Distance from the endocrinology clinic and diabetes control in a rural pediatric population.

OBJECTIVE: We analyzed the impact of geographic distance from the clinic on adherence to recommended clinic visits and diabetes control among patients with type 1 diabetes (T1D) seen in a pediatric endocrinology clinic serving a rural region in eastern North Carolina. METHODS: We retrospectively included patients with T1D age ≤20 years seen in our clinic during 2017. Outcomes were tracked until June 2018. Distance from the clinic was determined according to the zone improvement plan (ZIP) code of patient address. Visit adherence was defined based on the number of attended visits during the study period, aiming for 1 every 3 months. Glycated hemoglobin (HbA1c) was measured at the first and last visits during the review period. RESULTS: The analysis included 368 patients, of whom 218 (59%) completed at least 1 visit every 3 months. The median HbA1c was 9.1 (interquartile range [IQR]: 8.0, 10.3) at the initial visit, and 9.3 (IQR: 8.0, 11.1) at the final visit. Median distance from the clinic was 56 km (IQR: 35, 86). On multivariable logistic regression, greater distance from the clinic was associated with lower odds of visit adherence (odds ratio per 10 km: 0.93; 95% confidence interval: 0.87, 0.99; p=0.030). Neither distance to the clinic nor clinic visit adherence were associated with HbA1c. CONCLUSIONS: Patients living further away from the clinic were less likely to adhere to the recommended visit schedule, but distance was not correlated with HbA1c levels. Further work is needed to assist families living far from the clinic with adhering to recommended visits.

Insurance coverage and health care use among children with diabetes.

BACKGROUND: Health insurance coverage may be associated with pediatric diabetes mellitus (DM) management. However, it is unknown how continuity of insurance coverage is associated with health care use outcomes in pediatric DM. METHODS: We used the nationally representative 2016-2019 National Survey of Children's Health to examine how interruption of health insurance coverage may affect health care use among children with DM. Children ages 0-17 years with DM were included in the analysis. Outcomes included emergency department visits, specialist visits, and unmet health care needs in the last 12 months. Insurance coverage was classified as continuous private, continuous public, or discontinuous (including gaps in coverage and year-round lack of coverage). RESULTS: Based on a sample of 548 children, 56% percent had continuous private insurance coverage, as compared to 32% with continuous public insurance, and 12% with discontinuous coverage. Thirty-five percent of children had visited the ED in the past 12 months, and only 47% had visited any specialist in the past 12 months, including but not limited to a pediatric endocrinologist. An estimated 19% of children had unmet health care needs over the past 12 months. On multivariable analysis, children with coverage gaps were significantly less likely than children with continuous private coverage to have a visited a specialist in the past 12 months (adjusted odds ratio: 0.27; 95% CI: 0.08, 0.88; p = 0.030). CONCLUSIONS: This study points to a need to establish and maintain specialist follow-up for children with DM, especially those from socioeconomically disadvantaged backgrounds.

National Cooperative Growth Study: 25 Years of Growth Hormone Data, Insights, and Lessons for Future Registries.

BACKGROUND: The National Cooperative Growth Study (NCGS) data are reviewed from 1985-2010 to report on final demographic, efficacy, and safety findings, and to illustrate the value of long-term, real-world follow-up to physicians and patients. METHODS: The NCGS was a multicenter, open-label, observational, postmarketing surveillance study of Genentech growth hormone (GH) products for the treatment of children with growth failure in North America. FINDINGS: Data from 65,205 patients representing 240,951 patient-years of experience were collected. All etiological groups had clinically meaningful improvements in near-adult height SDS. Females and African Americans were under-represented in the NCGS with little change in accrual over time. The favorable safety profile of GH was validated through the registry. CONCLUSIONS: Twenty-five years of monitoring GH use through the NCGS yielded extensive insight into the utility of GH in various underlying etiologies. Demographic disparities were clear and became evident by analyzing data collected through the registry.

Bone age advancement in prepubertal children with obesity and premature adrenarche: possible potentiating factors.

Obesity and premature adrenarche (PA) are both associated with bone age (BA) advancement of unclear etiology, which may lead to earlier puberty, suboptimal final height and obesity in adulthood. Our objective was to understand the hormonal and anthropometric characteristics of BA advancement in a spectrum of prepubertal children with and without obesity and PA. In this cross-sectional study of 66 prepubertal children (35 PA, 31 control, 5-9 years), BMI z-score, hormonal values and response to an oral glucose tolerance test were the main outcome measures. Subjects were divided into tertiles by BA divided by chronological age (BA/CA), an index of BA advancement. Subjects in the top tertile for BA/CA had the highest dehydroepiandrosterone sulfate (DHEAS), free testosterone (%), hemoglobin A(1C), BMI z-score, and weight (P < 0.05). BMI z-score (r = 0.47), weight (r = 0.40), free testosterone (%) (r = 0.34), and DHEAS (r = 0.30) correlated with BA/CA (P < 0.02). Regression analysis showed greater BA/CA in PA compared to controls after controlling for weight (0.21 ± 0.56, P < 0.004). An exploratory stepwise regression model showed that weight, estradiol, and DHEAS were the strongest predictors of BA/CA accounting for 24% of its variance. Obesity was highly associated with BA advancement in this study of prepubertal children. In addition, children with PA had greater BA/CA at any given weight when compared to controls. These findings suggest a possible hormonal factor, which potentiates the effect of obesity on BA advancement in children with obesity and/or PA.

Pituitary and systemic autoimmunity in a case of intrasellar germinoma.

Germinomas arising in the sella turcica are difficult to differentiate from autoimmune hypophysitis because of similar clinical and pathological features. This differentiation, nevertheless, is critical for patient care due to different treatments of the two diseases. We report the case of an 11-year-old girl who presented with diabetes insipidus and growth retardation, and was found to have an intra- and supra-sellar mass. Initial examination of the pituitary biopsy showed diffuse lymphocytic infiltration of the adenohypophysis and absent placental alkaline phosphatase expression, leading to a diagnosis of hypophysitis and glucocorticoid treatment. Because of the lack of clinical and radiological response, the pituitary specimen was re-examined, revealing this time the presence of scattered c-kit and Oct4 positive germinoma cells. The revised diagnosis prompted the initiation of radiotherapy, which induced disappearance of the pituitary mass. Immunological studies showed that the patient's serum recognized antigens expressed by the patient's own germinoma cells, as well as pituitary antigens like growth hormone and systemic antigens like the Sjögren syndrome antigen B and alpha-enolase. The study first reports the presence of pituitary and systemic antibodies in a patient with intrasellar germinoma, and reminds us that diffuse lymphocytic infiltration of the pituitary gland and pituitary antibodies does not always indicate a diagnosis of autoimmune hypophysitis.

Neonatal hypoglycemia in a growth hormone registry: incidence and pathogenesis.

OBJECTIVE: To examine the characteristics of infants with neonatal hypoglycemia treated with growth hormone (GH) in order to gain insights into factors aiding in the identification of and timely treatment of hypopituitary neonates. STUDY DESIGN: The National Cooperative Growth Study (NCGS) database was examined to identify infants with neonatal hypoglycemia started on GH by 6 months of age. 169 infants (100 males, 69 females) were found and their data analyzed for physical characteristics, the presence of other hormone deficits, and the diagnostic methods used. RESULTS: Mean +/- SD baseline length standard deviation score (SDS) was -1.5 +/- 1.8. 148/169 infants had hypopituitarism. Twelve had isolated GH deficiency (GHD). Nine had hypoglycemia without hypothalamic or pituitary pathology. Structural central nervous system (CNS) lesions and/or midline facial defects were present in 66/169. 55/100 males had micropenis. Although 158 infants had GHD, only 90 infants had it documented by stimulation testing (80) or a critical sample when hypoglycemic (10). Multiple hormone replacement therapy was necessary in 89% of the hypoglycemic infants. CONCLUSIONS: The great majority of these hypoglycemic infants had GHD, usually secondary to hypopituitarism. Over 1/3 had structural lesions of the hypothalamic-pituitary area or midline facial defects. Although lengths may be normal in these infants, physical features such as micropenis or cleft lip and/or palate should suggest pituitary dysfunction as the etiology of their hypoglycemia. A critical blood sample for GH taken during hypoglycemia is a quick and definitive diagnostic tool.