index and midwall fractional shortening [MFS] as a percentage of predicted for circumferential end-systolic stress [stress-independent shortening]) in 1935 American Indian participants in the Strong Heart Study phase 2 examination without mitral regurgitation or segmental wall motion abnormalities. Weak positive relations of LV mass with systolic and diastolic pressures (r=.22 and r=.20) were exceeded by positive relations with height (r=.30), weight (r=.47), body mass index (r=.31), body surface area (r=.49), and Doppler SV (r=.50) and negative relations with ESS/volume index ratios (r= -.33 and -.29) and stress-independent MFS (r= -.26, all P<.0001). In multivariate analyses that included blood pressure, SV, and a different contractility measure in each model, systolic pressure, stroke volume, and the contractility measure were independent correlates of LV mass (multiple R=.60 to .66, all P<.0001). When demographic variables were added, LV mass was more strongly predicted by higher SV and lower afterload-independent MFS than by greater systolic pressure, height, and body mass index (each P<.00001, multiple R=.71). CONCLUSIONS: Additional characterization of volume load and contractile efficiency improves hemodynamic prediction of LV mass (R(2)=.30 to .44) over the use of systolic blood pressure alone (R(2)=.05), with a further increase in R(2) to .51 when demographic variables are also considered. However, nearly half of the ventricular mass variability remains unexplained.