Association of Adverse Childhood Experiences with Glycemic Control and Lipids in Children with Type 1 Diabetes.

Adverse childhood experiences (ACE) have been associated with a greater prevalence of risky behaviors and chronic health conditions, such as diabetes in adulthood. While adolescents with risk taking behaviors experience worsening of diabetic metabolic control, it is yet to be determined whether glycemic management in children and adolescents is negatively and independently influenced by ACEs. This study examines the relationship between ACEs in children and adolescents with type 1 diabetes (T1DM) and glycemic control, BMI and lipids. For such children, we hypothesized that hemoglobin A1c (HbA1c) is positively correlated with ACE scores. Parents of children (age 2-18 years) with T1DM completed a validated ACE questionnaire. The associations between parent and child ACE score and HbA1c, lipids and BMI z-scores were assessed using linear regression. The prevalence of any ACE was 27.9% among children and 49.0% among parents. HbA1c was significantly higher in children who had exposure to three or more ACEs (ß:0.63 (4.5 mmol/mol); p = 0.02), in those who had a parent exposed to four or more ACEs (ß:0.87 (7.2 mmol/mol); p = 0.03), in children who had exposure to household incarceration (ß:0.62 (4.4 mmol/mol); p = 0.05) and children who witnessed or had been victim of violence in the neighborhood (ß:0.71 (5.4 mmol/mol); p = 0.02). ACEs were highly prevalent among children with T1DM and had a positive association with glycemic control.

Improved utilization of waist-to-height ratio in cardiometabolic risk counselling in children: Application of DMAIC strategy.

RATIONALE, AIMS, AND OBJECTIVES: Waist circumference (WC) and waist-to-height ratio (WHtR) are superior surrogate markers of central obesity than body mass index. However, WC is not measured routinely in paediatric clinics. The objective of this study was to implement measurement of WC during routine assessment of children in an ambulatory outpatient clinic setting and subsequent dissemination of cardiometabolic risk counselling in children with central obesity (defined as WHtR ≥0.5). METHOD: Prospective cohort of patients aged 6 to 20 years. Study period was divided into three phases: baseline (3 months), process improvement (2 months), and implementation (6 months). Define-Measure-Analyse-Improve-Control (DMAIC) strategy was applied. Measurement of WC was implemented as a component of the physical examination in patients. Outcome measures were (1) improvement in frequency of WC measurement and (2) utilization of WHtR in cardiometabolic risk counselling. RESULTS: Waist circumference was not measured in any patient during baseline phase (n = 551). During process improvement phase, of the total 347 patients, WC was measured in 35% vs target of 30%. In the implementation phase, WC was measured in 37% patients (365 out of 964). Of these 365 patients, 175 (48%) had elevated WHtR, and 73% of them (n = 128) were counselled about their increased cardiometabolic risk. CONCLUSIONS: Application of an evidence-based DMAIC protocol led to significant improvement in assessment for central obesity in an ambulatory clinic practice and appropriate counselling regarding cardiometabolic risk reduction in children and adolescents with central obesity over an 8-month period. Meticulous planning and execution, frequent reinforcement, and integrating feedback from the involved multi-disciplinary team were important factors in successful implementation of this quality improvement project.

Spreading the concept: an attempt to translate an interprofessional clinical placement across a Danish hospital.

In a Danish Interprofessional Training Unit (ITU), the clinical tutors have succeeded in developing a safe learning environment combined with challenging the students by giving them responsibility for the patient's care and rehabilitation. In the ITU, students improved their uniprofessional and interprofessional knowledge and capability while strengthening their professional identity. It was, therefore, decided to make an attempt to transfer these interprofessional learning and teaching methods to another setting. The aims of this study were to evaluate whether the students learned about interprofessional collaboration and strengthened their professional identity and whether the clinical tutors could create a safe and challenging learning environment. Clinical tutors from the professions occupational therapy, physiotherapy, and nursing together planned the pedagogical approach and practical organization of two pilot studies in an orthopedic ward. After the intervention, focus group interviews of students and clinical tutors were performed and analyzed. The findings indicated that a one-week interprofessional clinical placement can contribute to students learning about interprofessional collaboration and to their development of professional identity. The data from the clinical tutors indicated that they needed to create a safe and challenging learning environment but emphasized that a thorough planning and continuous monitoring and adjusting of the clinical placement is necessary for success. The study documents that it is possible to create successful interprofessional learning opportunities in a normal ward environment in a restricted time frame. This knowledge can be applied to other ward settings where interprofessional clinical training is a natural possibility.

Vitamin E and C supplementation does not ameliorate muscle dysfunction after anterior cruciate ligament surgery.

Muscle atrophy and weakness are predominant impairments after anterior cruciate ligament (ACL) surgical repair. We tested the hypothesis that vitamin E and C supplementation will improve recovery from ACL injury. Men undergoing elective ACL surgery were randomly assigned to twice-daily supplements of either antioxidants (AO; vitamins E and C, n=10) or matching placebos (n=10) from 2 weeks before until 3 months after surgery. Each subject provided several fasting blood draws, two muscle biopsies from the thigh muscle of the injured limb, and strength and thigh circumference measurements of the lower limbs. Muscle atrophy was apparent in both groups before and several days after surgery. Compared with baseline measurements, peak isometric force of the injured limb increased significantly (P<0.05) by 3 months postsurgery in both treatment groups; however, AO supplementation did not augment these strength gains. By contrast, baseline plasma ascorbic acid concentrations correlated (r=0.59, P=0.006) with subsequent improvement in the strength of the injured limb. In summary, vitamin E and C supplementation was ineffective in potentiating the improvement in force production by the injured limb; however, baseline vitamin C status was associated with beneficial outcomes in strength, suggesting that long-term dietary habits are more effective than short-term supplements.