Diabetes
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Item CLASSIFICATION OF CHILDREN WITH NEWLY DIAGNOSED DIABETES MELLITUS(2014-03) Prakash, Sameer; Leung-Pineda, Van; Suzuki, Sumihiro; Radack, Jill A.; Dallas, John; Thornton, Paul; Wilson, DonPurpose (a): Historically the diagnosis of Type 2 Diabetes Mellitus (T2DM) has relied on a well described clinical phenotype. The reliability of this clinical phenotype in classifying children with diabetes is, however, not clear. The ability of experienced clinicians to correctly classify the type of diabetes based upon the clinical phenotype has recently been challenged. According to the American Diabetes Association, the diagnosis of T2DM requires a fasting plasma glucose of 126 mg/dL or higher, a 2-hour glucose level of 200 mg/dl or higher during a 75-g oral glucose tolerance test, or a random plasma glucose of 200 mg/dL or higher in a patient with classic symptoms of hyperglycemia or hyperglycemia crisis. In addition, those with T2DM should demonstrate the absence of diabetes auto-antibodies. Since the appropriate classification of a child's diabetes has important implications with regard to treatment options, expected outcomes and genetic counseling, a systematic, cost-effective algorithm to assist in the initial classification of diabetes mellitus is needed. Methods (b): We propose a retrospective analysis of diabetes related autoantibody tests (GAD, IA-2, Tg, Gliadin Peptide IGA, Gliadin Peptide IGG) in children (< 18 yrs of age) seen for evaluation of newly diagnosed diabetes mellitus in the Pediatric Endocrine Clinic hospitalized at Cook Children’s Medical Center for Jan 2010-June 2012.Following IRB approval, children and adolescents. Results (c): Following IRB approval, we conducted a retrospective chart review of 348 children(178 males; 170 females) hospitalized at Cook’s Children’s Medical Center from Jan 2010 – Jun 2012 with new onset diabetes mellitus to determine the frequency of antibody positive vs. antibody negative diabetes mellitus. In addition the frequency and test results for other diabetes-associated conditions (i.e. thyroid and celiac disease) were summarized. As expected the majority of patients were positive for one or more diabetes related antibodies. A much smaller number of patients were also tested for diabetes-associated conditions. Conclusions (d): We conclude that the majority of children < 18 years of age with new onset diabetes are positive for diabetes antibodies at the time of presentation. Those that are antibody negative need further evaluation to 1) determine whether these patients may have T2DM, a genetic form of DM (i.e. MODY) or some other form of diabetes and 2) to provide appropriate therapeutic and genetic counseling. Given the complexity of diagnosing diabetes mellitus and the rising cost of healthcare, a systematic algorithm may be useful in providing a cost-effective means of classifying children with new onset diabetes mellitus.Item THE ASSOCIATION BETWEEN ACCULTURATION AND RISK FOR TYPE 2 DIABETES IN MEXICAN-AMERICAN CHILDREN AND ADOLESCENTS(2014-03) Retana, Jos� D.; Proffitt Leyva, Randi; Fulda, Kimberly; Franks, SusanThe Association between Acculturation and Risk for Type 2 Diabetes in Mexican-American Children and Adolescents Purpose/Intro: Type 2 diabetes mellitus (DM2) is increasing in children and adolescents of all races/ethnicities in the United States, but especially in minorities such as Hispanics. In particular, Mexican-American children and adolescents are experiencing onset of DM2 at alarming rates. The purpose of this study was to examine the relationship between acculturation to a Mexican or Anglo orientation and risk for DM2. Methods: Participants completed demographic questions and the brief Acculturation Rating Scale for Mexican Americans II (Brief ARSMA-II). A linear acculturation score was derived from the Mexican Oriented Scale (MOS) and the Anglo Oriented Scale (AOS). Adolescents 10-14 years and a parent/legal guardian were included. At risk for DM2 was determined by having ≥3 of the following: relative with diabetes, BMI 95th percentile, blood pressure 95th percentile, elevated glucose, or positive for Acanthosis Nigricans. Simple and multiple logistic regressions were performed with risk of DM2 (high/low) as the outcome and acculturation score as the primary predictor. The adjusted model controlled for child’s age, gender, highest household education, child and maternal birth country (US/not US). Results: Participants (N=144) were 49% female and 51% male. The mean age was 11.96 years (SD=1.45). Forty-five children/adolescents (31.3%) had 3 of 5 risk factors for DM2. Approximately half (53.3%) of high risk children/adolescents were “strongly Anglo-oriented” and “Assimilated”. Higher acculturation was associated with an increased odds of being high risk for DM2 [OR=1.50; 95% CI (1.00-2.25)] Conclusions: For each degree of increased Anglo acculturation, risk for DM2 increased by 50%. Therefore, children of Mexican descent are more at risk for DM2 as they/their families become more acculturated to the Anglo cultural orientation. The degree of acculturation of a child/family should be taken into consideration when developing diabetes preventions and interventions.Item EFFECTIVNESS OF BALANCE TRAINING WITH VIRTUAL REALITY AND VIBROTACTILE DEVICE IN DIABETIC PATIENTS(2014-03) Behan, Francis; Jafari, Roozbeh; Patterson, Rita M.; Bugnariu, NicoletaPurpose (a): Patients with diabetic peripheral neuropathy experience different degrees of sensory loss in their feet and tend to rely heavily on visual inputs to maintain their balance. This is an efficient coping strategy for as long as they can attend to the placements of their feet, but becomes a high risk of falls when they have to visually attend to something else, like crossing a street or a conversation. The purpose of this research is to assess the effectiveness of a training program designed to improve balance through sensory reweighting based on the principles of stochastic resonance and using virtual reality (VR). Moreover, biomarkers for diabetic control and neuro-protection pre- and post- sensory retraining will be studied to identify possible correlations between balance control and specific lab values. In addition, membrane androgen receptor (mAR ) has been linked to poor cognitive performance in animal models and this link will be examined in terms of balance control in the human subjects. Methods (b): Subjects with peripheral neuropathy due to diabetes undergo 6 one hour long training sessions in which they practice increasingly more challenging task of balance and walking while their visual attention is engaged by the VR. During training subjects were fitted with vibratory devices placed above the level of sensory loss (around the ankles). The intended to enhance somatosensory perception in the feet vibration was constant and sub-threshold. At visit 1 and 8, Pre- and Post- training assessments of balance and gait function as well as blood values for mAR, follicle stimulating hormone, estradiol, estrogen, C reactive protein, glucose, and a lipid panel. Results (c): To date two subjects have been enrolled in the study and one diabetic subject has completed the entire 8 weeks training protocol. Comparison of pre- and post-training revealed an improved balance function expressed by increased anterior and lateral center of pressure movement (ability to reach forward and laterally without losing balance) and increased walking speed. At the end of the training subject was able to maintain a straight walking trajectory even in the presence of visual inputs entraining lateral movements. Conclusions (d): Preliminary results show that sensory retraining with VR and vibratory device is feasible in diabetic subjects and holds promise for improvement of balance due to an increased ability to integrate all sensory inputs available and a decreased reliance on visual inputs.Item INCREASED POTENTIAL FOR GLUCOSE METABOLISM INTERFERENCE AND RETINAL ANEURYSMS FROM CARBON DISFULDIE EXPOSURE IN OIL AND NATURAL GAS WORKERS: A SYSTEMATIC REVIEW(2014-03) Patel, Jay T.; Rich, Alisa L.; Al-Angari, Samiah S.Exposure to chemicals in the air from manufacturing emissions may cause health impact to workers and the general public. A chemical historically found in rayon manufacturing emissions, carbon disulfide (CS2) is also present in emissions from oil and natural gas operations. This research identified how exposure to CS2 can affect blood glucose levels and can lead to damage to eyes. With the current trend in urban drilling, the general public may experience these health impacts from breathing CS2 in the air. Workers need to be tested regularly to prevent health complications. Purpose (a): This study examined the relationship of glucose metabolism interference and retinal microaneurysms from exposure to carbon disulfide (CS2) in natural gas workers. This study is the first to identify an increased potential for glucose metabolism interference, resulting in diabetogenic effect and subsequent retinal microaneurysms in natural gas occupational workers exposed to CS2. Methods (b): The review of literature was conducted as an evaluative assessment rather than an annotated bibliography and focused on the potential diabetogenic effects from CS2 exposure. The search criteria were inclusive to all papers on occupational health effects related to CS2 exposure. Relevant articles were identified by a systematic search of Medline, TOXLINE, Scopus, and PubMed databases. Due to the lack of current literature, all study designs were included. Results (c): The literature review found a strong association in viscose rayon occupational workers exposed to CS2 and an increased potential for alteration of normal glucose metabolism and retinal microaneurysms. CS2 wasalso found to be present in emissions from extraction and processing of oil and natural gas. The mechanism of action of CS2 on a biochemical level proved similar in viscose rayon and oil and natural gas workers. Conclusions (d): Natural gas occupational workers exposed to CS2 may experience an increased potential for glucose metabolism interference, which has been an indicator for diabetogenic effect and increased incidence for retinal disease. The recommendation is for regular monitoring of blood glucose levels in CS2-exposed workers preventing diabetogenic effect and ensuing retinopathy.Item A PROCESS IMPROVEMENT TOOL TO ENHANCE AND MONITOR THE TREATMENT OF CHILDREN AND ADOLESCENTS WITH DIABETIC KETOACIDOSIS (DKA)(2014-03) Wilson, Don; Nelson, Ashley; Bowman, W. PaulDiabetic ketoacidosis remains a significant cause of morbidity and mortality in children with diabetes mellitus with complications ranging from severe dehydration, electrolyte imbalance, hypercoagulability, pulmonary aspiration, and cerebral edema. Hourly monitoring of laboratory values, especially glucose and sodium [Na+], and fluid status of patients is utilized in many treatments. These values are generally recorded on static sheets next to the patient’s bedside or in an electronic medical record. Such static measures provide limited tools to evaluate trends in treatment and deviations from standard treatment protocols, therefore a process improvement tool was developed to enhance and monitor the treatment of children with DKA. A retrospective chart analysis from fifteen (15) children who were previously admitted to the pediatric intensive care unit (PICU) for treatment of DKA at Cook Children’s Medical Center was conducted. The data previously obtained during the child’s inpatient hospital course was used to assess the functionality of a newly developed computer monitoring tool. Purpose (a): The purpose of this research is to conduct a proof of concept study to determine the ability of a novel process improvement tool to enhance the treatment of children < 18 years of age with diabetic ketoacidosis (DKA). Methods (b): A process improvement tool was developed using an Excel platform. A retrospective study of fifteen patients admitted to the pediatric intensive care unit (PICU) at Cook Children's Medical Center for the treatment of DKA was used to evaluate the functionality of the process improvement tool. Results (c):The process improvement tool enables visual assessment of treatment trends and outcomes along with immediate feedback on the treatment course upon discharge from the PICU. Conclusions (d): A process improvement tool with visual monitoring and tracking of treatment trends is desirable in the treatment if DKA.Item COMPARISON OF BODY MASS INDEX PERCENTILE AND PERCENT BODY FAT ON RISK FACTORS FOR TYPE 2 DIABETES MELLITUS IN CHILDREN AGED 10-14(2014-03) Fernando, Shane I.; Fulda, Kimberly; Franks, Susan; Bowman, W. Paul; Shah, Deep; Proffitt-Leyva, Randi; Bawa, Binky; Habiba, NusrathThe growing rate of type 2 diabetes mellitus (T2DM) in children presents a critical public health problem for the future. However, assessment of T2DM risk among children can be challenging. Therefore, to improve assessment of risk, we examined the association between BMIP (body mass index percentile, a traditional indicator) with risk, compared to the association of percent body fat (PBF) with risk. Methods: Data were obtained from 290 10-14 year old adolescents who were patients in the pediatrics department of the University of North Texas Health Science Center, patients at Seminary Clinic in Fort Worth and recruited from community events. During study visits, subjects’ BMI percentile and percent body fat were obtained using standard height/weight measurements as well as through the use of a Tanita body composition device. Associations were then assessed using statistical regression models. Results: Among 290 subjects, 78.2% were of Hispanic origin, with approximately 13.4% being Black. Approximately 51% of subjects were female, while age distribution was evenly spread across 10-14. Logistic regression models found that both PBF and BMIP were significantly associated with Acanthosis nigricans (PBF: Sβ 0.584 vs. BMIP: Sβ 0.489), average systolic BP above 95th percentile (PBF: Sβ 0.219 vs. BMIP: Sβ 0.124), family history of T2DM (PBF: Sβ 0.189 vs. BMIP: Sβ 0.172), and high blood sugar test (PBF: Sβ 0.152 vs. BMIP: Sβ 0.119). Conclusions: The data from this study provides evidence that PBF may be a better measurement of T2DM risk among children compared to BMIP. It may be beneficial for pediatric and family physicians to measure PBF alongside BMIP to better ascertain a particular pediatric patient’s risk of T2DM. Purpose (a): The growing rate of type 2 diabetes mellitus (T2DM) in children presents a critical public health problem for the future. However, assessment of T2DM risk among children can be challenging. Therefore, to improve assessment of risk, we examined the association between BMIP (body mass index percentile, a traditional indicator) with risk, compared to the association of percent body fat (PBF) with risk. Methods (b): Data were obtained from 290 10-14 year olds in North Central Texas participating in a study examining risk for T2DM. During study visits, subjects’ BMI percentile and percent body fat were obtained using a Tanita body composition device. Associations were then assessed using logistic regression models against four of the five critical risk factors for T2DM: Average blood pressure (BP) above 95th percentile or History of high BP, family history of type 2 diabetes mellitus, positive sign of Acanthosis nigricans and a high blood sugar test. Results (c): Among 290 subjects, 78.2% were of Hispanic origin, with approximately 13.4% being Black. Approximately 51% of subjects were female, while age distribution was evenly spread across 10-14. Logistic regression models found that both PBF and BMIP were significantly associated with Acanthosis nigricans (PBF: Sβ 0.584 vs. BMIP: Sβ 0.489), average systolic BP above 95th percentile (PBF: Sβ 0.219 vs. BMIP: Sβ 0.124), family history of T2DM (PBF: Sβ 0.189 vs. BMIP: Sβ 0.172), and high blood sugar test (PBF: Sβ 0.152 vs. BMIP: Sβ 0.119). Conclusions (d): The data from this study provides evidence that PBF may be a better measurement of T2DM risk among children compared to BMIP. It may be beneficial for pediatric and family physicians to measure PBF alongside BMIP to better ascertain a particular pediatric patient’s risk of T2DM.Item PARENT'S PERCEPTIONS OF NEIGHBORHOOD SAFETY AND RISK OF TYPE 2 DIABETES IN MEXICAN AMERICAN CHILDREN AND ADOLESCENTS(2014-03) Ramirez, Roberto C.; Fulda, Kimberly; Lee, Michelle; Proffitt Leyva, Randi; Franks, Susan; Espinoza, AnnaWe conducted a study with Mexican American children and their parents and found that having playgrounds in the child's neighborhood lowers the risk of having type 2 diabetes. Purpose (a): The number of people suffering from type 2 diabetes (2 DM) has increased drastically over the last 30 years, especially in children under the age of 18. Specifically, Mexican American children have been diagnosed at alarming rates. Inactivity in children has contributed to these high rates of diabetes, but there is not sufficient information on factors that contribute to this inactivity. The purpose of this study was to explore parent’s perceptions of the features in their neighborhoods and its safety as it relates to their child being at risk of developing 2 DM. Methods (b): 144 Mexican American participants, ages 10-14 were enrolled in this study which included one visit that lasted approximately two hours. The primary caregiver was asked via a survey to assess the features and safety of the neighborhood in which the child participant lives. A set of measurements and family history were taken on each participant. “High-risk” status was assigned if participants had ≥3 of the following risk factors: BMI ≥95 percentile, high blood glucose, presence of Acanthosis Nigricans, family history of 2 DM in a 1st or 2nd degree relative, and history of hypertension or blood pressure ≥95th percentile. Simple and multiple logistic regressions were performed with high risk status for 2 DM as the outcome variable and neighborhood safety, presence of sidewalks and playgrounds in neighborhoods as the primary predictors. The adjusted model controlled for child’s age, gender, highest education level of household and household income. Results (c): Adjusted analyses illustrate that the presence of playgrounds in the respondent’s neighborhoods presented a 76% decreased odds of being at risk for 2 DM [OR: 0.24; 95% CI (0.06-0.86)]. The parent’s perceptions of neighborhood safety and the presence of sidewalks were not significant findings. In secondary findings, participants who responded that Spanish was the primary language spoken in the home had 79% decreased odds of being at risk for 2 DM [OR: 0.21; 95% CI (0.11-1.35)]. Conclusions (d): Potential policy implications resulting from the analysis of the study point to an increase in potential support for the establishment of playgrounds in areas that are deprived of such elements.