Family Engagement at the Systems Level: A Framework for Action.

While family engagement at the individual level of health care, such as families partnering with providers in decision-making about health care for an individual child has been well studied, family engagement in systems-level activities (e.g., participation in advisory and other decision-making groups, or creation and revision of policies) that impact the health services families and children receive has not. This note from the field presents a framework that describes the information and supports that help families partner with professionals and contribute to systems-level activities. Without attention to these components of family engagement, family presence and participation may be only token. We engaged an expert Family/Professional Workgroup whose members represented key constituencies and diverse geography, race/ethnicity, and areas of expertise; conducted a review of peer-reviewed publications and grey literature; and conducted a series of key informant interviews to identify best practices for supporting meaningful family engagement at the systems level. Based on an analysis of the findings, the authors identified four action-oriented domains of family engagement and key criteria that support and strengthen meaningful family engagement in systems-level initiatives. Child- and family-serving serving organizations can use this Family Engagement in Systems framework to support meaningful family engagement in the design of policies, practices, services, supports, quality improvement projects, research, and other systems-level activities.

Use of continuous subcutaneous insulin infusion versus multiple daily injections in emerging adults with type 1 diabetes is associated with better clinical engagement but not glycaemic control.

BACKGROUND: Limited studies have compared outcomes between emerging adults with type 1 diabetes mellitus (T1D) attending a diabetes transition support programme using multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). AIMS: To assess glycaemic control and service utilisation in emerging adults with T1D on MDI or CSII attending a young adult diabetes clinic (YAC). METHODS: A retrospective cohort analysis was conducted from January 2013 to December 2015. Data collected included clinic visits per year, after-hours mobile telephone use, diabetic ketoacidosis (DKA) admissions and all HbA1c levels. Independent t-test was used to compare continuous variables whilst Pearson's Chi-squared test was used for categorical variables. Linear mixed effects models explored mean changes in HbA1c levels over time. RESULTS: Over 3 years, 318 youth with T1D (176 MDI, 121 CSII, 21 switched from MDI to CSII) attended our YAC. Aggregated mean HbA1c levels remained similar between modalities (CSII 9.1% vs MDI 9.3%; P = 0.23); however, mean change in HbA1c at 3 years was significantly increased in CSII users at 0.55% (95% CI 0.15-0.95; P < 0.01) compared with no significant change in MDI users. Clinic visits per year were improved in CSII users (CSII 2.8 vs MDI 2.5; P = 0.02), while DKA admissions remained similar between MDI and CSII users (3.6 admissions per 100 patient-years). CONCLUSION: In our YAC cohort, glycaemic control in CSII and MDI users was similar but well below recommended international glycaemic targets (HbA1c level < 7.0%). Despite increased clinical engagement occurring in CSII users, glycaemic deterioration was observed over the 3 years.

Impact of continuous glucose monitoring in youth with type 1 diabetes aged 15-21 years.

BACKGROUND: People with type 1 diabetes (T1D) aged <21 years are eligible for subsidised continuous glucose monitoring (CGM) products under the Australian National Diabetes Services Scheme. There are few real-world published studies to evaluate the benefits of CGM in young adults. AIMS: To perform a real-world observation study among youth with T1D to evaluate CGM use and benefits of CGM. METHODS: Patients at the Westmead Hospital Young Adult Diabetes Clinic aged 15-21 years who commenced CGM before July 2018 were followed for 6 months post commencement of CGM. Differences in HbA1c and glucose metrics at baseline and follow up are compared between those commencing CGM and those that did not. RESULTS: Forty-four (38%) of 115 eligible patients commenced CGM. Demographic characteristics and baseline HbA1c did not differ significantly between those started on CGM and those that did not. At 6 months, 18 (41%) of 44 patients still used CGM, with discomfort and inconvenience the most common reasons for dropout. In CGM continuers, at 6 months compared with baseline, there was no change in HbA1c (8.2% vs 8.0%; P = 0.8), coefficient of variation of glucose (38% vs 39%; P = 0.5) or percentage time in range (52% vs 58%; P = 0.3). Six-month follow-up HbA1c in CGM non-users deteriorated significantly compared with users. Mean hypoglycaemia fear scores (worry scale) were significantly decreased from baseline at 6 months (33 vs 18; P < 0.01). CONCLUSION: There are high rates of discontinuation in CGM use among youth with T1D. At 6 months of CGM use, there was no significant change in glycaemic control, although HbA1c in non-users deteriorated significantly. Worry of hypoglycaemia was significantly decreased among those who continued CGM.

A Review of the Maternal and Child Health APHA Policy Statements, 1970-2019.

INTRODUCTION: The American Public Health Association (APHA) policy statements are written by members and approved by the APHA Governing Council. Policy statements inform APHA's position on key public health issues. Maternal and child health (MCH) is a broad discipline focused on health issues concerning women, children, youth, and families. APHA's MCH policies from the last 50 years were reviewed in celebration of the 100th anniversary of the MCH Section of APHA. METHODS: A cross-sectional design was utilized to identify MCH-related statements within the larger APHA policy statement database from 1970 to 2019 (N = 1,110). The policy statements were coded as primary MCH (main focus was MCH) or secondary MCH (mentioned MCH subpopulations as vulnerable population). The primary MCH themes were also identified. RESULTS: 545 (49%) of the APHA policy statements were related to MCH, including 226 (20%) coded as primary MCH and 319 (29%) secondary MCH. The primary MCH policy statements had a main focus on the following subpopulations: women (44%), children (33%), adolescents/young adults (15%), infants (12%), families (5%), and men (2%). Major themes included reproductive health/family planning, school health, children's health, pregnancy/childbirth, and breastfeeding/nutrition. CONCLUSIONS: MCH policy statements remained an important part of APHA's policy and advocacy focus over time as indicated through the continuous high number and proportion of MCH policy statements. The historical overview of MCH policy provides insight into critical policy issues confronting the MCH field over the decades and provides guidance for future policy initiatives including a need for increased emphasis on diverse MCH populations. SIGNIFICANCE: This analysis provides a 50 year overview of MCH themes as viewed by the policy statements published by APHA, the largest public health professional organization in the United States. These policy statements represent the cutting edge of MCH policy efforts and were written to influence national, state, and local public health policy. APHA policy statements should continue to address these important MCH topics in the future with an increased emphasis on diverse MCH populations. APHA policy making is a valuable national professional activity for the MCH field with the goal of improving the health for MCH communities.

Clinical and Radiologic Response of Central Giant Cell Granuloma to Denosumab: A 6-Year Prospective Observational Study.

Central giant cell granuloma (CGCG) is a rare lesion of the jaw occurring in young adults and adolescents. Surgery, the traditional mainstay of therapy, is associated with significant morbidity. Denosumab, a humanised monoclonal antibody to RANKL, is effective in a related entity, giant cell tumour of bone (GCTB), but experience in the more indolent CGCG is limited. This prospective observational study of all denosumab-treated CGCG at a tertiary referral centre (2015-2021) aimed to evaluate the safety, efficacy and recurrence risk using denosumab in CGCG at lower-frequency dosing than used for GCTB. All received standardised, time-limited courses of denosumab 120 mg with stepwise increase in dosing interval based on response. They were followed for up to 75 months using a radiation-minimising protocol: 3-monthly clinical, biochemical and radiological assessment (orthopantomograms, cone beam CT). Eight patients, median age 20.5 years [IQR 6], received 13 initial doses [IQR 10] of denosumab 120 mg. Radiologic response was seen after 5.5 doses [IQR 4.5]: ossification in all and size reduction in three. Recurrence occurred in four of seven completing therapy, observed 12 months post-cessation [IQR 6.5]. Larger baseline size, aggressive subtype and fewer than 12 initial doses were more common in the recurrence group. There was no osteonecrosis of the jaw. Hypocalcaemia occurred in one receiving modified dosing. This study represents the largest, most diverse cohort of denosumab-treated CGCG with the longest follow-up in literature. It demonstrates the efficacy of lower-frequency, time-restricted course of denosumab but highlights the risk of recurrence. Long-term follow-up is critical.

Loneliness and Depressive Symptoms among Pregnant Black Women during the COVID-19 Pandemic.

We explored the associations among perceived stress, depressive symptoms, loneliness, and social support during the COVID-19 pandemic; and differences in perceived stress, depressive symptoms, and social support prior to the pandemic and during the pandemic among pregnant Black women. A sample of 33 pregnant Black women who participated in the Biosocial Impact on Black Births (BIBB) and were still pregnant in May-June 2020 were invited to complete an online survey about their experiences during the pandemic. Fifteen women responded very much or somewhat to experiencing stress and anxiety because of the COVID-19 pandemic. Eight women had CES-D scores ≥23, which have been correlated with depression diagnosis. Women who reported higher levels of loneliness during the COVID-19 pandemic also reported higher levels of perceived stress and depressive symptoms and lower levels of social support during the pandemic. Women who reported lower levels of social support during the pandemic also reported higher levels of perceived stress and depressive symptoms during the pandemic. There were no changes in perceived stress, depressive symptoms, or social support prior to the pandemic and during the pandemic. Clinicians should assess for signs of loneliness and depressive symptoms for pregnant women and offer recommendations for therapy and support groups.

Universal Subsidized Continuous Glucose Monitoring Funding for Young People With Type 1 Diabetes: Uptake and Outcomes Over 2 Years, a Population-Based Study.

OBJECTIVE: Continuous glucose monitoring (CGM) is increasingly used in type 1 diabetes management; however, funding models vary. This study determined the uptake rate and glycemic outcomes following a change in national health policy to introduce universal subsidized CGM funding for people with type 1 diabetes aged <21 years. RESEARCH DESIGN AND METHODS: Longitudinal data from 12 months before the subsidy until 24 months after were analyzed. Measures and outcomes included age, diabetes duration, HbA1c, episodes of diabetic ketoacidosis and severe hypoglycemia, insulin regimen, CGM uptake, and percentage CGM use. Two data sources were used: the Australasian Diabetes Database Network (ADDN) registry (a prospective diabetes database) and the National Diabetes Service Scheme (NDSS) registry that includes almost all individuals with type 1 diabetes nationally. RESULTS: CGM uptake increased from 5% presubsidy to 79% after 2 years. After CGM introduction, the odds ratio (OR) of achieving the HbA1c target of <7.0% improved at 12 months (OR 2.5, P < 0.001) and was maintained at 24 months (OR 2.3, P < 0.001). The OR for suboptimal glycemic control (HbA1c ≥9.0%) decreased to 0.34 (P < 0.001) at 24 months. Of CGM users, 65% used CGM >75% of time, and had a lower HbA1c at 24 months compared with those with usage <25% (7.8 ± 1.3% vs. 8.6 ± 1.8%, respectively, P < 0.001). Diabetic ketoacidosis was also reduced in this group (incidence rate ratio 0.49, 95% CI 0.33-0.74, P < 0.001). CONCLUSIONS: Following the national subsidy, CGM use was high and associated with sustained improvement in glycemic control. This information will inform economic analyses and future policy and serve as a model of evaluation diabetes technologies.

Establishing a path to unity: Recommendations for the Biden/Harris administration.

The Biden/Harris Administration faces many challenges, from systems and policies that do not work for or benefit all Americans to stark social and political divisions. Multiple courses of action will be necessary, and there must be commitment and investment for the "long haul." When considering the nation's challenges, overarching themes emerge that must be addressed. For instance, recommendations for justice reform cannot be followed without significant focus on race and equity. This focus will also be needed in considering solutions to affordable housing shortages, economic crises, and social and economic immobility concerns. In a similar vein, if the interests and rights of our nation's children are not recognized now, the social consequences will impact every aspect of their livelihoods-and those of future generations. The recommendations put forward by the Global Alliance are bold and will take time to fully implement. The implementation of these recommendations will challenge our systems and our policymakers to acknowledge our past and reenvision the future-and they will help address the multifaceted behavioral health and well-being needs of our nation, its communities, and its people. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Insulin resistance in type 1 diabetes managed with metformin (INTIMET): Study protocol of a double-blind placebo-controlled, randomised trial.

BACKGROUND: Insulin resistance is an under-recognised metabolic defect and cardiovascular risk factor in Type 1 diabetes. Whether metformin improves hepatic, muscle or adipose tissue insulin sensitivity has not been studied in adults with Type 1 diabetes. We initiated the INTIMET study (INsulin resistance in Type 1 diabetes managed with METformin), a double-blind randomised, placebo-controlled trial to measure the effect of metformin on tissue-specific insulin resistance in adults with Type 1 diabetes. METHODS: We will study 40 adults aged 20-55 years with Type 1 diabetes (HbA1c ≤ 80 mmol/mol [9.5%], fasting C-peptide <0.3 nmol/L) and 20 age-, gender- and body mass index (BMI)-matched controls. Insulin sensitivity will be determined by the two-step hyperinsulinaemic-euglycaemic clamp method with deuterated glucose to document liver, muscle and adipose insulin sensitivity. Subjects with Type 1 diabetes will be randomised to metformin extended-release 1500 mg daily or matched placebo for 26 weeks. The primary outcome is change in hepatic insulin sensitivity, assessed by change in basal rate of appearance (Ra) of glucose and suppression of endogenous glucose production (EGP) during the low-dose stage of the clamp. CONCLUSION: The INTIMET study is the first clinical trial to quantify the impact of metformin on liver, muscle and adipose insulin resistance in adults with Type 1 diabetes. This study may identify factors that predict an individual's response to metformin in Type 1 diabetes. TRIAL REGISTRATION: ACTRN12619001440112.

Parenting and social determinants of health.

Social determinants of health is a concept relevant to parenting in two ways. First, parenting behavior is a social determinant for child health and development; effective parenting is essential for successful emotional, physical and cognitive development. Second, social determinants of health are critical to the development and sustainability of adequate parenting behaviors, which, in term, are a social determinant of child health. Key social determinants related to parenting include economic stability, education, social and community context, neighborhood and built environment, access to health care and parenting interventions, and racism.

Combining Three Cohorts of World Trade Center Rescue/Recovery Workers for Assessing Cancer Incidence and Mortality.

Three cohorts including the Fire Department of the City of New York (FDNY), the World Trade Center Health Registry (WTCHR), and the General Responder Cohort (GRC), each funded by the World Trade Center Health Program have reported associations between WTC-exposures and cancer. Results have generally been consistent with effect estimates for excess incidence for all cancers ranging from 6 to 14% above background rates. Pooling would increase sample size and de-duplicate cases between the cohorts. However, pooling required time consuming steps: obtaining Institutional Review Board (IRB) approvals and legal agreements from entities involved; establishing an honest broker for managing the data; de-duplicating the pooled cohort files; applying to State Cancer Registries (SCRs) for matched cancer cases; and finalizing analysis data files. Obtaining SCR data use agreements ranged from 6.5 to 114.5 weeks with six states requiring >20 weeks. Records from FDNY (n = 16,221), WTCHR (n = 29,372), and GRC (n = 33,427) were combined de-duplicated resulting in 69,102 unique individuals. Overall, 7894 cancer tumors were matched to the pooled cohort, increasing the number cancers by as much as 58% compared to previous analyses. Pooling resulted in a coherent resource for future research for studies on rare cancers and mortality, with more representative of occupations and WTC- exposure.

Prenatal cigarette smoking as a mediator between racism and depressive symptoms: The Biosocial Impact on Black Births Study.

OBJECTIVE: This study examined whether cigarette smoking mediated the association of racial discrimination with depressive symptoms among pregnant Black women. DESIGN: Cross-sectional. SAMPLE: Two hundred Black women at 8-29 weeks gestation. MEASUREMENTS: Women completed questionnaires including the Experiences of Discrimination and the Center for Epidemiologic Studies-Depression (CES-D) scales, as well as questions about sociodemographic characteristics and cigarette smoking. RESULTS: The mean age of the sample was 26.9 ± 5.7 years and the mean gestational age at data collection was 15.6 ± 5.7 weeks. Approximately 17% of women reported prenatal cigarette smoking; 27% had prenatal CES-D scores ≥23, which have been correlated with depression diagnoses; and 59% reported ever (lifetime) experiencing discrimination in at least one situation (e.g., at work). Path analysis results indicated that the standardized indirect effect of experiences of racial discrimination on CES-D scores through prenatal smoking was statistically significant (standardized indirect effect = 0.03; 95% CI: 0.001, 0.094; p = .042). CONCLUSION: Cigarette smoking during pregnancy partially mediated the association between lifetime experiences of racial discrimination and prenatal depressive symptoms among pregnant Black women. Smoking cessation programs should focus on identifying and treating depressive symptoms among pregnant Black women.