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Heffernan ME, Barrera L, Guzman ZR, Golbeck E, Jedraszko AM, Hays PT, Herzog KA, D’Aquila RT, Ison MG, McColley SA. Barriers and facilitators to recruitment of underrepresented research participants: Perspectives of clinical research coordinators. J Clin Transl Sci 2023; 7:e193. [PMID: 37745931 PMCID: PMC10514687 DOI: 10.1017/cts.2023.611] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/14/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Background Insufficient recruitment of groups underrepresented in medical research threatens the generalizability of research findings and compounds inequity in research and medicine. In the present study, we examined barriers and facilitators to recruitment of underrepresented research participants from the perspective of clinical research coordinators (CRCs). Methods CRCs from one adult and one pediatric academic medical centers completed an online survey in April-May 2022. Survey topics included: participant language and translations, cultural competency training, incentives for research participation, study location, and participant research literacy. CRCs also reported their success in recruiting individuals from various backgrounds and completed an implicit bias measure. Results Surveys were completed by 220 CRCs. CRCs indicated that recruitment is improved by having translated study materials, providing incentives to compensate participants, and reducing the number of in-person study visits. Most CRCs had completed some form of cultural competency training, but most also felt that the training either had no effect or made them feel less confident in approaching prospective participants from backgrounds different than their own. In general, CRCs reported having greater success in recruiting prospective participants from groups that are not underrepresented in research. Results of the implicit bias measure did not indicate that bias was associated with intentions to approach a prospective participant. Conclusions CRCs identified several strategies to improve recruitment of underrepresented research participants, and CRC insights aligned with insights from research participants in previous work. Further research is needed to understand the impact of cultural competency training on recruitment of underrepresented research participants.
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Affiliation(s)
- Marie E. Heffernan
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Leo Barrera
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Zecilly R. Guzman
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Emily Golbeck
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Aneta M. Jedraszko
- Department of Pediatrics (Neonatology), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - P. Toddie Hays
- Clinical and Translational Sciences Institute (NUCATS), Northwestern University, Chicago, IL, USA
| | - Keith A. Herzog
- Clinical and Translational Sciences Institute (NUCATS), Northwestern University, Chicago, IL, USA
| | - Richard T. D’Aquila
- Clinical and Translational Sciences Institute (NUCATS), Northwestern University, Chicago, IL, USA
- Department of Medicine (Infection Diseases), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael G. Ison
- Clinical and Translational Sciences Institute (NUCATS), Northwestern University, Chicago, IL, USA
- Respiratory Diseases Branch, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Susanna A. McColley
- Clinical and Translational Sciences Institute (NUCATS), Northwestern University, Chicago, IL, USA
- Department of Pediatrics (Pulmonary and Sleep Medicine), Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Tamborlane WV, Bishai R, Geller D, Shehadeh N, Al-Abdulrazzaq D, Vazquez EM, Karoly E, Troja T, Doehring O, Carter D, Monyak J, Sjöström CD. Once-Weekly Exenatide in Youth With Type 2 Diabetes. Diabetes Care 2022; 45:1833-1840. [PMID: 35679098 PMCID: PMC9346995 DOI: 10.2337/dc21-2275] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Approved treatments for type 2 diabetes in pediatric patients include metformin, liraglutide, and insulin. However, approximately one-half of the youth fail metformin monotherapy within 1 year, insulin therapy is associated with challenges, and liraglutide requires daily injections. Consequently, the efficacy and safety of once-weekly injections of exenatide for the treatment of youth with type 2 diabetes was evaluated. RESEARCH DESIGN AND METHODS Participants (aged 10 to <18 years) were randomized (5:2) to once-weekly exenatide 2 mg or placebo, respectively. The primary efficacy end point was change in glycated hemoglobin from baseline to week 24. Secondary efficacy end points were also evaluated, and the frequency of adverse events (AEs) was assessed. RESULTS A total of 83 participants were randomized (exenatide, 59; placebo, 24) and 72 completed 24-week treatment (exenatide, 49; placebo, 23). At 24 weeks, the least squares mean change in glycated hemoglobin was -0.36% for the exenatide and +0.49% for the placebo groups (between-group difference, -0.85%; 95% CI -1.51, -0.19; P = 0.012). Nonsignificant least squares mean differences from baseline to 24 weeks favoring exenatide were observed: fasting glucose -21.6 mg/dL (-49.0, 5.7; P = 0.119), systolic blood pressure -2.8 mmHg (-8.0, 2.4; P = 0.284), and body weight -1.22 kg (-3.59, 1.15; P = 0.307). AEs occurred in 36 (61.0%) and 17 (73.9%) participants in the exenatide and placebo groups, respectively. CONCLUSIONS In youth with type 2 diabetes suboptimally controlled with current treatments, once-weekly exenatide reduced glycated hemoglobin at 24 weeks and was well tolerated.
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Affiliation(s)
| | - Raafat Bishai
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - David Geller
- The Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Naim Shehadeh
- Bruce Rappaport Faculty of Medicine, Technion, and Institute of Diabetes and Endocrinology, Rambam Health Care Campus, Haifa, Israel
| | - Dalia Al-Abdulrazzaq
- Department of Population Health, Dasman Diabetes Institute, Dasman, Kuwait
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | | | | | | | - Orlando Doehring
- Biometrics, Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, U.K
| | - Debra Carter
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - John Monyak
- Biometrics, Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD
| | - C. David Sjöström
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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Parker AE, Scull TM, Morrison AM. DigiKnowIt News: Educating youth about pediatric clinical trials using an interactive, multimedia educational website. J Child Health Care 2022; 26:139-153. [PMID: 33836627 DOI: 10.1177/13674935211003774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric clinical trials allow for the testing of appropriate and effective treatments for children. However, some challenges exist with recruitment. This study examined the effectiveness of DigiKnowIt News, an interactive, multimedia website (which includes activities, videos, and comic books) designed to educate children about clinical trials. A randomized controlled trial was conducted in 2018 with 91 participants (M age = 10.92 years; SD = 2.06). Participants were randomly assigned to intervention or wait-list control groups and completed questionnaires at pretest and posttest (1 week later) about their knowledge, attitudes, beliefs about clinical trials, and self-efficacy for participating in clinical trials. Participants in the intervention group received access to DigiKnowIt News between pretest and posttest and completed a satisfaction questionnaire at posttest. At the end of the study, participants in the wait-list control group were offered the option to use the website and complete a satisfaction questionnaire. At posttest, participants in the intervention group, compared to participants in the wait-list control group, had more knowledge about clinical trials and more reported confidence for participating in clinical trials. Participants reported high levels of satisfaction with DigiKnowIt News. The findings suggest that an educational website can improve factors related to increasing rates of participation in clinical trials.
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Tumin D, Khanchandani A, Sasser G, Buckman C. Factors Influencing US Hospital and Medical School Participation in Pediatric COVID-19 Research. Hosp Pediatr 2022; 12:e8-e15. [PMID: 34907433 DOI: 10.1542/hpeds.2021-006051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Literature suggests that funding for pediatric clinical trials is inequitably awarded. Furthermore, although coronavirus disease 2019 (COVID-19) affected all hospitals, institutions with already limited resources were more severely impacted. We hypothesized that there would be difference in schools and hospitals that were able to participate in the initial round of pediatric COVID-19 clinical research. METHODS We searched online databases for preregistered studies using the keywords "COVID-19," "COVID," "SARS-CoV-2," "2019-nCov," "2019 novel coronavirus," and "severe acute respiratory syndrome coronavirus 2." Search results were limited to studies enrolling participants from birth to 17 years, studies started in 2020, and studies originating in the United states. We calculated the proportion of institutions with active COVID-19 pediatric clinical studies in 2020 and compared institutional characteristics between institutions with and without at least one qualifying COVID-19 study, using rank-sum tests, χ2 tests, or Fisher's exact tests, as appropriate. RESULTS We identified 150 allopathic medical schools, 34 osteopathic medical schools, and 178 children's hospitals meeting inclusion criteria. Among included institutions, 25% of medical schools and 20% children's hospitals participated in 1 of the registered pediatric COVID-19 studies the year before the study period. Institutions that participated in pediatric COVID-19 studies had more publications, more National Institutes of Health funding, and more studies registered on Clinicaltrials.gov in 2019. CONCLUSIONS Despite the pandemic affecting everyone, participation in early clinical research on the impact of COVID-19 in pediatric populations was concentrated in a few well-resourced institutions that were highly experienced in research.
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Affiliation(s)
| | - Ashish Khanchandani
- Brody School of Medicine at East Carolina University, Greenville, North Carolina
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Jiang B, Cheng Z, Liu F, Li Q, Fu H, Mao J. Renoprotection with sodium-glucose cotransporter-2 inhibitors in children: Known and unknown. Nephrology (Carlton) 2021; 27:126-132. [PMID: 34545979 DOI: 10.1111/nep.13979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/11/2022]
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors represent novel hypoglycemic drugs for the treatment of adult diabetes that have shown considerable potential for cardioprotection and renoprotection. This new drug can inhibit SGLT2 at the proximal tubule, increase glucosuria and natriuresis, and thus decreases the serum glucose level and blood pressure. Furthermore, the tubuloglomerular feedback activated by the natriuresis can decrease glomerular hyperfiltration, acknowledged as the main foundation of renoprotection. Several studies have confirmed the protective effects of SGLT2 inhibitors on the kidneys of adult diabetic patients and those with non-diabetic nephropathy; however, limited researches are seen in paediatric patients. In this review, we have summarized the mechanisms of action of SGLT2 inhibitors, the current experiences in adults, results of exploratory studies in children, and adverse events & obstacles of paediatric use. We further explore the potential and possible future research direction of SGLT2 inhibitors in paediatric diseases.
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Affiliation(s)
- Buchun Jiang
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiwen Cheng
- Department of General Pediatrics, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fei Liu
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiuyu Li
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haidong Fu
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Van Name M, Klingensmith G, Nelson B, Wintergerst K, Mitchell J, Norris K, Tamborlane WV. Transforming Performance of Clinical Trials in Pediatric Type 2 Diabetes: A Consortium Model. Diabetes Technol Ther 2020; 22:330-336. [PMID: 31859529 PMCID: PMC7869879 DOI: 10.1089/dia.2019.0448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background: Completing phase 3 trials of new drugs for youth with type 2 diabetes is challenging. The Pediatric Diabetes Consortium (PDC) of U.S. pediatric treatment centers developed a Consortium model to improve the efficiency of successfully completing these trials. Aims and Innovations: An aim of the PDC model is to utilize the resources of the PDC Coordinating Center and Executive Committee to improve study protocols, centralize interactions with sponsors, and oversee the performance of PDC Clinical Centers. Key features include a Consulting Group to improve protocol design; Master Service Agreements between the Coordinating Center and Clinical Centers covering confidentiality agreements and contract language; negotiation of a standard Site Budget with Contract Research Organizations (CROs)/Sponsors that reflect actual Clinical Center costs; Weekly Conference Calls with CROs/sponsors to track progress of Clinical Center launches, Monthly Oversight Calls with investigators and study Coordinators to track Clinical Center performance, discuss enrollment strategies, and identify emerging problems. Successes and Challenges: The Consortium model played a key role in the completion of the pivotal trial of liraglutide for treatment of youth with type 2 diabetes. PDC centers also played a pivotal role in exceeding the projected number of randomized subjects needed by two ongoing studies that are nearing completion. Conclusions: While the Consortium model is still a work in progress, PDC has assisted in the successful launch of new type 2 diabetes studies, and negotiations are in underway for PDC participation in pediatric type 1 diabetes and other diabetes-related studies.
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Affiliation(s)
- Michelle Van Name
- Department of Pediatrics, Yale University, New Haven, Connecticut
- Address correspondence to: Michelle Van Name, MD, Department of Pediatrics, Yale University, 333 Cedar Street, New Haven, CT 06452
| | - Georgeanna Klingensmith
- Department of Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado
| | - Bryce Nelson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Kupper Wintergerst
- Wendy Novak Diabetes Center, Department of Pediatrics, University of Louisville, Louisville, Kentucky
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Jalaludin MY, Barrientos-Pérez M, Hafez M, Lynch J, Shehadeh N, Turan S, Weghuber D. Recommendations for improving clinical trial design to facilitate the study of youth-onset type 2 diabetes. Clin Trials 2019; 17:87-98. [PMID: 31450961 DOI: 10.1177/1740774519870190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The prevalence of type 2 diabetes is increasing in youths and differs from adult-onset type 2 diabetes in its characteristics and progression. Currently, only two drugs are approved for youth-onset type 2 diabetes and many patients are not meeting glycemic targets. Clearly, there is an urgent need to complete clinical trials in youths with type 2 diabetes to increase the therapeutic choice for these patients. However, factors such as limited patient numbers, unwillingness of patients to participate in trials, failure to meet strict inclusion and exclusion criteria, and poor clinic attendance have limited the size and number of trials in this complicated patient demographic. RECOMMENDATIONS This is a narrative opinion piece on the design of clinical trials in youth-onset type 2 diabetes prepared by researchers who undertake this type of study in different countries. The review addresses possible ways to enhance trial designs in youth-onset type 2 diabetes to meet regulatory requirements, while minimizing the barriers to patients' participation. The definition of adolescence, recruitment of sufficient patient numbers, increasing flexibility in selection criteria, improving convenience of trial visits, requirements of a control group, possible endpoints, and trial compliance are all considered. The authors recommend allowing extrapolation from adult data, using multiple interventional arms within future trials, broadening inclusion criteria, and focusing on endpoints beyond glucose control, among others, in order to improve the successful completion of more trials in this population. CONCLUSIONS Improvements in trial design will enable better recruitment and retention and thereby more evidence for treatment outcomes for youth-onset type 2 diabetes.
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Affiliation(s)
| | | | - Mona Hafez
- Department of Paediatrics, Cairo University, Cairo, Egypt
| | - Jane Lynch
- Division of Endocrinology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Naim Shehadeh
- Endocrinology, Diabetes & Metabolism Institute, Rambam Health Care Campus, Haifa, Israel
| | - Serap Turan
- Department of Paediatrics, Subdivision of Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Daniel Weghuber
- Department of Paediatrics, Paracelsus Medical University, Salzburg, Austria
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Tamborlane WV, Chang P, Kollman C, Klingensmith GJ, Ruedy K, Gal RL, Van Name M, Bacha F, Willi S, Beck RW. Eligibility for clinical trials is limited for youth with type 2 diabetes: Insights from the Pediatric Diabetes Consortium T2D Clinic Registry. Pediatr Diabetes 2018; 19:1379-1384. [PMID: 30175440 DOI: 10.1111/pedi.12763] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/20/2018] [Accepted: 08/28/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/OBJECTIVE Restrictive eligibility criteria have hampered enrollment into trials for new drugs for youth with type 2 diabetes (T2D). We utilized Pediatric Diabetes Consortium (PDC) T2D Registry enrollment data to estimate the percentage of patients who would be excluded from current T2D trials based on out-of-range HbA1c levels. We also examined whether well-controlled patients could be included because baseline HbA1c would rise during a 6 to 12-month study if assigned to control group. METHODS Clinical characteristics and HbA1c levels were collected from 956 T2D patients aged 10 to <18 years upon Registry enrollment. HbA1c levels were also analyzed in 6-month intervals during the first 30 months of T2D duration. RESULTS There was an approximately 2:1 ratio of females to males; the majority were obese and from economically disadvantaged minority families. On enrollment in the Registry, 53% of patients would be excluded from current trials because HbA1c levels were either <6.5% (<48 mmol/mol) (37%) or >10.5% (>91 mmol/mol) (16%). Furthermore, in patients with HbA1c levels <6.5% (<48 mmol/mol) and T2D duration between 6 and 30 months, mean HbA1c levels increased by 0.6% (6 mmol/mol) and 0.9% (10 mmol/mol) over the subsequent 6 and 12 months, respectively. CONCLUSIONS Eligibility criteria for current clinical trials still exclude a large proportion of pediatric T2D patients because of HbA1c levels. Including patients with HbA1c <6.5% (<48 mmol/mol) would enhance recruitment and allow comparisons of the investigational treatment with placebo-assigned subjects in whom HbA1c levels would on average increase during the 6 to 12 months of the trial.
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Affiliation(s)
| | | | | | - Georgeanna J Klingensmith
- Department of Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado
| | | | - Robin L Gal
- Jaeb Center for Health Research, Tampa, Florida
| | - Michelle Van Name
- Department of Pediatric Endocrinology, Yale University, New Haven, Connecticut
| | - Fida Bacha
- USDA/ARS Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas.,Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Steven Willi
- The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
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Van Name MA, Guandalini C, Steffen A, Patel A, Tamborlane W. The present and future treatment of pediatric type 2 diabetes. Expert Rev Endocrinol Metab 2018; 13:207-212. [PMID: 30063424 DOI: 10.1080/17446651.2018.1499467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Treatment of type 2 diabetes (T2D) in children and adolescents is particularly challenging. Metformin monotherapy is the standard initial treatment for youth with T2D, once metabolic control is restored with insulin in patients who present with ketosis and/or marked hyperglycemia. Insulin, the only other drug approved for use in youth with T2D, is also used as add-on therapy when patients fail metformin mono-therapy. AREAS COVERED In this paper, we will summarize the current use of both metformin and insulin in the treatment of pediatric type 2 diabetes, as well as comment on their limitations. Given the rapid progression of T2D in youth, there is also considerable interest in treating youth with new oral and injectable agents that have been approved for use in adults with T2D. The potential for improving clinical outcomes of each of the main classes of new drugs for the treatment of pediatric T2D will be summerized. EXPERT COMMENTARY We will conclude by reviewing why phase 3 randomized clinical trials examining the safety and efficacy of these medications in the pediatric population have been difficult to complete and discuss a potential pathway to overcome these obstacles to regulatory approval for these drugs for adolescents with T2D.
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Affiliation(s)
- Michelle Anne Van Name
- a Department of Pediatrics , Yale School of Medicine, Yale-New Haven Children's Hospital , New Haven , Connecticut , USA
| | - Cindy Guandalini
- a Department of Pediatrics , Yale School of Medicine, Yale-New Haven Children's Hospital , New Haven , Connecticut , USA
| | - Amy Steffen
- a Department of Pediatrics , Yale School of Medicine, Yale-New Haven Children's Hospital , New Haven , Connecticut , USA
| | - Anisha Patel
- a Department of Pediatrics , Yale School of Medicine, Yale-New Haven Children's Hospital , New Haven , Connecticut , USA
| | - William Tamborlane
- a Department of Pediatrics , Yale School of Medicine, Yale-New Haven Children's Hospital , New Haven , Connecticut , USA
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