Evaluating the Impact of Telemedicine Expansion on Visit Frequency for Children with Type 1 Diabetes at a Single Academic Center in Oregon.

Objective: The telemedicine expansion (TE) that accompanied the COVID-19 pandemic presents a novel opportunity to increase access to care for rural-residing children with type 1 diabetes (T1D) who may live a great distance from their provider. The study objective was to compare trends in visit frequency among the pediatric T1D population at a single academic center in Oregon before and after TE by those living <100 miles versus ≥100 miles from clinic (MFC) and those residing in urban versus rural areas. Research Design and Methods: We evaluated electronic health record data from 790 children receiving care between July 2018 and December 2021. We estimated differences in likelihood of adequately timed monitoring care (ATMC) over time by patient residence using Generalized Estimating Equations. Results: Just before TE, 37.3% of children were receiving ATMC and those living ≥100 MFC were 20.6% less likely to receive ATMC compared with those living <100 MFC (relative risk [RR] 0.79; confidence interval [95% CI]: 0.57-1.11). Following TE, decreases in ATMC for those living ≥100 MFC were less than for those living <100 MFC (RR of interaction: 1.17; 95% CI: 0.68-2.00). Just before TE, those living in rural areas were as likely to receive ATMC compared with those living in urban areas (RR 1.00; 95% CI: 0.61-1.63). Following TE, decreases in ATMC were greater for those living in rural areas versus urban areas (RR of interaction: 0.79; 95% CI: 0.31-2.01). Conclusions: Between July 2020 and December 2021, the likelihood of ATMC decreased across the entire pediatric T1D population. Decreases in ATMC during this period were more substantial for those living <100 MFC and/or in rural areas, however, these discrepancies were not statistically significant.

Use of glucagon-like peptide-1 receptor agonists for pediatric patients with obesity and diabetes: The providers' perspectives.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RA) have been widely used in adults with Type 2 diabetes (T2D) and obesity. We sought to evaluate the experience of pediatric endocrinology providers with GLP-1RA and factors that guide them on whether and how to prescribe these medications. METHODS: We surveyed the members of the Pediatric Endocrine Society regarding the use of GLP-1RA in their practice. RESULTS: The respondents (n = 102) were predominantly from academic centers (84%) and 75%reported using GLP-1RA in pediatric patients, mostly to treat T2D and obesity. Patient tolerance for the medication was reported to be the driving factor determining the duration of treatment. Gastrointestinal side effects were observed more commonly than local reactions or elevation of pancreatic enzymes. Lack of clinical experience was reported to be a major barrier for prescribing GLP-1RA, particularly among those with more than 5 years of clinical experience. Finally, liraglutide was used more often (93%) than other GLP-1RA. CONCLUSIONS: The use of GLP-1RA has increased in pediatric patients. Recent Food and Drug Administration approval of liraglutide for pediatric obesity will likely further increase its prescription rate. Providers should be vigilant about side effects and adjust the doses of GLP-1RA accordingly. More efforts should be made by professional societies to educate pediatric endocrinology providers about the proper use of GLP-1RA and enhance their confidence in prescribing these medications.

Use of Telehealth Videoconferencing in Pediatric Type 1 Diabetes in Oregon.

INTRODUCTION: We reviewed the impact of telehealth videoconferencing clinics on outcomes of care in pediatric patients with type 1 diabetes in rural Oregon. METHODS: We performed a chart review as well as the review of patient satisfaction questionnaires from 27 patients seen in the first year of the program. RESULTS: The number of yearly visits to diabetes clinic increased from average 1.5 to 2.7, which was statistically significant (p < 0.0001). Glycemic control remained stable, and there was no difference in the amount of emergency department visits or hospitalizations related to diabetes. Patients expressed high satisfaction with the service and majority considered it equal to in-person visits. CONCLUSION: We conclude that telehealth videoconferencing visits have the potential to improve care in pediatric diabetes patients, particularly the patients living in areas distant from subspecialty centers.

Telemedicine care coordination and visit frequency in pediatric patients with type 1 diabetes in Oregon.

Introduction: Children with type 1 diabetes require close monitoring with visits every 3-4 months. COVID-19-induced telemedicine expansion may alleviate the challenge of high visit frequency that children with type 1 diabetes face. However, telemedicine's impact on access to care may be limited if patients lack adequate support for telemedicine. The purpose of this study was to evaluate the impact of telemedicine care coordination services on visit frequency in an urban medical center without care coordination services versus a rural outreach program with established care coordination services serviced by the same providers. Methods: We evaluated EHR data from 790 children receiving care between July 2018 and December 2021 at a single academic center in Oregon. We estimated differences in likelihood of adequately timed monitoring care over time by patient care coordination services status using Generalized Estimating Equations. Results: Just prior to telemedicine expansion, patients receiving care coordination services were 25.6 % less likely to receive adequately timed monitoring care (95 % CI: 51.6 %, 114 %). Following telemedicine expansion, likelihood of adequately timed monitoring care increased from 28.8 % to 58.2 % among those receiving care coordination services and decreased from 38.7 % to 22.0 % among those not receiving care coordination services; increases in adequately timed monitoring care were 3.55 times greater in patients receiving care coordination services relative to those not (95 % CI: 2.10, 6.01). Discussion: For pediatric patients with type 1 diabetes, telemedicine care coordination may be an important factor for increasing visit adherence and may increase the number of patients meeting goal visit frequency beyond levels seen prior to widespread telemedicine availability.

Pediatric Endocrinology in the Time of COVID-19: Considerations for the Rapid Implementation of Telemedicine and Management of Pediatric Endocrine Conditions.

BACKGROUND: Pediatric endocrine practices had to rapidly transition to telemedicine care at the onset of the novel coronavirus disease 2019 (COVID-19) pandemic. For many, it was an abrupt introduction to providing virtual healthcare, with concerns related to quality of patient care, patient privacy, productivity, and compensation, as workflows had to change. SUMMARY: The review summarizes the common adaptations for telemedicine during the pandemic with respect to the practice of pediatric endocrinology and discusses the benefits and potential barriers to telemedicine. Key Messages: With adjustments to practice, telemedicine has allowed providers to deliver care to their patients during the COVID-19 pandemic. The broader implementation of telemedicine in pediatric endocrinology practice has the potential for expanding patient access. Research assessing the impact of telemedicine on patient care outcomes in those with pediatric endocrinology conditions will be necessary to justify its continued use beyond the COVID-19 pandemic.

Concurrent Van der Woude syndrome and Turner syndrome: A case report.

Most cases of Van der Woude syndrome are caused by a mutation to interferon regulatory factor 6 on chromosome 1. Turner syndrome is caused by complete or partial absence of the second sex chromosome in girls. We describe a unique case of the two syndromes occurring concurrently though apparently independently in a girl with Van der Woude syndrome diagnosed at birth and Turner syndrome at 14 years 9 months. Short stature was initially misattributed to Van der Woude syndrome and pituitary insufficiency associated with clefts before correctly diagnosing Turner syndrome. We discuss the prevalence of delayed diagnosis of Turner syndrome, the rarity of reports of concurrent autosomal chromosome mutation and sex chromosome deletion, as well as the need to consider the diagnosis of Turner syndrome in all girls with short stature regardless of prior medical history.

Reliability of Trained Dogs to Alert to Hypoglycemia in Patients With Type 1 Diabetes.

BACKGROUND: We examined the reliability of trained dogs to alert to hypoglycemia in individuals with type 1 diabetes. METHODS: Patients with type 1 diabetes who currently used diabetes alert dogs participated in this exploratory study. Subjects reported satisfaction, perceived dog glucose sensing ability and reasons for obtaining a trained dog. Reliability of dog alerts was assessed using capillary blood glucose (CBG) and blinded continuous glucose monitoring (CGM) as comparators in 8 subjects (age 4-48). Hypoglycemia was defined as CBG or CGM <70 mg/dL. RESULTS: Dog users were very satisfied (8.9/10 on a Likert-type scale) and largely confident (7.9/10) in their dog's ability to detect hypoglycemia. Detection of hypoglycemia was the primary reason for obtaining a trained dog. During hypoglycemia, spontaneous dog alerts occurred at a rate 3.2 (2.0-5.2, 95% CI) times higher than during euglycemia (70-179 mg/dL). Dogs provided timely alerts in 36% (sensitivity) of all hypoglycemia events (n = 45). Due to inappropriate alerts, the PPV of a dog alert for hypoglycemia was 12%. When there was concurrence of a hypoglycemic event between the dog alert and CGM (n = 30), CGM would have alerted prior to the dog in 73% of events (median 22-minute difference). CONCLUSIONS: This is the first study evaluating reliability of trained dogs to alert to hypoglycemia under real-life conditions. Trained dogs often alert a human companion to otherwise unknown hypoglycemia; however due to high false-positive rate, a dog alert alone is unlikely to be helpful in differentiating hypo-/hyper-/euglycemia. CGM often detects hypoglycemia before a trained dog by a clinically significant margin.

Technology Use in Transition-Age Patients With Type 1 Diabetes: Reality and Promises.

Youth with chronic illnesses have the greatest risk for a decline in their health management during transition-age. Because of this demonstrated and well-known issue, research has focused on how to improve the transition of care process. Despite the increasing number of technological devices on the market and the advances in telemedicine modalities available to patients with type 1 diabetes (T1D), the utilization of technology is still suboptimal among patients of transition-age (ages 13-25). This article reviews the available resources, patterns of use in transition-age youth, and explores opportunities to advance technology use in transitioning patients with T1D from pediatric to adult care.

Approach to adolescent polycystic ovary syndrome (PCOS) in the pediatric endocrine community in the U.S.A.

OBJECTIVE: Polycystic ovarian syndrome (PCOS) is the most common endocrinopathy in adult women, and is emerging as a common cause of menstrual disturbances in the adolescent population. Insulin resistance, which is considered one of its underlying causes, has increased substantially in the past decade, putting more adolescent girls at risk for PCOS and its complications. Our objective was to survey pediatric endocrinologists' approach to diagnosis and treatment of PCOS in the adolescent population, as there is presently no structured recommended approach to this emerging problem. DESIGN/METHODS: A questionnaire survey was sent to 839 members of the Lawson Wilkins Pediatric Endocrine Society (LWPES). A total of 176 (21%) responses was received and analyzed. REDULTS: The majority of the participants would consider initiating work-up in an adolescent with oligomenorrhea or secondary amenorrhea 12-24 months after menarche. The following work-up was selected as a baseline for a teenager with oligomenorrhea or secondary amenorrhea by more than 50% of participants: LH and FSH, total and free testosterone, prolactin, 17-OH-progesterone, DHEAS and glucose/insulin measurements. For treatment of PCOS, the majority of surveyed endocrinologists suggested estrogen/progesterone combination. Metformin was considered appropriate treatment in the general adolescent population with PCOS by 30% and in obese teenagers with PCOS by 68% of surveyed endocrinologists. CONCLUSIONS: Our findings indicate the trend among pediatric endocrinologists towards earlier work-up of menstrual irregularities in adolescents--unlike the traditional practice of waiting for 2 years after menarche. Most pediatric endocrinologists would consider evaluation for insulin resistance using glucose/insulin measurement, but only a small percentage considers performing OGTT in these patients. Even though using estrogen/progesterone combination is the preferred therapeutic approach, 30% of surveyed endocrinologists consider metformin therapy for the general adolescent population with PCOS, and 68% would consider using it in obese adolescents with PCOS.

Perspectives from before and after the pediatric to adult care transition: a mixed-methods study in type 1 diabetes.

OBJECTIVE: Among the many milestones of adolescence and young adulthood, transferring from pediatric to adult care is a significant transition for those with type 1 diabetes. The aim of this study was to understand the concerns, expectations, preferences, and experiences of pretransition adolescents and parents and posttransition young adults. RESEARCH DESIGN AND METHODS: Participants completed questionnaires and responded to open-ended qualitative questions regarding self-management, self-efficacy, and their expectations and experiences with pediatric and adult care providers across the transition process. RESULTS: At a mean age of 16.1 years, most pretransition adolescents had not yet discussed transferring care with their parents or doctors. Although many posttransition young adults reported positive, supportive interactions, several described challenges locating or establishing a relationship with an adult diabetes care provider. Qualitative themes emerged related to the anticipated timing of transfer, early preparation for transition, the desire for developmentally appropriate interactions with providers, the maintenance of family and social support, and strategies for coordinating care between pediatric and adult care providers. CONCLUSIONS: Standardizing transition preparation programs in pediatric care and introducing transition-oriented clinics for late adolescents and young adults prior to adult care may help address patients' preferences and common transfer-related challenges.