Ecological Momentary Assessment of Positive and Negative Affect and Associations with Blood Glucose in Teens with Type 1 Diabetes.

BACKGROUND: Affect (i.e., emotions) can be associated with diabetes self-care and ambient glucose in teens with type 1 diabetes (T1D). We used momentary sampling to examine associations of daily affectwithblood glucose (BG) monitoring,BG levels,and BG variability in teens with T1D. METHOD: Over 2 weeks, 32 teens reported positive and negative affect (Positive and Negative Affect Scale) and BG levels on handheld computers 4x/day, coordinated with planned daily BG checks. BG values were classified as: in-range (70-180 mg/dL); low (<70 mg/dL); severe low (<54 mg/dL); high (>180 mg/dL); severe high (>250 mg/dL). Daily BG variability was derived from BG coefficient of variation (BGCV). To determine associations of positive and negative affect with BG checks, BG levels, and BGCV, separate generalized estimating equations were performed, adjusting for demographic and diabetes-related variables, for the overall sample and stratified by HbA1c (≤8%, >8%). RESULTS: Teens (44% male, ages 14-18, 63% pump-treated, HbA1c 8.8 ± 1.4%) reported 51% in-range, 6% low (2% severe low), and 44% high (19% severe high) BG. In teens with HbA1c ≤8%, positive affect was associated with in-range BG (OR = 1.08, 95% CI = 1.04-1.13, P = .0002), reduced odds of very low glucose (OR = 0.35, 95% CI = 0.16-0.74, P = .006), and less daily BGCV (ß = -0.9; 95% CI = -1.6, -0.2; P = .01). In teens with HbA1c >8%, negative affect was associated with less likelihood of checking BG (OR = 0.75, 95% CI = 0.64-0.87, P = .0003). CONCLUSIONS: Our findings shed light on individual differences in metabolic reactivity based on glycemic levels and the importance of incorporating affect into automated insulin delivery systems.

Fractures Among Inpatients in a Pediatric Hospital.

OBJECTIVE: Fractures occurring in hospitalized children may be an underrecognized preventable harm with implications for current and future bone health, but few data exist regarding the clinical characteristics of these pediatric patients. We describe the clinical characteristics of patients who sustained fractures during hospitalization over a 4.5-year period at a single tertiary care center. METHODS: We retrospectively identified subjects who experienced inpatient fractures using a voluntary safety event reporting system and computer-assisted keyword search of the electronic medical record. We used the medical record to collect clinical characteristics, laboratory data, and survival status. RESULTS: The safety event reporting system and keyword search identified 57% and 43% of subjects, respectively. Fifty-six subjects sustained 128 fractures while hospitalized, most frequently at the femur (33 fractures) and humerus (30 fractures). Twenty-seven subjects sustained multiple fractures. Common clinical characteristics included age ≤1 year (64%); preterm birth (53%); admission to an ICU (90%); immobilization (88%); and weight-for-age z score less than or equal to -2.0 (52%). Sixteen (29%) subjects died, and the mortality rate varied by primary diagnosis. CONCLUSIONS: Critically ill, immobilized infants under 1 year of age and who were often born preterm sustained the majority of fractures occurring during hospitalization. A voluntary reporting system was insufficient to identify all inpatient fractures. Future studies should explore optimal fracture screening strategies and the relationship among fractures, severity of illness and mortality in hospitalized children.

Momentary assessment of social context and glucose monitoring adherence in adolescents with type 1 diabetes.

PURPOSE: To investigate the associations between momentary social context and glucose monitoring adherence in adolescents with type 1diabetes (T1D). METHODS: For 14 days, patients (14-18 years old, T1D duration >1 year) of a pediatric diabetes clinic carried handheld computers that prompted them to report their location, companionship, and attitudes toward companions at the times they usually checked their glucose, and again 30 minutes later to report whether they checked their glucose and, if not, why. Associations between social context factors and checking glucose (adherence) were analyzed using logistic generalized estimating equations and adjusted for age, sex, duration of T1D, and pump use. RESULTS: Thirty-six participants (mean age 16.6 ± 1.5 years, mean duration of T1D 8.7 ± 4.4 years) completed 971 context and 1,210 adherence reports, resulting in 805 paired reports. Median signal response rate was 63%. The odds of checking glucose was higher when participants expressed very strong desire to blend in (adjusted odds ratio [AOR] = 2.30, 95% confidence interval 1.07-4.94, p = .03). Strong desire to impress others was associated with decreased likelihood of checking glucose (AOR = .52, 95% confidence interval .28-.97, p = .04.) Location, solitude, type of companion, and attitudes toward companions were not significantly associated with checking glucose. CONCLUSIONS: Desire to blend in may support glucose monitoring adherence and desire to impress others may impede this behavior in adolescents with T1D. Other dimensions of social context were not linked to checking glucose in this study.

Adherence challenges in the management of type 1 diabetes in adolescents: prevention and intervention.

PURPOSE OF REVIEW: Despite the availability of effective therapies, adolescents with type 1 diabetes demonstrate poorer adherence to treatment regimens compared with other pediatric age groups. Nonadherence is tightly linked to suboptimal glycemic control, increasing morbidity, and risk for premature mortality. This article will review barriers to adherence and discuss interventions that have shown promise in improving outcomes for this population. RECENT FINDINGS: Adolescents face numerous obstacles to adherence, including developmental behaviors, flux in family dynamics, and perceived social pressures, which compound the relative insulin resistance brought on by pubertal physiology. Some successful interventions have relied on encouraging nonjudgmental family support in the daily tasks of blood glucose monitoring and insulin administration. Other interventions overcome these barriers through the use of motivational interviewing and problem-solving techniques, flexibility in dietary recommendations, and extending provider outreach and support with technology. SUMMARY: Effective interventions build on teens' internal and external supports (family, technology, and internal motivation) in order to simplify their management of diabetes and provide opportunities for the teens to share the burdens of care. Although such strategies help to minimize the demands placed upon teens with diabetes, suboptimal glycemic control will likely persist for the majority of adolescents until technological breakthroughs allow for automated insulin delivery in closed loop systems.

Understanding of drug indications by ambulatory care patients.

PURPOSE: Patients' knowledge of the indications of their prescription medications was studied and those medications that were most likely to be taken without patients understanding the correct indication were identified. METHODS: Adult patients who received care at four primary care practices were surveyed. Patients were eligible to participate if they were over 18 years old and had received a prescription from a participating physician at a clinic visit. Patients were telephoned and asked to retrieve the bottles of all medications they were currently taking, identify their medications, and state the reason they took each medicine. The primary outcome was absent or incorrect knowledge of a drug's indication. RESULTS: A total of 2340 prescription medications were used by the 616 patients whose data were analyzed. Eighty-three patients (13.5%) lacked knowledge of the indication for at least one of their prescription medications. They did not know the indication for 148 medications (6.3%). After multivariable adjustment, lack of knowledge was more common for cardiovascular drugs (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.03-2.19) and less common for diabetes medications (OR, 0.37; 95% CI, 0.16-0.84) and analgesics (OR, 0.23; 95% CI, 0.05-1.01) compared with all other medications, and more common if the patient taking these medications was older, black, or had a high school education or less. CONCLUSION: More than 13% of patients in primary care practices did not know the indication of at least one of their prescription medications. Lack of knowledge was most prevalent for cardiovascular medications.