An Automated Risk Index for Diabetic Ketoacidosis in Pediatric Patients With Type 1 Diabetes: The RI-DKA.

Identifying patients at high risk for diabetic ketoacidosis (DKA) is crucial for informing efforts at preventive intervention. This study sought to develop and validate an electronic medical record (EMR)-based tool for predicting DKA risk in pediatric patients with type 1 diabetes. Based on analysis of data from 1,864 patients with type 1 diabetes, three factors emerged as significant predictors of DKA: most recent A1C, type of health insurance (public vs. private), and prior DKA. A prediction model was developed based on these factors and tested to identify and categorize patients at low, moderate, and high risk for experiencing DKA within the next year. This work demonstrates that risk for DKA can be predicted using a simple model that can be automatically derived from variables in the EMR.

A Comprehensive System for Identifying Patients With Type 1 Diabetes at Increased Risk for Diabetic Ketoacidosis at Texas Children's Hospital.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a project at Texas Children's Hospital aimed at improving identification of patients with type 1 diabetes at high risk for diabetic ketoacidosis.

Patient and Caregiver Attitudes toward Disorders of Sex Development Nomenclature.

PURPOSE: The medical terminology applied to differences/disorders of sex development has been viewed negatively by some affected individuals. A clinical population of patients with differences/disorders of sex development and their caregivers were surveyed regarding current nomenclature, hypothesizing that those unaffiliated with support groups would have more favorable attitudes. MATERIALS AND METHODS: We recruited English and Spanish speaking patients 13 years old or older with differences/disorders of sex development and their caregivers at 5 national tertiary care clinics from July 2016 to December 2018. No diagnoses were excluded. Participants completed a survey rating terminology commonly applied to differences/disorders of sex development. Responses were compared between subgroups, including members vs nonmembers of a support group. RESULTS: Of 185 potential participants approached 133 completed the survey (72% response rate). Congenital adrenal hyperplasia (33%) was the most common diagnosis. "Variation of sex development" was the most liked term (37%) but was not liked more significantly than "disorders of sex development" (27%, p=0.16). No term was liked by a majority of respondents. "Disorders of sex development" (37%) and "intersex" (53%) were the only terms most frequently viewed unfavorably. Support group members were significantly more likely to dislike the term "intersex" (p=0.02) and to like "variation of sex development" (p=0.02). CONCLUSIONS: A clinical population of patients and their caregivers had generally neutral attitudes toward nomenclature applied to differences/disorders of sex development. Members of a support group had clearer terminology preferences. "Variation of sex development" was the most liked term, and "disorders of sex development" and "intersex" were the most disliked. No term was liked by most respondents, and no clear alternative to the present nomenclature was identified.

Hormones and their Structural and Functional Effects on the Brain: How Can We Change our Practice Moving Forward?

Is hormone treatment an invasive procedure? In this paper, we discuss aspects related to the choice of treating disorders of sex development (DSD) using hormones. Specifically, we focus on some of the challenging issues related to this treatment and the need to establish a standard of care for the use of hormone therapy in this patient population. The objectives of this paper are to: 1) Enhance understanding of the uncertainties in the decision-making process regarding hormonal interventions to treat patients with DSD. 2) Recognize that the effects of hormonal interventions might require a consent process similar to that applied for surgical procedures. 3) Emphasize the need to establish treatment algorithms that could form the basis of a standard of care for this patient population.

USE OF INHALED INSULIN IN A PATIENT WITH SUBCUTANEOUS INSULIN RESISTANCE SYNDROME: A RARE CONDITION.

OBJECTIVE: Subcutaneous insulin resistance syndrome (SIRS) is a rare entity, characterized by increased resistance to subcutaneous insulin and normal sensitivity to intravenous insulin, with no increase in circulating insulin antibodies. Little is known about its pathophysiology, but it has been suggested to occur due to rapid subcutaneous degradation of insulin. Multiple treatment modalities have been used in the past to treat this condition. METHODS: We illustrate a case of a 17-year-old girl with type 1 diabetes mellitus (T1DM), presenting with recurrent episodes of diabetic ketoacidosis (DKA) due to resistance to subcutaneously delivered insulin. RESULTS: We describe the challenges faced while attempting different modalities during her hospital stay, and eventually using inhaled insulin, which was recently approved by the Food and Drug Administration for use in nonpregnant adults with T1DM. CONCLUSION: SIRS is a difficult condition that may lead to patient frustration and carries a serious risk of recurrent DKA. We described this case to create awareness about SIRS, provide insight into the challenges of its management, and report the use of inhaled insulin to successfully dose meal-time insulin, along with intramuscular glargine for basal insulin.

Maternal Placentophagy as a Possible Cause of Breast Budding and Vaginal Bleeding in a Breast-Fed 3-Month-Old Infant.

BACKGROUND: Placentophagy, or the practice of placental consumption, has grown in popularity over the past decade. Although advocates endorse prevention of postpartum depression, increased breast milk production, reduction in postpartum bleeding, and provision of nutrients postpartum, scientific studies have failed to show benefit. No studies have explored the effect of placental hormone consumption on the hypothalamic-pituitary-ovarian axis of the offspring. CASE: We present a case of vaginal bleeding and breast budding in a 3-month-old infant whose mother was exclusively breastfeeding. Maternal history was notable for placentophagy. Upon discontinuation of consuming encapsulated placenta, the infant's vaginal bleeding resolved. SUMMARY AND CONCLUSION: Our case raises concerns regarding placentophagy and infant endocrine function. More research is needed to assess maternal and infant exogenous estrogen exposure with maternal placental consumption.

Featured Article: Strengths-Based, Clinic-Integrated Nonrandomized Pilot Intervention to Promote Type 1 Diabetes Adherence and Well-Being.

Objective: Given persistent challenges achieving optimal diabetes outcomes in adolescence, new interventions to support disease self-management and emotional well-being are needed. Approaches that emphasize adolescents' positive behaviors and attitudes ("strengths") are designed to incorporate positive provider communications into clinical encounters to encourage youths' engagement in adherence behaviors and enhance well-being. Methods: This pilot study tested the feasibility, acceptability, and preliminary outcomes of a brief, strengths-based behavioral intervention for adolescents with type 1 diabetes. Adolescents (age 12-17 years) and parents were recruited, consented, and completed baseline and postintervention questionnaires. There was no randomization to a control group, and all participants received the pilot intervention. At the start of two clinic visits, diabetes care providers followed a semi-structured script to reinforce adolescents' diabetes-related strengths and adherence behaviors. Results: Of 116 eligible families, 84 consented and 64 completed baseline (M age = 15.0 ± 1.8 years, 56% female, 69% White, M HbA1c = 8.6 ± 1.6%). Providers reported the intervention usually (95%) took <10 min to deliver. Participants and providers enjoyed the intervention and would like to see it as part of routine clinical care. Pre-post data indicated significant improvements in youth-rated diabetes strengths, adherence, burden, and relationship with provider, parent-reported diabetes burden, and provider-rated relationship with family (p < .05). Objectively measured adherence and glycemic control did not change. Conclusions: This brief strengths-based, clinic-integrated intervention was feasible to conduct and stakeholders were satisfied. This intervention holds promise to have a positive impact on adolescents' diabetes adherence, well-being, and provider relationships. Lessons were learned to improve implementation and participant experience for a larger study.

Challenges in Prenatal Treatment with Dexamethasone.

Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency causes elevated androgen levels, which can lead to virilization of female external genitalia. Prenatal dexamethasone treatment has been shown to be effective in preventing virilization of external genitalia when started prior to 7-9 weeks of gestation in females with classic CAH. However, CAH cannot be diagnosed prenatally until the end of the first trimester. Treating pregnant women with a fetus at risk of developing classic CAH exposes a significant proportion of fetuses unnecessarily, because only 1 in 8 would benefit from treatment. Consequently, prenatal dexamethasone treatment has been met with much controversy due to the potential adverse outcomes when exposed to high-dose steroids in utero. Here, we review the short- and long-term outcomes for fetuses and pregnant women exposed to dexamethasone treatment, the ethical considerations that must be taken into account, and current practice recommendations.

Fluidity models in ancient Greece and current practices of sex assignment.

Disorders of sexual differentiation such as androgen insensitivity and gonadal dysgenesis can involve an intrinsic fluidity at different levels, from the anatomical and biological to the social (gender) that must be considered in the context of social constraints. Sex assignment models based on George Engel's biopsychosocial aspects model of biology accept fluidity of gender as a central concept and therefore help establish expectations within the uncertainty of sex assignment and anticipate potential changes. The biology underlying the fluidity inherent to these disorders should be presented to parents at diagnosis, an approach that the gender medicine field should embrace as good practice. Greek mythology provides many accepted archetypes of change, and the ancient Greek appreciation of metamorphosis can be used as context with these patients. Our goal is to inform expertise and optimal approaches, knowing that this fluidity may eventually necessitate sex reassignment. Physicians should provide sex assignment education based on different components of sexual differentiation, prepare parents for future hormone-triggered changes in their children, and establish a sex-assignment algorithm.

Camp for Youth With Type 1 Diabetes.

Camps for youth with type 1 diabetes (T1D) have grown in size and scope since they first emerged in the 1920s. Anecdotal evidence suggests that attending camp with other youth with T1D is beneficial, largely attributed to sharing fun, active experiences and removing the isolation of living with diabetes. However, few studies have evaluated the psychosocial and medical impacts of T1D camp attendance during and after camp sessions. In addition, T1D camps have been a setting for numerous studies on a variety of T1D-related research questions not related to camp itself, such as testing novel diabetes management technologies in an active, non-laboratory setting. This paper reviews the evidence of psychosocial and medical outcomes associated with T1D camp attendance across the globe, provides an overview of other research conducted at camp, and offers recommendations for future research conducted at T1D camp.