Lower Independent Self-Care Readiness Persists over Time in Teens with Type 1 Diabetes and Executive Function Challenges.

PURPOSE: Management of type 1 diabetes is complex and benefits from adequate executive function (EF) (planning, organization, problem-solving). Teens with diabetes and executive dysfunction may have challenges with acquisition of self-care skills. METHODS: Over 18 months, parents of teens with type 1 diabetes aged 13-17 completed the Diabetes Family Responsibility Questionnaire (DFRQ) and Readiness for Independent Self-Care Questionnaire (RISQ) every 6 months. Parents assessed teen EF, completing the Behavior Rating Inventory of Executive Function (BRIEF). T-score ≥60 defined EF challenges. EF, demographic, and diabetes treatment variables predicted RISQ score over time using longitudinal mixed modeling with false discovery rate adjustment. RESULTS: There were 169 teen participants (54% male) aged 15.9±1.3 years, diabetes duration 8.4±3.7 years, and A1c 8.6±1.2%. About a third (31.4%) of teens had parent-reported BRIEF Global Executive Composite (GEC) scores ≥60. After adjusting for age, gender, and DFRQ, those with GEC <60 had RISQ score 4.1 points higher than those with GEC ≥60, p=0.016. Behavioral regulation index (BRI; adjusted for age, CGM use, DFRQ, and A1c) did not predict RISQ while metacognition index (MI; adjusted for age, gender, and DFRQ) did; those with MI <60 had RISQ score 5.3 points higher than those with MI ≥60, p<0.001. In all models, older teen age (p<0.05) and less parental involvement (p<0.001) predicted higher RISQ score. CONCLUSIONS: EF skills, especially metacognition, appear important for acquisition of self-care behaviors in teens with type 1 diabetes. Evaluating EF during adolescence may identify teens needing extra support during the transition process.

Transition to self-management among emerging adults with type 1 diabetes: a mixed methods study.

Introduction: Emerging adulthood is challenging for young people with type 1 diabetes (T1D). This study evaluated transition to diabetes self-management and perceptions of care transfer using mixed methods. Methods: An online survey queried demographics, management characteristics, diabetes knowledge, self-care readiness, adherence, and diabetes distress. T-tests compared survey scores between those with self-reported target A1c <7.0% versus ≥7.0%. Pearson correlations assessed associations between A1c and diabetes distress, stratified by A1c <7.0% versus ≥7.0%. Qualitative semi-structured interviews elicited perceptions of young adults; transcripts were analyzed using directed qualitative content analysis. Results: Of 141 participants (30% male, 84% non-Hispanic white) completing the survey, 41% self-reported target A1c <7.0%. Diabetes knowledge and self-care readiness scores did not differ between those with A1c <7.0% versus ≥7.0%, while diabetes distress was lower (45 ± 20 vs 52 ± 20, p=0.01) and adherence higher (77 ± 12 vs 71 ± 14, p=0.02) in those with A1c <7.0% versus ≥7.0%. Diabetes distress was significantly associated with glycemic outcomes in those reporting A1c ≥7.0% (R=0.36, p<0.01). Qualitative analysis (24 participants) revealed five themes and two sub-themes, notable for need for more mental health support, support from others with T1D, benefits of technology for care autonomy, and challenges of obtaining diabetes supplies. Discussion: Emerging adults with self-reported target A1c endorsed lower diabetes distress and higher adherence than those with elevated A1c. Mental health access, support from others with T1D, technology use, and guidance for supply acquisition may improve transition to self-management and care transfer for emerging adults with T1D.

New-Onset Type 1 Diabetes in a Child With Diabetic Ketoacidosis and Severe Hypertriglyceridemia Without Pancreatitis.

Hypertriglyceridemia is a complication of diabetic ketoacidosis (DKA) secondary to insulin deficiency inhibiting lipoprotein lipase and increasing lipolysis, but it is rare in children. A 7-year-old boy with history of autism spectrum disorder (ASD) presented with abdominal pain, vomiting, and "heavy breathing." Initial laboratory tests revealed pH 6.87 and glucose 385 mg/dL (21.4 mmol/L), consistent with new-onset diabetes and DKA. His blood appeared lipemic; triglycerides were 17 675 mg/dL (199.6 mmol/L) with normal lipase (10 units/L). He received intravenous insulin and DKA resolved within 24 hours. Insulin infusion continued through day 6 for management of hypertriglyceridemia; triglycerides decreased to 1290 mg/dL (14.6 mmol/L) during this period. He never developed pancreatitis (lipase peaked at 68 units/L) or required plasmapheresis. With his ASD history, he had a restrictive diet high in saturated fat, which included up to 30 breakfast sausages daily. His triglycerides normalized after discharge. Severe hypertriglyceridemia can complicate DKA in newly diagnosed type 1 diabetes (T1D). Hypertriglyceridemia can be safely managed with insulin infusion in the absence of end-organ dysfunction. This complication should be considered in patients with DKA at diagnosis of T1D.

Surgical Diagnoses of Pancreatic Adenocarcinoma Not Found on Previous Endoscopic Ultrasound: A Case Series and Review of the Literature.

INTRODUCTION: Pancreatic cancer is a leading cause of death in North America and Western Europe with rising rates in the developing world. Endoscopic ultrasound (EUS) with FNA (fine needle aspiration) is a critical component in the evaluation and diagnosis of pancreatic lesions with a high sensitivity and specificity. In this paper, we report patients at our center who eventually developed pancreatic cancer despite an early negative EUS, and identifying factors that may result in a missed diagnosis. METHODS: The University of Louisville database was queried for patients who had a Whipple procedure for presumed benign disease and had a pre-operative EUS between 2008 and 2018. Patients who had pancreatic adenocarcinoma on final pathology were identified. Demographic, clinical, EUS, operative, and pathologic details were reviewed for each case in efforts to identify factors associated with failure to diagnose a pancreatic malignancy on EUS. RESULTS: Five patients who had pancreatic adenocarcinoma on final pathology were reviewed in detail and their cases are presented in the paper. Four of the patients had dilation of the common bile duct, three had chronic pancreatitis. Two of them had previous surgery on the pancreas or bile ducts. CONCLUSIONS: All of the patients presented in the paper had variables that made their EUS evaluation challenging. A high index of suspicion must be maintained in patients that do not improve after appropriate treatment of their strictures or pancreatic lesions. In the future, new techniques, such as fine needle biopsy and biomarker assays, may improve diagnosis accuracy.

"Fear That One Day I May Not Be Able to Afford Insulin": The Emotional Burden of Diabetes Costs During Emerging Adulthood.

Emerging adults (EAs) with type 1 diabetes (T1D) often experience challenges in diabetes management, in particular transitioning to financial independence. EAs 18-30 years of age with T1D completed online surveys about diabetes distress and an open-ended query about the most important worry among survey questions. Most of the 287 respondents (89.5%) endorsed "Agree" or "Somewhat agree" to the statement "I worry about the cost of diabetes." Responses did not differ by gender, age, diabetes duration, race/ethnicity, diabetes technology use, student status, income, or insurance status. However, a greater proportion of those not endorsing cost as a substantial burden achieved A1c <7% (92.9%) versus those who were neutral (46.2%) or who endorsed cost as a burden (50.6%) (P = 0.004). Furthermore, in open-ended responses, cost was the most frequently noted worry. Diabetes costs are a major concern for EAs, likely contributing to diabetes distress during this developmental stage, and clinicians should consider discussing diabetes costs with this population.

Diabetes Distress in Emerging Adulthood: Content Validity of the Problem Areas in Diabetes-Emerging Adult Version (PAID-EA) Using Qualitative Analysis.

PURPOSE: The purpose of this study was to explore the emotional work of diabetes during emerging adulthood and to explicate the validity of a newly developed measure of diabetes distress (DD) for use with emerging adults living with type 1 diabetes mellitus (T1DM), the Problem Areas in Diabetes-Emerging Adult version (PAID-EA). METHODS: Young people ages 18 to 30 with T1DM were recruited online to complete a cross-sectional survey including measures of DD, depressive symptomology, and the PAID-EA. To evaluate content validity, 2 open-ended questions asked what was the most significant emotion or worry discussed in the survey items and what feelings were missed in those items. Responses were analyzed using directed qualitative content analysis. RESULTS: A total of 254 (87%) participants responded to at least 1 of the 2 open-ended questions. Three themes and 1 subtheme were identified: (1) fear of the future with the subtheme of worry about the cost of diabetes, (2) acute worries about living with diabetes, and (3) challenges with finding support. More PAID-EA items corresponded with these themes than items on the original Problem Areas in Diabetes or Center for Epidemiologic Studies Depression Scale, supporting the validity of the PAID-EA and clarifying the developmental-stage-specific aspects of DD. CONCLUSIONS: Emerging adulthood is a period in which the future should hold infinite possibility, but young people with T1DM describe a staggering fear of the future with markedly limited possibilities, supporting the need to measure the developmental-stage-specific experience of DD as captured on the PAID-EA.

Primary Hyperparathyroidism From Ectopic Parathyroid Adenoma in a 12-Year-Old With Slipped Capital Femoral Epiphysis.

Primary hyperparathyroidism has been reported in pediatric patients presenting with slipped capital femoral epiphysis (SCFE), but never in patients with ectopic parathyroid adenoma. A 12-year-old boy with obesity and autism spectrum disorder presented with a limp and was found to have bilateral SCFE. Calcium was elevated to 12.3 mg/dL with parathyroid hormone (PTH) of 1191 pg/mL. Neck ultrasound revealed no parathyroid adenoma. He was discharged following bilateral surgical pinning with plans for outpatient workup. Repeat labs 5 days later demonstrated calcium had risen to 16.7 mg/dL. Technetium-99m sestamibi scintigraphy and a computed tomography scan revealed a 2.7 × 1.6 × 1.9 cm intrathymic mediastinal lesion. He underwent a thoracoscopic resection of the mass, and intraoperative PTH levels fell appropriately. Pathology revealed a parathyroid adenoma. Postoperatively, the patient developed hungry bone syndrome followed by normocalcemic secondary hyperparathyroidism which resolved with high-dose vitamin D supplementation. Primary hyperparathyroidism presenting as SCFE in a pediatric patient has been reported in 13 previous cases. This is the first reported case of bilateral SCFE arising from an ectopic parathyroid adenoma. Thoracoscopic resection is a relatively new approach in pediatrics. Primary hyperparathyroidism can be associated with SCFE, especially bilateral, and should be considered in patients with traditional risk factors for SCFE. Pediatric patients with primary hyperparathyroidism and negative neck imaging should be further evaluated for ectopic parathyroid adenomas with nuclear medicine or cross-sectional imaging that includes the head, neck, and mediastinum. Thoracoscopic resection can be considered in pediatric patients with mediastinal ectopic parathyroid adenoma.

Sodium-Glucose Transporter Inhibition in Adult and Pediatric Patients with Type 1 Diabetes Mellitus.

Adjunctive therapies to insulin for treatment of type 1 diabetes mellitus (T1D) have gained popularity in efforts to achieve glycemic targets, and sodium-glucose transporter (SGLT) inhibitors are an appealing option due to associated weight loss, low risk of hypoglycemia, and improved cardiorenal outcomes seen in persons with type 2 diabetes mellitus. The increased risk of diabetic ketoacidosis (DKA), including euglycemic DKA, has led many to be wary of their use in T1D, especially given limited pediatric data and data regarding cardiorenal protection in this population. The phase 3 trials of these agents in T1D have yielded lower HbA1c, decreased total daily insulin dose, and small but significant weight loss with no increase in hypoglycemia. These trials also reported increased risks of genital mycotic infection and DKA. SGLT inhibitors have been approved as adjunctive therapy to insulin in adults with T1D in Europe and Japan, but the United States Food and Drug Administration has rejected similar applications. Although approaches to mitigate the risk of DKA have been developed, no randomized trials using such tools have been conducted. More research is needed to minimize the risk of DKA and to better evaluate the cardiorenal impact of these agents in persons with T1D.

A new interventional home care model for COVID management: Virtual Covid IP.

AIM: Amidst COVID-19 pandemic, the health care delivery in India faces major challenges owing to the overwhelming hospitals, exhausted healthcare workers, and shortage of crucial medical supplies such as ventilators and oxygen. The study aims to propose a novel successful interventional home care model, the Virtual COVID In-Patient (VCIP) care for effective COVID management. METHODS: The Covid-19 positive patients enrolled in VCIP were chosen for the study. A 24/7 active multidisciplinary WhatsApp group was created for each patient, for remote monitoring of temperature, blood pressure, blood glucose, respiratory and pulse rate along with the symptoms. Advice on sleep and exercises were given along with the medication via video-audio consultations. Lab facility was provided at the doorstep. Training on various devices, medications including steroids, delivering subcutaneous injections etc were given via video platforms. RESULTS: Among the 220 patients who availed the VCIP facility, only two were hospitalized, yielding a 99.5 % success rate in preventing hospitalizations and patients enrolled have been immensely satisfied with their experience. CONCLUSIONS: With similar pandemics anticipated in near future, VCIP model may be considered for successful domiciliary treatment and overcoming the challenges.

Euglycemic Diabetic Ketoacidosis With COVID-19 Infection in Patients With Type 2 Diabetes Taking SGLT2 Inhibitors.

OBJECTIVE: Diabetes mellitus is associated with poor outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Diabetic ketoacidosis (DKA) has also been reported to occur with this virus. A cluster of cases of euglycemic DKA (euDKA) was identified in patients with type 2 diabetes mellitus using sodium-glucose cotransporter-2 inhibitors (SGLT2is) who developed SARS-CoV-2 infection. METHODS: The cases were identified by the authors while providing clinical care, and details were collected. RESULTS: Five cases of euDKA, presenting with glucose levels <300 mg/dL, were identified over the course of 2 months by the endocrinology consult service. All patients had a history of type 2 diabetes mellitus with no known history of DKA. All were taking SGLT2is. Oral antihyperglycemic medications were stopped for all patients on admission. All received intravenous insulin infusion to treat DKA before being transitioned to a subcutaneous insulin regimen. SGLT2i use was discontinued for all patients who were discharged. CONCLUSION: EuDKA has been seen in the setting of acute illness in patients using SGLT2is, but this cluster of cases suggests that there is a specific association with SARS-CoV-2 infection. In addition to the known risk of euDKA with SGLT2i use, coronavirus disease 2019-specific mechanisms may include a direct toxic effect of the virus on the pancreatic islets, an accelerated inflammatory response promoting ketosis, and the diuretic effect of SGLT2i in conjunction with anorexia and vomiting. It is crucial to counsel patients to stop SGLT2is when sick, especially if SARS-CoV-2 infection is suspected.

A resident-led project to improve documentation of overweight and obesity in a primary care clinic.

Background: Although the prevalence of overweight and obesity (OW/OB) has increased in the last three decades, studies show that these conditions are sub-optimally documented by physicians. Health information technology tools have varying effects on improving documentation of OW/OB but often have to be complemented with other interventions to be effective. Objective: Upon identifying low rates of documentation of diagnoses of overweight and obesity by resident and attending physicians, despite the use of an electronic health record (EHR) with automated BMI calculations, we performed a quality improvement (QI) project to improve documentation of these diagnoses for patients in our community hospital primary care clinic. Methods: The EHR was reviewed to determine documentation rates by resident and attending physicians between 1 March 2018 and 31 September 2018. We collected pre-intervention data, developed interventions, and implemented tests of change using Plan-Do-Study-Act (PDSA) cycles to improve documentation of OW/OB. Results: Documentation of overweight and obesity diagnoses increased from a baseline of 46% to 79% over a 20-week period after initiation of our project. Conclusion: We demonstrate the successful implementation of resident-led, multi-faceted interventions in a team-based QI project to optimize documentation of OW/OB in the EHR.

Improving patient satisfaction through improved telephone triage in a primary care practice.

OBJECTIVE: The objective of this study was to improve the telephone communication experience for patients in a primary care practice. DESIGN: An exploratory survey was conducted that revealed suboptimal patient satisfaction with clinic access due to the telephone triage system. Several interventions were designed: a monthly quality meeting was established among clinic staff, all phone interactions were recorded in the electronic medical record (EMR) and clinic appointments were made available several months in advance. A follow-up survey was conducted to evaluate these interventions. SETTING: The study was conducted in a multispecialty, urban-based, resident-faculty practice from November 2016 to November 2017. PARTICIPANTS: Subjects were recruited in a convenience sample from the waiting room. 200 subjects participated in the initial survey and 215 in the second survey. RESULTS: After the interventions, patients felt that their questions were answered more frequently than before (p<0.01). They also felt that appointments were easier to make (p=0.03). A similar number of patients reported seeking emergency care because they were unable to reach a provider (33.8% vs 31.9%, p=0.68). The percentage of patients who received a call back within 24 hours increased, but it was not statistically significant (38.6% vs 44%, p=0.13). CONCLUSION: Improving telephone triage through implementing a monthly quality improvement meeting, optimising use of the EMR and opening schedules several months in advance resulted in several improvements in the patient experience, but did not change use of emergency services. Further interventions, including increased resource allocation, are needed to optimise patient experience.

Developing an evidence-based program sustainability training curriculum: a group randomized, multi-phase approach.

BACKGROUND: The emergence of dissemination and implementation (D&I) science has driven a rapid increase in studies of how new scientific discoveries are translated and developed into evidence-based programs and policies. However, D&I science has paid much less attention to what happens to programs once they have been implemented. Public health programs can only deliver benefits if they reach maturity and sustain activities over time. In order to achieve the full benefits of significant investment in public health research and program development, there must be an understanding of the factors that relate to sustainability to inform development of tools and trainings to support strategic long-term program sustainability. Tobacco control programs, specifically, vary in their abilities to support and sustain themselves over time. As of 2018, most states still do not meet the CDC-recommended level for funding their TC program, allowing tobacco use to remain the leading cause of preventable disease and death in the USA. The purpose of this study is to empirically develop, test, and disseminate training programs to improve the sustainability of evidence-based state tobacco control programs and thus, tobacco-related health outcomes. METHODS: This paper describes the methods of a group randomized, multi-phase study that evaluates the empirically developed "Program Sustainability Action Planning Training" and technical assistance in US state-level tobacco control programs. Phase 1 includes developing the sustainability action planning training curriculum and technical assistance protocol and developing measures to assess long-term program sustainability. Phase 2 includes a group randomized trial to test the effectiveness of the training and technical assistance in improving sustainability outcomes in 24 state tobacco control programs (12 intervention, 12 comparison). Phase 3 includes the active dissemination of final training curricula materials to a broader public health audience. DISCUSSION: Empirical evidence has established that program sustainability can improve through training and technical assistance; however, to our knowledge, no evidence-based sustainability training curriculum program exists. Therefore, systematic methods are needed to develop, test, and disseminate a training that improves the sustainability of evidence-based programs. TRIAL REGISTRATION: NCT03598114 . Registered 25 July 2018-retrospectively registered.

An Effective Diabetic Ketoacidosis Prevention Intervention in Children With Type 1 Diabetes.

The objective of this study was to evaluate the effectiveness of a brief, office-based educational intervention to increase parent or patient recognition of the early warning signs and symptoms of diabetic ketoacidosis (DKA). Forty-two patients aged > 13 years and 34 parents of children aged ≤ 13 years were given a pretest questionnaire about their knowledge of signs and symptoms of DKA and sick day management practices. They received a brief refresher course on sick day management specific to their treatment modality (pump vs. injection) and were given a take-home flow sheet of guidelines for diabetes sick day management. Subjects were retested with the same knowledge questionnaire after 6 to 12 months. Patients or parents scored higher on the posttest than the pretest and called the emergency line for assistance more frequently (p = .032) following the intervention. Emergency department visits were significantly reduced in adolescents (p = .024). A short educational intervention and printed management tool is effective in improving sick day and DKA knowledge and appears to be effective in reducing emergency department visits by increasing utilization of a diabetes emergency line for early outpatient intervention.

The two levels of care for diabetes in a developing country: Mechanisms for improved intermediate health outcomes.

India has over 70 million citizens with diabetes, the second-most of any country worldwide. Disparities in learning skills, resources, education, and physician practices make it difficult to practically implement the diabetes management guidelines recommended by international scientific organizations. In its guidelines, the International Diabetes Federation advocates for three different levels of care based on availability of resources. This study investigates the differences in intermediate health outcomes between two diabetes care programs: one a comprehensive diabetes centre, the other a limited care setting. The comprehensive centre offers telemedicine and periodic diabetes education, empowering patients and providing 24-hour advice on lifestyle modifications, diet, and exercise. All patients of this centre practice self-monitoring of blood glucose. The subjects in the limited care setting receive minimal investigations and periodic physical follow-ups, and few patients have access to home glucose monitoring. The results showed that HbA1c (7.62 vs. 8.58, p=0.003), cholesterol (134.4 vs. 173.4, p<0.001), and diastolic blood pressure (72.9 vs. 77.0, p=0.016) were significantly lower in patients receiving comprehensive care, while the reductions in systolic blood pressure (134.6 vs. 138.7, p=0.202) did not achieve statistical significance. These reductions, which remained significant after correcting for confounding factors, could be attributed to more aggressive treatment regimens in the comprehensive care centre, as well as the real-time, frequent communication with medical professionals in the telemedicine program.

Adjuvant induced glucose uptake by activated T cells is not correlated with increased survival.

Authors contributed equally to this manuscript Natural adjuvants, such as bacterial lipopolysaccharide (LPS), activate antigen presenting cells via Toll-like receptors and, indirectly, increase the survival of antigen-activated T cells. The molecular mechanisms leading to increased survival remain poorly defined. Because T cell clonal expansion leads to high energy demands, we hypothesized that increased glucose uptake and/or utilization in adjuvant-activated T cells could be important molecular event(s) that would lead to adjuvant-associated T cell survival advantage. Using a fluorescent analog of 2-deoxyglucose, 2-NBDG, we measured glucose accumulation and rate of uptake in T cells from mice treated with antigen in the absence or presence of LPS. Although adjuvant activated T cells increased the accumulation of 2-NBDG, the rate of uptake was unchanged compared to cells activated with only antigen. Furthermore, glucose transport inhibitors, cytochalasin B or phloretin, decreased the accumulation of glucose in adjuvant-treated T cells, but this decrease did not impair adjuvant-associated survival advantages. Together, these data indicate that increased glucose uptake through glucose transporters is not required for increased survival of activated T cells.