Background: Members of our group previously reported that monetary reinforcement of SMBG related behaviors shows robust increases in frequency of SMBG and modest decreases in A1c among youth with ...type 1 diabetes (T1D). In these secondary data analyses, we explored effects on psychosocial functioning.
Methods: Sixty youth ages 12-21 (Mage=15.58, SD=2.31) with T1D, A1c 7.5-13%, and <4 BG checks per day were randomized to either a 24-week reinforce intervention or enhanced usual care (EUC). The intervention consisted of monetary incentives for completing blood glucose checks, texts with provider, glucose data uploads, and glucose pattern recognition forms. Validated psychosocial questionnaires were administered at baseline, 6, 12, 24, and 36 weeks. Measures included youth reported diabetes distress, family conflict, and negative affective responses to out-of-range glucose results.
Results: Generalized linear models showed no significant time x condition effects. In t-tests at discrete follow-ups, compared to the control group, the reinforce group had significantly lower youth-reported diabetes related family conflict at 12 weeks (22.39 vs. 25.11, p=.043) and significantly higher negative affective responses to out-of-range glucose results at 24 weeks (13.62 vs. 11.71, p=.047).
Conclusion: Monetary reinforcers targeting SMBG behaviors may produce transitory decreases in youth perceptions of family conflict and transitory iatrogenic increases in youth’s negative affective responses to out-of-range glucose results. The timing of changes in family conflict, negative affect, and previously reported changes in A1c suggest that psychosocial changes may reflect youth responses to A1c as well as to reinforcers per se. For broader effects, the intervention could include psychosocial components that seek to directly maintain decreased family conflict and mitigate negative affect related to increased awareness of glucose control.
Disclosure
J.J. Wong: None. A. Addala: None. K.K. Hood: Consultant; Self; Lilly Diabetes. Research Support; Self; Dexcom, Inc. Speaker's Bureau; Self; Johnson & Johnson Diabetes Institute. J. Wagner: None. E. Cengiz: Advisory Panel; Self; Abvance, ADOCIA, MannKind Corporation, Novo Nordisk Inc. Speaker's Bureau; Self; Novo Nordisk Inc. E.M. Tichy: None. K. Weyman: None. D. Naranjo: Advisory Panel; Spouse/Partner; Eli Lilly and Company. Speaker's Bureau; Spouse/Partner; Johnson & Johnson Diabetes Institute. Other Relationship; Self; Abbott.
Funding
National Institutes of Health
Screening for depression, diabetes distress, and disordered eating in youth with type 1 diabetes (T1D) is recommended, as these comorbidities contribute to poor glycemic control. No consensus exists ...on which measures are optimal, and most previous studies have used nondisease-specific measures. We examined the utility of screening for these disorders using two disease-specific and one general measure at the time of transition from pediatric to adult care.
Forty-three young adults from a T1D transition clinic completed the Patient Health Questionnaire, the Diabetes Distress Scale, and the Diabetes Eating Problem Survey-Revised. Chart review determined if clinicians noted similar symptoms during the year prior to transition. Metabolic data were also recorded.
Chart review identified 5 patients with depressive symptoms and 8 patients with diabetes distress. Screening identified 2 additional patients with depressive symptoms and 1 additional patient with diabetes distress. Of those noted to have symptomatic depression or diabetes distress on chart review, several subsequently screened negative on transition. Disordered eating was not detected by chart review, but 23.5% screened positive on transition. While depression, diabetes distress, and disordered eating positively correlated with glycated hemoglobin (HbA1c) (r = 0.31, P = .05; r = 0.40, P = .009; r = 0.63, P<.001, respectively), disordered eating accounted for the majority of observed variance (df = 1; F = 18.6; P<.001). Even though HbA1c was higher in patients with versus without disordered eating (P<.001), body mass index did not differ between the 2 groups (P = .51).
In young adults with T1D, formal screening provides an opportunity to detect psychological problems, which, when treated, may help optimize metabolic control during the transition process.
T1D = type 1 diabetes HbA1C = hemoglobin A1c YCDP = Yale Children's Diabetes Program PHQ-8 = Patient Health Questionnaire-8 DDS = Diabetes Distress Scale DEPS-R = Diabetes Eating Problem Survey-Revised.
Purpose
The purpose of this paper is to discuss contemporary approaches to workplace health and well‐being, articulating key differences in the intervention architecture between public and workplace ...health contexts and implications for intervention design.
Design/methodology/approach
Contemporary practice is discussed in light of calls for a paradigm shift in occupational health from a treatment orientation to an holistic approach focused on mitigation of the causes of ill health and the promotion of well‐being. In practice, relatively few organizations have or seem able to engage with a broader perspective that encompasses challenges to health and well‐being associated with contextual organizational drivers, e.g. job design/role, workload, systems of reward, leadership style and the underpinning climate. Drawing upon insights from public health and the workplace safety tradition, the scope for broadening the perspective on intervention (in terms of vectors of harm addressed, theory of change and intervention logic) is discussed.
Findings
There are important differences in scope and options for intervention between public health and workplace health contexts. While there is scope to emulate public health practice, this should not constrain thinking over intervention opinions. Increased awareness of these key differences within work organizations, and an evidence‐based epidemiological approach to learning has the potential to strengthen and broaden the approach to workplace health and well‐being management.
Originality/value
The authors argue that approaches to workplace well‐being interventions that selectively cross‐fertilise and adapt elements of public health interventions offer promise for realising a broader change agenda and for building inherently healthy workplaces.
Despite organized provincial cancer screening programs, people living with low income consistently have lower rates of screening in Ontario, Canada than their more socioeconomically advantaged peers. ...We previously published results of a two-phase, exploratory qualitative study involving both interviews and focus groups whose objective was to integrate knowledge of people living with low income on how to improve primary care strategies aimed at increasing cancer screening uptake. In the current paper, we report previously unpublished findings from that study that identify how taking a community outreach approach in primary care may lead to increased cancer screening uptake among people living with low income. Participants told us that they saw value in a community outreach approach to cancer screening. They recommended specific actionable approaches, in particular, mobile community-based screening and community information sessions, and recommended taking an ethno-specific lens depending on the communities being targeted. Participants expressed a desire for primary care providers to go out into the community to learn more about the whole patient, such as could be achieved with home visits, but they simultaneously believed that this may be challenging in urban settings and in the context of perceived physician shortages. Models of primary care that provide support to an entire local community and provide some of their services directly in that community may have a meaningful impact on cancer screening for socially marginalized groups.
IMPORTANCE: Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no ...charge to patients. OBJECTIVE: To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, unblinded, parallel, 2-group, superiority, outcomes assessor–blinded, individually randomized clinical trial conducted at 9 primary care sites in Ontario, Canada, enrolled 786 patients between June 1, 2016, and April 28, 2017, who reported cost-related nonadherence. Follow-up occurred at 12 months. The primary analysis was performed using an intention-to-treat principle. INTERVENTIONS: Patients were randomly allocated to receive free medicines on a list of essential medicines in addition to otherwise usual care (n = 395) or usual medicine access and usual care (n = 391). MAIN OUTCOMES AND MEASURES: The primary outcome was adherence to treatment with all medicines that were appropriately prescribed for 1 year. Secondary outcomes were hemoglobin A1c level, blood pressure, and low-density lipoprotein cholesterol levels 1 year after randomization in participants taking corresponding medicines. RESULTS: Among the 786 participants analyzed (439 women and 347 men; mean SD age, 51.7 14.3 years), 764 completed the trial. Adherence to treatment with all medicines was higher in those randomized to receive free distribution (151 of 395 38.2%) compared with usual access (104 of 391 26.6%; difference, 11.6%; 95% CI, 4.9%-18.4%). Control of type 1 and 2 diabetes was not significantly improved by free distribution (hemoglobin A1c, −0.38%; 95% CI, −0.76% to 0.00%), systolic blood pressure was reduced (−7.2 mm Hg; 95% CI, −11.7 to −2.8 mm Hg), and low-density lipoprotein cholesterol levels were not affected (−2.3 mg/dL; 95% CI, −14.7 to 10.0 mg/dL). CONCLUSIONS AND RELEVANCE: The distribution of essential medicines at no charge for 1 year increased adherence to treatment with medicines and improved some, but not other, disease-specific surrogate health outcomes. These findings could help inform changes to medicine access policies such as publicly funding essential medicines. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02744963
Glucose is a primary fuel source to the brain, yet the influence of dysglycemia on neurodevelopment in children with type 1 diabetes remains unclear. We examined brain activation using functional MRI ...in 80 children with type 1 diabetes (mean ± SD age 11.5 ± 1.8 years; 46% female) and 47 children without diabetes (control group) (age 11.8 ± 1.5 years; 51% female) as they performed a visuospatial working memory (N-back) task. Results indicated that in both groups, activation scaled positively with increasing working memory load across many areas, including the frontoparietal cortex, caudate, and cerebellum. Between groups, children with diabetes exhibited reduced performance on the N-back task relative to children in the control group, as well as greater modulation of activation (i.e., showed greater increase in activation with higher working memory load). Post hoc analyses indicated that greater modulation was associated in the diabetes group with better working memory function and with an earlier age of diagnosis. These findings suggest that increased modulation may occur as a compensatory mechanism, helping in part to preserve working memory ability, and further, that children with an earlier onset require additional compensation. Future studies that test whether these patterns change as a function of improved glycemic control are warranted.
To evaluate the feasibility of a respiratory-gated proton beam therapy for liver tumors.
Fifteen patients were enrolled in a prospective institutional review board-approved protocol. Eligibility ...criteria included Childs-Pugh A/B cirrhosis, unresectable biopsy- proven hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), or metastatic disease (solid tumors only), 1-3 lesions, and tumor size of ≤6 cm. Patients received 15 fractions to a total dose of 45-75 GyE gray equivalent using respiratory-gated proton beam therapy. Gating was performed with an external respiratory position monitoring based system.
Of the 15 patients enrolled in this clinical trial, 11 had HCC, 3 had ICC, and 1 had metastasis from another primary. Ten patients had a single lesion, 3 patients had 2 lesions, and 2 patients had 3 lesions. Toxicities were grade 3 bilirubinemia-2, grade 3 gastrointestinal bleed-1, and grade 5 stomach perforation-1. One patient had a marginal recurrence, 3 had hepatic recurrences elsewhere in the liver, and 2 had extrahepatic recurrence. With a median follow-up for survivors of 69 months, 1-, 2-, and 3-year overall survivals are 53%, 40%, and 33%, respectively. Progression-free survivals are 40%, 33%, and 27% at 1, 2, and 3 years, respectively.
Respiratory-gated proton beam therapy for liver tumors is feasible. Phase 2 studies for primary liver tumors and metastatic tumors are underway.
Hybrid closed-loop systems increase time-in-range (TIR) and reduce glycemic variability. Person-reported outcomes (PROs) are essential to assess the utility of new devices and their impact on quality ...of life. This article focuses on the PROs for pediatric participants (ages 6-13 years) with type 1 diabetes (T1D) and their parents during a trial using the Tandem Control-IQ system, which was shown to increase TIR and improve other glycemic metrics.
One hundred and one children 6 to 13 years old with T1D were randomly assigned to closed-loop control (CLC) or sensor-augmented pump (SAP) in a 16-week randomized clinical trial with extension to 28 weeks during which the SAP group crossed over to CLC. Health-related quality of life and treatment satisfaction measures were obtained from children and their parents at baseline, 16 weeks, and 28 weeks.
Neither the children in the CLC group nor their parents had statistically significant changes in PRO outcomes compared with the SAP group at the end of the 16-week randomized controlled trial and the 28-week extension. Parents in the CLC group reported nonsignificant improvements in some PRO scores when compared with the SAP group at 16 weeks, which were sustained at 28 weeks. Sleep scores for parents improved from "poor sleep quality" to "adequate sleep quality" between baseline and 16 weeks, however, the change in scores was not statistically different between groups.
Children with T1D who used the Control-IQ system did not experience increased burden compared with those using SAP based on person-reported outcomes from the children and their parents. Clinical Trials Registration: NCT03844789.
Youth with T1D and high HbA1c are at higher risk of DKA. This study examined whether daily school-supervised basal insulin injections reduced the risk of morning ketosis in youth with high HbA1c. We ...hypothesized that glargine and degludec would reduce the risk of ketosis, and explored whether the prolonged action of degludec protects from ketosis after 2-4 days unsupervised injections. After a 2-4 week run-in, youth (10-18y) on injections with A1c ≥ 8.5% were randomized to supervised administration of either degludec or glargine for 4 months. School nurses observed daily fasting blood β-hydroxybutyrate (βHB) and glucose checks and basal insulin doses. During COVID closures, our research team is supervising procedures remotely. Twenty-four youth (mean age 14.4 ± 2.4 y, 67% F, HbA1c 11.6% ± 1.9%) were analyzed. Supervised injections of both basal insulins for 1-4 days progressively lowered the % participants with elevated βHB (Figure). The % of participants with elevated βHB after 2 days of unsupervised basal insulin tended to be greater in the glargine group. HbA1c did not change. None had DKA. In high risk youth with T1D, daily supervised insulin administration decreased the probability of elevated ketone levels the following school day, regardless of insulin type. A larger sample is needed to determine if degludec's longer action profile offers additional protection from ketosis during days off from school.
Optimal glycemic control is particularly difficult to achieve in children and adolescents with type 1 diabetes (T1D), yet the influence of dysglycemia on the developing brain remains poorly ...understood.
Using a large multi-site study framework, we investigated activation patterns using functional magnetic resonance imaging (fMRI) in 93 children with T1D (mean age 11.5 ± 1.8 years; 45.2% female) and 57 non-diabetic (control) children (mean age 11.8 ± 1.5 years; 50.9% female) as they performed an executive function paradigm, the go/no-go task. Children underwent scanning and cognitive and clinical assessment at 1 of 5 different sites. Group differences in activation occurring during the contrast of "no-go > go" were examined while controlling for age, sex, and scan site. Results indicated that, despite equivalent task performance between the 2 groups, children with T1D exhibited increased activation in executive control regions (e.g., dorsolateral prefrontal and supramarginal gyri; p = 0.010) and reduced suppression of activation in the posterior node of the default mode network (DMN; p = 0.006). Secondary analyses indicated associations between activation patterns and behavior and clinical disease course. Greater hyperactivation in executive control regions in the T1D group was correlated with improved task performance (as indexed by shorter response times to correct "go" trials; r = -0.36, 95% CI -0.53 to -0.16, p < 0.001) and with better parent-reported measures of executive functioning (r values < -0.29, 95% CIs -0.47 to -0.08, p-values < 0.007). Increased deficits in deactivation of the posterior DMN in the T1D group were correlated with an earlier age of T1D onset (r = -0.22, 95% CI -0.41 to -0.02, p = 0.033). Finally, exploratory analyses indicated that among children with T1D (but not control children), more severe impairments in deactivation of the DMN were associated with greater increases in hyperactivation of executive control regions (T1D: r = 0.284, 95% CI 0.08 to 0.46, p = 0.006; control: r = 0.108, 95% CI -0.16 to 0.36, p = 0.423). A limitation to this study involves glycemic effects on brain function; because blood glucose was not clamped prior to or during scanning, future studies are needed to assess the influence of acute versus chronic dysglycemia on our reported findings. In addition, the mechanisms underlying T1D-associated alterations in activation are unknown.
These data indicate that increased recruitment of executive control areas in pediatric T1D may act to offset diabetes-related impairments in the DMN, ultimately facilitating cognitive and behavioral performance levels that are equivalent to that of non-diabetic controls. Future studies that examine whether these patterns change as a function of improved glycemic control are warranted.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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