SAI-CH-6: Development of a Short Form of the State Anxiety Inventory for Children At-Risk for Type 1 Diabetes.

OBJECTIVE: To develop a reliable and valid short form of the State Anxiety Subscale of the State-Trait Anxiety Inventory for Children (STAI-CH) in the Environmental Determinants of Diabetes in the Young (TEDDY) study. METHODS: A Development Sample of 842 10-year-old TEDDY children completed the STAI-CH State Subscale about their type 1 diabetes (T1D) risk. The best 6 items (three anxiety-present and three anxiety-absent) for use in a short form (SAI-CH-6) were identified via item-total correlations. SAI-CH-6 reliability was examined in a Validation Sample (n = 257) of children who completed the full 20-item STAI-CH State Subscale and then again in an Application Sample (n = 2,710) who completed only the SAI-CH-6. Expected associations between the children's SAI-CH-6 scores and country of residence, sex, T1D family history, accuracy of T1D risk perception, worry about getting T1D, and their parents' anxiety scores were examined. RESULTS: The SAI-CH-6 was reliable (α = 0.81-0.87) and highly correlated with the full 20-item STAI-CH State Subscale (Development Sample: r = 0.94; Validation Sample: r = 0.92). SAI-CH-6 scores detected significant differences in state anxiety symptoms associated with T1D risk by country, T1D family history, accuracy of T1D risk perception, and worry about getting T1D and were correlated with the child's parent's anxiety. CONCLUSION: The SAI-CH-6 appears useful for assessing children's state anxiety symptoms when burden and time limitations prohibit the use of the STAI-CH. The utility of the SAI-CH-6 in older children with and without chronic conditions needs to be assessed.

Parental monitoring for type 1 diabetes in genetically at-risk young children: The TEDDY study.

OBJECTIVE: We examined parental diabetes monitoring behaviors in a cohort of children at increased genetic risk for type 1 diabetes. We hypothesized that being informed of a positive islet autoantibody (IA) would increase monitoring behaviors. RESEARCH DESIGN AND METHODS: The Environmental Determinants of Diabetes in the Young (TEDDY) study follows 8676 children with high-risk human leucocyte antigen-DQ genotypes from birth to age 15, including general population (GP) children and those with a first-degree relative (FDR) with diabetes. Data on parental monitoring behaviors were solicited yearly. Serum samples were tested for IA and parents were informed of child results. We examined parental monitoring behaviors during the first 7 years of TEDDY. RESULTS: In IA- children, the most common monitoring behavior was participating in TEDDY study tasks; up to 49.8% and 44.2% of mothers and fathers, respectively, reported this. Among FDRs, 7%-10% reported watching for diabetes symptoms and 7%-9% reported monitoring the child's glucose, for mothers and fathers, respectively. After IA+ notification, all monitoring behaviors significantly increased in GP parents; only glucose monitoring increased in FDR parents and these behaviors continued for up to 4 years. FDR status, accurate diabetes risk perception, and anxiety were associated with glucose monitoring in IA+ and IA- cohorts. CONCLUSIONS: Many parents view TEDDY participation as a way to monitor for type 1 diabetes, a benefit of enrollment in a longitudinal study with no prevention offered. IA+ notification increases short- and long-term monitoring behaviors. For IA- and IA+ children, FDR parents engage in glucose monitoring, even when not instructed to do so.

The Association Between Glycemic Variability and Macronutrients in Young Children with T1D.

OBJECTIVE: There is limited information regarding the potential effect macronutrients have on postprandial glycemic variability in young children with type 1 diabetes (T1D). To date, studies examining nutrition and glycemic outcomes either assess these factors at a single timepoint, or aggregate large datasets for group level analyses. This study examined how inter- and intraindividual fluctuations in carbohydrate, fat, and protein intake impact glycemic variability in the postprandial period for young children with T1D. METHODS: Thirty-nine young children, aged 2-6 years, wore a continuous glucose monitor for 72 hr, while their parents completed detailed diet records of all food intake. The analyses tested three multilevel models to examine intra- and interindividual differences between food intake and postprandial glycemic variability. RESULTS: The results suggest carbohydrate intake, relates to greater postprandial glycemic variability. In contrast, the results reveal the inverse effect for protein, suggesting a tendency for young children who ate more protein at some meals to have lower postprandial glycemic variability, with the exception of lunch. There was no effect for fat on postprandial glycemic variability. CONCLUSION: These results suggest protein consumption may be an important consideration when aiming for optimal glycemic levels for some meals. When counseling parents of young children with T1D on common behaviors underlying glycemic excursion, pediatric psychologists may consider discussing the nutritional make up of children's meals. Further, the results demonstrate retaining longitudinal data at the person level, versus aggregating individual data for group level analyses, may offer new information regarding macronutrient intake and glycemic outcomes.

An Examination of Sex Differences in a Disease-Specific Model of Disordered Eating Behaviors in Type 1 Diabetes.

OBJECTIVE: Preliminary evidence supports the integration of type 1 diabetes (T1D) disease-specific factors into eating disorder risk models. The current study explored whether cross-sectional associations among constructs included in the modified dual pathway model of eating disorder risk for individuals with T1D are similar across sex among adolescents and young adults with T1D. METHODS: Original study participants were recruited from the T1D Exchange Clinic Network, a U.S. registry of individuals with T1D. Online surveys included measures of general eating disorder risk factors, hypothesized T1D-specific risk factors, and a T1D-specific eating disorder questionnaire. The current study is a secondary analysis with the adolescents (13-17 years; n = 307; 46.9% female) and young adults (18-25 years; n = 313; 62.6% female) from the original sample. In the absence of strong measurement invariance for all measures of interest, sex-specific path models were estimated among the adolescent and young adult cohorts. RESULTS: Only two paths emerged as significant in the female, but not male, adolescent model. In the young adult cohort, all significant paths were the same across sex. CONCLUSIONS: Both general and T1D-specific risk factors are associated with disordered eating behaviors in the T1D population. Patterns of associations were similar across male and female youth with T1D, suggesting that sex-specific prevention approaches to disordered eating behaviors among T1D youth may not be warranted.

School-Based Management of Pediatric Type 1 Diabetes: Recommendations, Advances, and Gaps in Knowledge.

PURPOSE OF REVIEW: Children and adolescents with type 1 diabetes (T1D) spend much of their waking time in the school environment. However, there is limited empirical understanding of the challenges youth face in managing their T1D at school. There is even less literature focused on potential interventions to improve health or psychological outcomes in youth with T1D in this milieu. This review seeks to summarize the recent literature on diabetes T1D management in the school setting, including recommendations for care, barriers, and targets for intervention. RECENT FINDINGS: T1D organizations recommend strong collaboration amongst families, school personnel, and health care providers to enable successful T1D management in schools. While challenges remain according to parent, child, and teacher reports, perceptions of school-based management of T1D show signs of improvement. The few existing school-based intervention studies have generally focused on educational or structural interventions to improve diabetes care. The management of T1D within the school setting is critical for overall diabetes management. While barriers to effective T1D care have been examined, a greater understanding of the impact of new diabetes technologies and well-characterized interventions is lacking in this area.

Test of the modified dual pathway model of eating disorders in individuals with type 1 diabetes.

OBJECTIVE: Adolescents and young adults with type 1 diabetes (T1D) demonstrate high rates of disordered eating behaviors (DEBs) and may experience physiological and psychological vulnerabilities not currently included in established risk models of DEBs. This study examined associations among constructs included in the recently proposed T1D-specific modified dual pathway model and examined age as a moderator of these associations. METHOD: Participants included adolescents (n = 307; age M = 15.71, SD = 1.33), young adults (n = 313; age M = 21.20, SD = 2.10), and adults (n = 198; age M = 30.51, SD = 2.81) recruited via the T1D Exchange Clinic Registry. Data were collected from participants' medical records and from self-report questionnaires assessing dietary regimen, dietary restraint, body dissatisfaction, hunger/satiety, diabetes-specific negative affect, and DEBs. Multiple group path modeling was used to test hypotheses. RESULTS: Approximately 31% of participants were at risk for an eating disorder. The original modified dual pathway model had poor model fit. The addition of three empirically defensible paths improved model fit. Diabetes-specific dietary regimen, diabetes-specific negative affect, and hunger/satiety disruption all were associated with DEBs. A fully varying multiple group model by age fit best; however, only the dietary restraint to DEBs pathway demonstrated a distinct pattern across age cohort, which attenuated from the adolescent to the adult cohort. DISCUSSION: This study provides preliminary support for associations proposed in the modified dual pathway model and suggests potential for intervening on disease-specific risk factors of DEBs in a T1D population.

Family adjustment to diabetes diagnosis in children: Can participation in a study on type 1 diabetes genetic risk be helpful?

BACKGROUND: Diagnosis of type 1 diabetes often causes a negative psychological impact on families. We examined whether parents and children enrolled in The Environmental Determinants of Diabetes in the Young (TEDDY) study differ in their psychological adjustment to diabetes diagnosis compared to children diagnosed with diabetes in the community. METHODS: TEDDY follows 8676 children at genetic risk for type 1 diabetes from birth. Fifty-four TEDDY children diagnosed with diabetes and 54 age-matched community control children diagnosed with diabetes were enrolled. Participants were aged 3 to 10 years and study visits occurred at 3, 6, and 12 months postdiagnosis. Psychological measures included an adapted diabetes-specific State Anxiety Inventory, the Pediatric Quality of Life Inventory-Diabetes Module, and the Pediatric Inventory for Parents, which measures frequency and difficulty of parenting stress. RESULTS: A generalized estimating equation analysis based on a difference score between TEDDY children and community controls found no significant differences between TEDDY parents and community controls on parent diabetes-specific anxiety (P = .30). However, TEDDY children exhibited better diabetes-specific quality of life (P = .03) and TEDDY parents reported lower frequency (P = .004) and difficulty (P = .008) of parenting stress compared to community controls. CONCLUSIONS: Children diagnosed with at-risk for type 1 diabetes who have previously enrolled in research monitoring have improved diabetes quality of life and lower parenting stress postdiagnosis compared to children diagnosed in the community. Families in follow-up studies may be more prepared if their child is diagnosed with diabetes.

Shared decision-making among caregivers and health care providers of youth with type 1 diabetes.

The present study aimed to examine perceptions of shared decision-making (SDM) in caregivers of youth with type 1 diabetes (T1D). Interview, survey data, and HbA1c assays were gathered from caregivers of 439 youth with T1D aged 3-18 years. Caregiver-report indicated high perceived SDM during medical visits. Multivariable linear regression indicated that greater SDM is associated with lower HbA1c, older child age, and having a pediatric endocrinologist provider. Multiple logistic regression found that caregivers who did not perceive having made any healthcare decisions in the past year were more likely to identify a non-pediatric endocrinologist provider and to report less optimal diabetes self-care. Findings suggest that youth whose caregivers report greater SDM may show benefits in terms of self-care and glycemic control. Future research should examine the role of youth in SDM and how best to identify youth and families with low SDM in order to improve care.

Children's emotional and behavioral reactions to disasters: role of the primary care physician.

BACKGROUND: Children are especially vulnerable to the effects of disasters. The coming tornado season raises concerns about enduring problems and anniversary reactions related to the May 2013 tornadoes as well as anxiety about the possibility of new events. METHODS: This article describes common emotional and behavioral disaster reactions in children and also identifies reactions unique to a particular age. Reactions are clustered into depressive, anxious, and behavioral symptoms and physiological responses. PRIMARY RESULTS: This article outlines the key elements in assessing children's disaster reactions and provides specific recommendations for situations that would indicate the need for a mental health evaluation such as for directly-exposed children, children who experience disaster-related losses, those with pre-existing vulnerabilities, and those with significant symptoms. PRINCIPAL CONCLUSIONS: Primary care physicians can help identify the emotional and behavioral effects of disasters in children, educate parents to recognize children's reactions, and refer children in need of specialized care.

Incidence and predictors of nephrotoxicity associated with intravenous colistin in overweight and obese patients.

Intravenous colistin is used to treat resistant Gram-negative infections and is associated with nephrotoxicity. In overweight and obese adults, a paucity of data exists regarding the incidence and predictors of such toxicity. A retrospective nested case-control study was performed over 35 months for patients receiving intravenous colistin for ≥ 72 h with a body mass index (BMI) of ≥ 25 kg/m(2). The objective was to investigate the incidence and predictors of nephrotoxicity. Severity of acute kidney injury was defined by RIFLE (risk, injury, failure, loss, and end-stage kidney disease) criteria. Dosing and mortality were secondarily investigated. Forty-two patients met the inclusion criteria, and 20 (48%) developed nephrotoxicity. Patients with toxicity were in the risk (15%), injury (5%), and failure (80%) categories based on RIFLE criteria. A logistic regression model identified four predictors of colistin-associated nephrotoxicity: a BMI of ≥ 31.5 kg/m(2) (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.15 to 8.35), diabetes (OR, 2.11; 95% CI, 0.84 to 5.29), the length of hospitalization in days prior to receipt of colistin (OR, 1.04; 95% CI, 0.99 to 1.08), and age (OR, 1.08; 95% CI, 1.00 to 1.17). Among all of the patients, dosing based on the actual body weight and excessive dosing due to the use of the actual body weight were frequent at 64% and 92%, respectively. The 30-day all-cause in-hospital mortality rate was 40% in the toxicity group and 14% in the nontoxicity group (P = 0.14). Patients receiving intravenous colistin should be monitored for nephrotoxicity, especially when the BMI exceeds 31.5 kg/m(2). Prospective, randomized, controlled trials are warranted to further examine nephrotoxicity incidence and predictors and appropriate dosing strategies in this population.

Heavy metal wombats? Metal exposure pathways to bare-nosed wombats (Vombatus ursinus) living on remediated tin mine tailings.

Rehabilitation of disused mine sites through stabilisation and botanical restoration is ecologically important, but metal transfer pathways to colonising wildlife are often less understood and have never been studied in marsupials. The rehabilitated Royal George tin mine tailings (Tasmania, Australia) and colonisation by bare-nosed wombats (Vombatus ursinus) represented an opportunity to examine potential metal transfer from mine tailings to an herbivorous marsupial. The aim of this study was to examine metal transfer pathways from the mine tailings to wombats, and to determine if wombats are at risk from metal exposure. Concentrations of metals were measured in the tailings substrate, surface water and vegetation, as well as fur samples from a resident wombat, and non-resident (control) wombats. The mineralogy of the tailings is dominated by quartz, muscovite, feldspars, topaz, kaolinite and calcite. Concentrations of several metals were high (exceeding varying health standards) in the tailings (As, Cu, Hg, Pb, Ni, Zn), water (As, Cd, Cu, Zn) and vegetation (As, Cd, Cu, Pb, Mn, Zn). Relative to non-resident wombats, elevated levels of As, Cd, Cu, Pb and Sn were measured in the fur of a resident wombat. Based on modelling of the exposure pathways, consumption of plant material is the most likely metal transfer pathway for As, Cu and Pb, although the risks from ingestion of tailings to this fossorial marsupial should not be discounted. This study is the first to investigate metal exposure pathways to marsupials using rehabilitated mine tailings. Further research is needed to accurately quantify ecological risks and toxicity for wombats and other marsupials native to mining landscapes.

Pediatric parenting stress and its relation to depressive symptoms and fear of hypoglycemia in parents of young children with type 1 diabetes mellitus.

Parents of young children with type 1 diabetes (T1DM) maintain full responsibility for their child's daily diabetes self-care and thus may be vulnerable to experiencing parenting stress. This study examined several psychological correlates of pediatric parenting stress in parents of young children with T1DM. Parents of 39 young children with T1DM (ages 2-7 years) completed measures of pediatric parenting stress, mealtime behavior problems, depressive symptoms, and fear of hypoglycemia. For parents of young children, higher stress frequency and difficulty were associated with higher parental depressive symptoms and fear. Regression analyses identified that 58% of the variance in stress frequency was associated with parental depressive symptoms. For stress difficulty, 68% of the variance was associated with parental depressive symptoms and fear. Pediatric parenting stress is common in parents of young children with T1DM. Stress and the psychological correlates measured in this study are amenable to intervention and should be regularly assessed in parents of young children with T1DM.

Connected care: reducing errors through automated vital signs data upload.

Vital signs are a fundamental component of patient care. Omitted or inaccurately transcribed vital sign data could result in inappropriate, delayed, or missed treatment. A previous baseline study determined that error rates for vital signs captured on plain paper then entered into a paper chart or EMR were 10% and 4.4%, respectively. This study evaluated the impact of automated vital signs captured using a PDA with bar-code technology for patient identification. The PDA enabled the wireless capture and transmission of data directly from the vital sign monitor into the EMR. Researchers reviewed 1514 sets of vital signs collected electronically for accuracy and compared the error rate with data from the previous paper and EMR systems. Automated upload of vital signs directly into an EMR reduced the documentation error rate to less than 1%. This represented a significant reduction in vital sign documentation errors with the use of mobile technology when compared with traditional charting methods (P < .001). The automated vital sign data upload system helped promote a culture of patient safety by greatly reducing documentation error rates. Additional safety benefits may include improved timeliness to vital sign data and clinical work-flow processes.

Psychological Manifestations of Celiac Disease Autoimmunity in Young Children.

BACKGROUND AND OBJECTIVES: Psychological symptoms can be associated with celiac disease; however, this association has not been studied prospectively in a pediatric cohort. We examined mother report of psychological functioning in children persistently positive for tissue transglutaminase autoantibodies (tTGA), defined as celiac disease autoimmunity (CDA), compared with children without CDA in a screening population of genetically at-risk children. We also investigated differences in psychological symptoms based on mothers' awareness of their child's CDA status. METHODS: The Environmental Determinants of Diabetes in the Young study followed 8676 children to identify triggers of type 1 diabetes and celiac disease. Children were tested for tTGA beginning at 2 years of age. The Achenbach Child Behavior Checklist assessed child psychological functioning at 3.5 and 4.5 years of age. RESULTS: At 3.5 years, 66 mothers unaware their child had CDA reported more child anxiety and depression, aggressive behavior, and sleep problems than 3651 mothers of children without CDA (all Ps ≤ .03). Unaware-CDA mothers also reported more child anxiety and depression, withdrawn behavior, aggressive behavior, and sleep problems than 440 mothers aware of their child's CDA status (all Ps ≤.04). At 4.5 years, there were no differences. CONCLUSIONS: In 3.5-year-old children, CDA is associated with increased reports of child depression and anxiety, aggressive behavior, and sleep problems when mothers are unaware of their child's CDA status. Mothers' knowledge of their child's CDA status is associated with fewer reports of psychological symptoms, suggesting that awareness of the child's tTGA test results affects reporting of symptoms.

Enhancing patient safety through electronic medical record documentation of vital signs.

As technology becomes more sophisticated in healthcare, there is increasing need to measure its impact on key quality indicators, such as error reduction, patient safety, and cost-benefit ratios. When a product is designed to decrease medical errors, the baseline error rate must be determined before implementation to accurately measure the impact. Given the opportunity to adopt a technology that would eliminate the need to manually document vital signs, a large Florida hospital decided to measure the current process and error rate of vital signs documentation. University Community Hospital in Tampa, Fla., designed a two-phase study to evaluate this process. Phase I of the study evaluated errors in the electronic medical record and traditional manual documentation. The results demonstrate that use of an EMR can reduce vital sign documentation errors by more than half compared with traditional manual documentation in paper charts. Researchers found the error rate for electronic vital signs documentation to be less than 5 percent, compared with the paper chart error rate of 10 percent.

Factors associated with maternal-reported actions to prevent type 1 diabetes in the first year of the TEDDY study.

OBJECTIVE: Mothers of children at risk for type 1 diabetes report engaging in preventive behaviors. The purpose of this study is to further document these actions in an international, longitudinal sample and examine variables that predict whether mothers engage in these behaviors. RESEARCH DESIGN AND METHODS: This study examined an international sample (from Finland, Germany, Sweden, and the U.S.) from the naturalistic, longitudinal The Environmental Determinants of Diabetes in the Young (TEDDY) study, which tracked children genetically at risk for type 1 diabetes from birth to age 15 years. Mothers of 7,613 infants aged 6 months and 6,503 infants aged 15 months completed questionnaires assessing psychosocial factors and actions intended to prevent diabetes. RESULTS: Many mothers (29.9% at 6 months and 42.8% at 15 months) reported engaging in a behavior intended to prevent type 1 diabetes, with the largest percentages (20.9-29.2%) reporting making changes to their child's diet (e.g., reducing the consumption of sweets and carbohydrates). Factors related to engaging in preventive behaviors include older maternal age; higher maternal education; minority status; having only one child; having a first-degree relative with type 1 diabetes; being from a country other than Sweden; having an accurate perception of the child's increased risk for developing diabetes; having postpartum depression, maternal anxiety, and worry about the risk of diabetes; and believing that diabetes can be prevented. CONCLUSIONS: The findings of this study suggest that many mothers engage in actions to prevent diabetes and highlight the importance of tracking these behaviors to ensure the validity of naturalistic observational studies.

Examining mealtime behaviors in families of young children with type 1 diabetes on intensive insulin therapy.

This study examined mealtime behaviors in families of young children with type 1 diabetes (T1DM) on intensive insulin therapy. Behaviors were compared to published data for children on conventional therapy and examined for correlations with glycemic control. Thirty-nine families participated and had at least three home meals videotaped while children wore a continuous glucose monitor. Videotaped meals were coded for parent, child, and child eating behaviors using a valid coding system. A group difference was found for child request for food only. There were also associations found between children's glycemic control and child play and away. However, no associations were found between parent and child behaviors within meals and children's corresponding post-prandial glycemic control. Results reinforce existing research indicating that mealtime behavior problems exist for families of young children even in the context of intensive therapy and that some child behaviors may relate to glycemic control.

Gene expression profiling in neutrophils from children with polyarticular juvenile idiopathic arthritis.

OBJECTIVE: We have previously reported a defect in neutrophil activation in children with polyarticular juvenile idiopathic arthritis (JIA). The current study was undertaken to determine whether gene expression abnormalities persist in JIA in remission and to use systems biology analysis to elucidate pathologic pathways in polyarticular JIA. METHODS: We performed gene expression profiling on neutrophils from children with polyarticular JIA. Children were grouped according to disease status. We studied 14 children with active disease who were taking medication, 8 children with clinical remission of disease who were taking medication (CRM status), and 6 children with clinical remission of disease who were not taking medication (CR status). We also studied 13 healthy children whose age ranges overlapped those of the patients. RESULTS: Neutrophil abnormalities persisted in children with polyarticular JIA even after disease remission was achieved. Children with active disease and those with CRM status showed no differences in expression of specific genes, although they could be separated on cluster analysis. A comparison of children with CR status and healthy control children revealed networks of pro- and antiinflammatory genes that suggested that remission is a state of homeostasis and balance rather than a return to normal immune function. Furthermore, gene overexpression in patients with CR status supports the hypothesis that neutrophils play a role in regulating adaptive immunity in this disease. CONCLUSION: Neutrophil gene profiling in polyarticular JIA suggests important roles for neutrophils in disease pathogenesis. These findings suggest the presence of complex interactions between innate and adaptive immunity, that are not easily modeled in conventional, linear, reductionist systems.