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Müller-Godeffroy E, Schmid S, Reinauer C, Galler A, Hilgard D, Marshall L, Kapellen T, Lilienthal E, Mönkemöller K, Brosig B, Prchla C, Holl RW. Mental disorders in children and adolescents with type 1 diabetes before and during the COVID-19 pandemic: results from the DPV registry. J Pediatr Endocrinol Metab 2024; 37:586-596. [PMID: 38905521 DOI: 10.1515/jpem-2024-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/27/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVES The COVID-19 pandemic affected the mental health of children and adolescents in the general population, yet its impact on those with chronic conditions is relatively unknown. This study aimed to compare the incidences of comorbid mental disorders and substance misuse in children and adolescents with type 1 diabetes before and during the pandemic. METHODS A total of 42,975 patients aged 6-18 years from the multicentre DPV (Diabetes Prospective Follow-up) registry were included. Multivariable regression models were applied to compare newly diagnosed comorbid mental disorders, adjusted for demographic and clinical variables, among them the number of medical visits, during the pre-pandemic period (09/2017-02/2020) and the COVID-19 pandemic period (03/2020-08/2022). RESULTS Analysing both sexes together, there were no differences in the incidence rates of overall mental disorders between the pandemic and the pre-pandemic period. However, girls showed an increased incidence rate (odds ratio 1.2, CI 1.1-1.3) during the pandemic. Adolescent girls also displayed higher incidence rates of depression, eating disorders, and self-harm. Substance misuse declined overall during the pandemic (odds ratio 0.8, CI 0.7-0.9). CONCLUSIONS During the COVID-19 pandemic, we found higher incidence rates of overall mental disorders in girls, but not in boys and not in the total study population of children and adolescents with type 1 diabetes. Adolescent girls displayed increased incidence rates of depression, eating disorders, and self-harm. Substance misuse declined substantially. Clinicians should be aware of the high-risk group of adolescent girls during times of increased strain.
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Affiliation(s)
- Esther Müller-Godeffroy
- Department of Paediatrics, University Clinic of Schleswig-Holstein, University of Luebeck, Luebeck, Germany
| | - Stefanie Schmid
- Institute for Epidemiology and Medical Biometry, ZIBMT, University Ulm, Ulm, Germany
| | - Christina Reinauer
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, University Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Angela Galler
- Charite - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Sozialpädiatrisches Zentrum, Berlin, Germany
| | - Dörte Hilgard
- Paediatric and Adolescent Medical Practice, Witten, Germany
| | - Louise Marshall
- Department of Paediatrics, University Clinic of Schleswig-Holstein, University of Luebeck, Luebeck, Germany
| | - Thomas Kapellen
- Department of Paediatrics, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Eggert Lilienthal
- Department of Paediatrics, University Hospital St. Josef Bochum, Bochum, Germany
| | - Kirsten Mönkemöller
- Department of Paediatrics, Kinderkrankenhaus Amsterdamer Straße, Cologne, Germany
| | - Burkhard Brosig
- Family Psychosomatics, Centre of Paediatric and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | | | - Reinhard W Holl
- Institute for Epidemiology and Medical Biometry, ZIBMT, University Ulm, Ulm, Germany
- German Centre for Diabetes Research (DZD), Neuherberg, Germany
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Zhang K, Huang Q, Wang Q, Li C, Zheng Q, Li Z, Xu D, Xie C, Zhang M, Lin R. Telemedicine in Improving Glycemic Control Among Children and Adolescents With Type 1 Diabetes Mellitus: Systematic Review and Meta-Analysis. J Med Internet Res 2024; 26:e51538. [PMID: 38981114 PMCID: PMC11267117 DOI: 10.2196/51538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/28/2024] [Accepted: 05/21/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Type 1 diabetes mellitus (T1DM) is the most common chronic autoimmune disease among children and adolescents. Telemedicine has been widely used in the field of chronic disease management and can benefit patients with T1DM. However, existing studies lack high-level evidence related to the effectiveness of telemedicine for glycemic control in children and adolescents with T1DM. OBJECTIVE This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM. METHODS In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis. RESULTS Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001). CONCLUSIONS Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.
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Affiliation(s)
- Kun Zhang
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Qiyuan Huang
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Qiaosong Wang
- School of Nursing, Fujian Medical University, Fuzhou, China
- Department of Nursing, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, China
| | - Chengyang Li
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Qirong Zheng
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Zhuoyue Li
- Department of Infectious diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Dan Xu
- Foreign Language Department, Xuzhou Medical University, Xuzhou, China
| | - Cuiling Xie
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Mingqi Zhang
- School of Nursing, Fujian Medical University, Fuzhou, China
| | - Rongjin Lin
- School of Nursing, Fujian Medical University, Fuzhou, China
- Department of Nursing, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, China
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Dave S, Kim SC, Beaver S, Hasimoglu YG, Katz I, Luedke H, Yandulskaya AS, Sharma N. Peer support in adolescents and young adults with chronic or rare conditions in northern America and Europe: Targeted literature review. J Pediatr Nurs 2024:S0882-5963(24)00221-5. [PMID: 38964964 DOI: 10.1016/j.pedn.2024.06.001] [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] [Received: 01/05/2024] [Revised: 05/31/2024] [Accepted: 06/01/2024] [Indexed: 07/06/2024]
Abstract
PROBLEM Adolescents and young adults with chronic or rare conditions face unique risks to their physical, social and emotional development. Research suggests that peer support improves their quality of life and reduces social isolation. However, there is a paucity of current information considering multiple intervention formats. ELIGIBILITY CRITERIA A targeted literature review was conducted to identify peer support interventions and assess their feasibility, acceptability and efficacy for this population. Searches were conducted in MEDLINE, Embase and American Psychological Association PsycINFO for records reporting peer support interventions in young adults with chronic or rare conditions. Data were extracted from relevant publications and qualitatively evaluated. SAMPLE Thirty studies were included, which assessed the use of peer support for young adults (aged 13-30 years) with chronic or rare conditions in Europe or North America. RESULTS Peer support interventions had positive effects on social positivity, psychosocial development and medical outcomes, though significance was not always demonstrated. CONCLUSIONS Peer support can enhance care for young adults with chronic or rare conditions. Current literature suggests that once-weekly virtual interventions are the most feasible and acceptable for patients, leading to multifaceted improvements in their well-being. IMPLICATIONS This study is one of the first to discuss in-person, virtual and hybrid peer-based interventions for young adults with chronic and rare conditions. While all formats improved social, psychological and medical outcomes, virtual formats may be most accessible to participants. Interventions should be made available to this population, and guidelines for optimal implementation of peer support are needed.
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Affiliation(s)
| | - Sandra C Kim
- Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Children's Hospital, 8950 Euclid Ave R3, Cleveland, OH 44195, United States
| | - Steph Beaver
- Costello Medical (UK), 55 Old Broad Street, London EC2M 1RX, United Kingdom
| | - Yasemin G Hasimoglu
- Costello Medical (US), 175 Federal St Floor 16, Boston, MA 02110, United States
| | - Isabel Katz
- Costello Medical (US), 175 Federal St Floor 16, Boston, MA 02110, United States
| | - Hannah Luedke
- Costello Medical (UK), 55 Old Broad Street, London EC2M 1RX, United Kingdom
| | | | - Niraj Sharma
- Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, United States; Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States
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Wu Y, Long TX, Huang J, Zhang Q, Forbes A, Li MZ. Delivering a Smartphone Serious Game-Based Intervention to Promote Resilience for Adolescents With Type 1 Diabetes: A Feasibility Study. J Pediatr Health Care 2024:S0891-5245(24)00139-1. [PMID: 38935014 DOI: 10.1016/j.pedhc.2024.05.009] [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] [Received: 04/01/2024] [Revised: 04/16/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION The aim of this study is to test the feasibility of a smartphone serious game-based intervention to promote resilience for adolescents with type 1 diabetes mellitus (T1DM). METHOD A two-arm feasibility study was employed. Adolescents with T1DM were recruited. Adolescents in intervention group completed the serious game (named "WeCan") in one month. We evaluated feasibility and acceptability using criteria such as the recruitment response rate, the follow-up response rate, and satisfaction. RESULTS Sixty-one adolescents with T1DM were included in this study. The study had a recruitment response rate of 62.89% (61/97) and an intervention completion rate of 64.52% (20/31). Eighty-two percent of the adolescents were satisfied with WeCan, which they perceived to have the advantages of being a lively format, attractive, and privacy, easy to operate, and improved attitude towards diabetes. CONCLUSIONS These findings suggest that WeCan demonstrated good feasibility among the target population. However, the efficacy of health-related outcomes needs to be clarified in future studies.
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Tilden DR, Anifowoshe K, Jaser SS. Observed collaborative and intrusive parenting behaviours associated with psychosocial outcomes of adolescents with type 1 diabetes and their maternal caregivers. Diabet Med 2024; 41:e15300. [PMID: 38303663 PMCID: PMC11021143 DOI: 10.1111/dme.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/11/2024] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
AIMS Maternal caregiver involvement is strongly associated with psychosocial and glycemic outcomes amongst adolescents with type 1 diabetes (T1D); however, previous studies have lacked detailed, objective examinations of caregiver involvement. We examined the relationship between observed parenting behaviors and psychosocial and glycemic outcomes amongst youth with T1D. METHODS Data collected from adolescents with T1D (age 11-17) and their female caregivers as a part of a randomized controlled trial were analyzed. These included structured, observation-based scores of adolescent-caregiver dyads engaged in videotaped interactions and selected psychosocial and glycemic outcome measures. RESULTS In adjusted analyses, higher levels of intrusive parenting behaviors during observed interactions were associated with higher diabetes distress in adolescents, but no difference in HbA1c. Associations between intrusive parenting behaviors and psychosocial outcomes were stronger for females compared to males for both diabetes distress and quality of life. Similarly, associations between collaborative parenting behaviors and quality of life were stronger for female adolescents than males. No associations were observed between collaborative parenting behaviors and glycemic outcomes. Consistent with previous work, we noted higher levels of adolescent-reported family conflict were associated with lower adolescent quality of life and higher diabetes distress with no significant difference between male and female adolescents. CONCLUSION These findings indicate that high levels of intrusive parenting behaviors, such as lecturing or over-controlling behaviors, are associated with lower levels of adolescent well-being, particularly among adolescent girls. This work suggests that interventions to reduce intrusive parenting by maternal caregivers could result in improved psychosocial outcomes for adolescents with T1D.
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Affiliation(s)
- Daniel R Tilden
- Division of Endocrinology, Diabetes and Clinical Pharmacology, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kashope Anifowoshe
- Division of Pediatric Psychology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah S Jaser
- Division of Pediatric Psychology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ghitha N, Vathania N, Wiyono L, Pulungan A. Delayed menarche in children and adolescents with type 1 diabetes mellitus: a systematic review and meta-analysis. Clin Pediatr Endocrinol 2024; 33:104-112. [PMID: 38993726 PMCID: PMC11234191 DOI: 10.1297/cpe.2023-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/26/2024] [Indexed: 07/13/2024] Open
Abstract
Several studies have reported an association between age at menarche and the onset of type-1 diabetes mellitus (T1DM). This review compared the age at menarche in patients who had menarche after T1DM diagnosis with that of patients who were healthy and/or had menarche before T1DM diagnosis. Searches were conducted using four databases. The outcome was the age at menarche of patients who had menarche after T1DM diagnosis and patients who were healthy and/or had menarche before T1DM diagnosis. A qualitative analysis was performed using the JBI (Joanna Briggs Institute) Critical Appraisal. Quantitative analysis of the mean differences was performed using Revman 5.4 tool. A total of 1952 studies were obtained from the initial search. The final results were 13 articles that met the inclusion criteria for the qualitative assessment and eight for the quantitative assessment. Eight studies included 1030 patients who had menarche after being diagnosed with T1DM and 1282 patients who were healthy and/or had menarche before T1DM diagnosis. The meta-analysis showed a cumulative effect on a mean difference of 0.87 (95% CI: 0.75; 0.99, p-value < 0.00001), indicating a later age at menarche in patients who had menarche after T1DM diagnosis. The age at menarche was later in patients who had menarche after T1DM diagnosis compared to healthy subjects and those who had menarche beforehand.
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Affiliation(s)
- Nida Ghitha
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nabila Vathania
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Lowilius Wiyono
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Aman Pulungan
- Division of Endocrinology, Department of Child's Health, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Kim-Dorner SJ, Saßmann H, Heidtmann B, Kapellen TM, Kordonouri O, Nettelrodt KM, Schweizer R, von Sengbusch S, Lange K. Using person reported outcomes: Psychometric properties of the German diabetes treatment satisfaction questionnaire (DTSQ) for teens and parents. Heliyon 2024; 10:e27614. [PMID: 38524562 PMCID: PMC10957384 DOI: 10.1016/j.heliyon.2024.e27614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 02/12/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024] Open
Abstract
Aims To examine psychometric properties including the factor structure of the German versions of the Diabetes Treatment Satisfaction Questionnaire for teens and parents (DTSQ-T/-P). Methods Linguistically validated questionnaires were completed by 363 adolescents with type 1 diabetes and 655 parent-caregivers in a multicenter study. Confirmatory factor analysis (CFA), reliability, and correlations were examined. Results CFA confirmed the 2-factor model of treatment satisfaction (TS) & perceived diabetes control (PDC) with an adjustment of removing the "medical support" item from the TS and examining it as a single item in this study. Cronbach's α of TS for DTSQ-T/-P was 0.82 & 0.83, respectively, and α of the two-item PDC factor was 0.70 & 0.60, respectively. The DTSQ scale scores positively correlated with time in range and inversely correlated with HbA1c. Scale scores of DTSQ-T/-P showed significantly positive relations to the KIDSCREEN-10 Index and negative associations with the Problem Areas in Diabetes (PAID). The TS of the parents was correlated with depressive symptoms measured in the Patient Health Questionnaire-9. Conclusions The DTSQ-T/-P produced psychometrically sound scores in measuring diabetes treatment satisfaction in German teens with type 1 diabetes and their parents. German DTSQ versions for teens and parents are recommended in research and clinical practice.
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Affiliation(s)
- Su-Jong Kim-Dorner
- Medical Psychology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Heike Saßmann
- Medical Psychology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Bettina Heidtmann
- Pediatric Endocrinology and Diabetes, Wilhelmstift Catholic Children's Hospital, Liliencronstr. 130, 22149, Hamburg, Germany
| | - Thomas M. Kapellen
- MEDIAN Children's Hospital “Am Nicolausholz”, Elly-Kutscher-Str.16, 06628, Naumburg, Germany
- Department of Pediatrics, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Children's Hospital AUF DER BULT, Janusz-Korczak-Allee 12, 30173, Hannover, Germany
| | | | - Roland Schweizer
- Pediatric Endocrinology and Diabetology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Simone von Sengbusch
- Clinic for Pediatric and Adolescent Medicine, University Medical Center Schleswig-Holstein, Lübeck Campus, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Karin Lange
- Medical Psychology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Passanisi S, Piona C, Salzano G, Marigliano M, Bombaci B, Morandi A, Alibrandi A, Maffeis C, Lombardo F. Aiming for the Best Glycemic Control Beyond Time in Range: Time in Tight Range as a New Continuous Glucose Monitoring Metric in Children and Adolescents with Type 1 Diabetes Using Different Treatment Modalities. Diabetes Technol Ther 2024; 26:161-166. [PMID: 37902743 DOI: 10.1089/dia.2023.0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Introduction: To evaluate time in tight range (TITR) 70-140 mg/dL (3.9-7.8 mmol/L), its correlation with standard continuous glucose monitoring (CGM) metrics and the clinical variables that possibly have a substantial impact on its value, in a large cohort of pediatric subjects using different treatment strategies. Materials and Methods: A total of 854 children and adolescents with type 1 diabetes were consecutively recruited in this real world, dual center, cross-sectional study. Participants were categorized into four treatment groups (multiple daily injections [MDI] + real-time CGM, MDI + intermittently scanned CGM, sensor augmented pump, and hybrid closed loop [HCL]). Demographical and clinical data, including CGM data, were collected and analyzed. Results: The overall study population exhibited an average TITR of 36.4% ± 12.8%. HCL users showed higher TITR levels compared to the other treatment groups (P < 0.001). A time in range (TIR) cut-off value of 71.9% identified subjects achieving a TITR ≥50% (area under curve [AUC] 0.98; 95% confidence interval 0.97-0.99, P < 0.001), and a strong positive correlation between these two metrics was observed (r = 0.95, P < 0.001). An increase in TIR of 1% was associated with 1.84 (R2 Nagelkerke = 0.35, P < 0.001) increased likelihood of achieving TITR ≥50%. Use of HCL systems (B = 7.78; P < 0.001), disease duration (B = -0.26, P = 0.006), coefficient of variation (B = -0.30, P = 0.004), and glycated hemoglobin (B = -8.82; P < 0.001) emerged as significant predictors of TITR levels. Conclusions: Our study highlights that most children and adolescents with type 1 diabetes present TITR levels below 50%, except those using HCL. Tailored interventions and strategies should be implemented to increase TITR.
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Affiliation(s)
- Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital, Verona, Italy
| | - Giuseppina Salzano
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
| | - Marco Marigliano
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital, Verona, Italy
| | - Bruno Bombaci
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
| | - Anita Morandi
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital, Verona, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Claudio Maffeis
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital, Verona, Italy
| | - Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi," University of Messina, Messina, Italy
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Shapiro JB, Garza KP, Feldman MA, Suhs MC, Ellis J, Terry A, Howard KR, Weissberg-Benchell J. Psychosocial Care for Youth with Type 1 Diabetes: Summary of Reviews to Inform Clinical Practice. Endocrinol Metab Clin North Am 2024; 53:107-122. [PMID: 38272590 DOI: 10.1016/j.ecl.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
The intensive demands of diabetes care can be difficult for youth with type 1 diabetes and their families to integrate into daily life. Standards of care in pediatric diabetes highlight the importance of evidence-based psychosocial interventions to optimize self-management behaviors and psychological well-being. The current review summarizes select systematic reviews and meta-analyses on evidence-based behavioral health interventions in pediatric diabetes. Interventions include strategies to strengthen youth psychosocial skills, improve family dynamics and caregiver mental health, enhance health and mental health equity, and address psychosocial factors related to diabetes technology use.
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Affiliation(s)
- Jenna B Shapiro
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pritzker Department of Psychiatry and Behavioral Health, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, Department of Psychiatry & Behavioral Sciences, 446 E Ontario Street, Chicago, IL, USA.
| | | | - Marissa A Feldman
- Johns Hopkins All Children's Hospital, Child Development and Rehabilitation Center, 880 Sixth Street South #170, Saint Petersburg, FL 33701, USA
| | - Madeleine C Suhs
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pritzker Department of Psychiatry and Behavioral Health, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA
| | - Julia Ellis
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pritzker Department of Psychiatry and Behavioral Health, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA
| | - Amanda Terry
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pritzker Department of Psychiatry and Behavioral Health, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, Department of Psychiatry & Behavioral Sciences, 446 E Ontario Street, Chicago, IL, USA
| | - Kelsey R Howard
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pritzker Department of Psychiatry and Behavioral Health, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, Department of Psychiatry & Behavioral Sciences, 446 E Ontario Street, Chicago, IL, USA
| | - Jill Weissberg-Benchell
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pritzker Department of Psychiatry and Behavioral Health, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, Department of Psychiatry & Behavioral Sciences, 446 E Ontario Street, Chicago, IL, USA
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10
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Armocida B, Monasta L, Sawyer SM, Bustreo F, Onder G, Castelpietra G, Pricci F, Minardi V, Giacomozzi C, Abbafati C, Stafford LK, Pasovic M, Hay SI, Ong KL, Perel P, Beran D. The Burden of Type 1 and Type 2 Diabetes Among Adolescents and Young Adults in 24 Western European Countries, 1990-2019: Results From the Global Burden of Disease Study 2019. Int J Public Health 2024; 68:1606491. [PMID: 38420040 PMCID: PMC10899430 DOI: 10.3389/ijph.2023.1606491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/18/2023] [Indexed: 03/02/2024] Open
Abstract
Objectives: As little is known about the burden of type 1 (T1DM) and type 2 diabetes (T2DM) in adolescents in Western Europe (WE), we aimed to explore their epidemiology among 10-24 year-olds. Methods: Estimates were retrieved from the Global Burden of Diseases Study (GBD) 2019. We reported counts, rates per 100,000 population, and percentage changes from 1990 to 2019 for prevalence, incidence and years lived with disability (YLDs) of T1DM and T2DM, and the burden of T2DM in YLDs attributable to high body mass index (HBMI), for 24 WE countries. Results: In 2019, prevalence and disability estimates were higher for T1DM than T2DM among 10-24 years old adolescents in WE. However, T2DM showed a greater increase in prevalence and disability than T1DM in the 30 years observation period in all WE countries. Prevalence increased with age, while only minor differences were observed between sexes. Conclusion: Our findings highlight the substantial burden posed by DM in WE among adolescents. Health system responses are needed for transition services, data collection systems, education, and obesity prevention.
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Affiliation(s)
- Benedetta Armocida
- Division of Tropical and Humanitarian Medicine, University of Geneva, Geneva, Switzerland
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Lorenzo Monasta
- Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Susan M Sawyer
- Department of Paediatrics, Murdoch Children's Research Institute, Centre for Adolescent Health, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, VIC, Australia
| | | | - Graziano Onder
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Department of Geriatric and Orthopedic Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulio Castelpietra
- Outpatient and Inpatient Care Service, Central Health Directorate, Trieste, Italy
| | - Flavia Pricci
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Valentina Minardi
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| | - Claudia Giacomozzi
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Cristiana Abbafati
- Department of Juridical and Economic Studies, Sapienza University of Rome, Rome, Italy
| | - Lauryn K Stafford
- Institute for Health Metrics and Evaluation, Seattle, WA, United States
| | - Maja Pasovic
- Institute for Health Metrics and Evaluation, Seattle, WA, United States
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, Seattle, WA, United States
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, United States
| | - Kanyin Lian Ong
- Institute for Health Metrics and Evaluation, Seattle, WA, United States
| | - Pablo Perel
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
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11
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Naef AN, Fischbock N, Tezcan-Güntekin H, Amelung VE. Adolescents with type 1 diabetes' perspectives on digital health interventions to enhance health literacy: a qualitative study. Front Public Health 2024; 12:1340196. [PMID: 38414892 PMCID: PMC10896973 DOI: 10.3389/fpubh.2024.1340196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction Digital health intervention offers the potential to enhance health literacy, which is crucial for effective diabetes management, especially among adolescents. Diabetes is a major global public health issue, leading to devastating complications and increasing mortality rates. The incidence of type 1 diabetes mellitus (T1DM) is also on the rise, particularly among adolescents, necessitating multisectoral strategies to combat this disease. This study explores the perceptions of adolescents with T1DM in Germany regarding digital health interventions, with the aim of improving healthcare by addressing specific needs and guiding future research. Methodology This study employed a qualitative approach using semi-structured individual interviews with adolescents with T1DM (n = 20) aged 14 to 18 years old in Germany to explore their perspectives on digital interventions for health literacy promotion. The study adopted content analysis according to Kuckartz et al. and the research followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Ethical considerations were paramount and data were rigorously analyzed using coding and iterative processes to ensure data quality and reliability. Results The findings indicate that within three prominent domains, namely the utilization of digital health intervention for accessing and comprehending information, facilitating peer-to-peer interactions, and enhancing physician-patient communication and interaction, digital health interventions are either underutilized or insufficiently deployed. In addition, a notable observation is the apparent lack of patient-centered approaches for adolescents with T1DM in relation to digital health interventions and health literacy. Conclusion In order to enhance the utilization of digital health interventions and enhance health literacy it is essential to focus on capacity building through a patient-centered approach, to promote digital health literacy, and foster the cultivation of a participatory culture. The outcomes of this study offer valuable insights that can inform practical applications, further research endeavors, and influence policymaking.
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Affiliation(s)
- Aurélia Naoko Naef
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Nadine Fischbock
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Hürrem Tezcan-Güntekin
- Department of Health and Education, Alice Salomon Hochschule Berlin, Berlin, Germany
- Berlin School of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Eric Amelung
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
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12
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Zafra-Tanaka JH, Del Valle A, Bernabé-Ortiz A, Miranda JJ, Beran D. Outcomes measured in studies assessing health systems interventions for type 1 diabetes management: A scoping review. Diabet Med 2024; 41:e15223. [PMID: 37683837 DOI: 10.1111/dme.15223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/10/2023]
Abstract
AIMS Describe the outcomes reported in research on health systems interventions for type 1 diabetes management in comparison to the outcomes proposed by a core outcome set (COS) for this condition, an essential list of outcomes that studies should measure. METHODS Systematic search of studies published between 2010 and 2021 reporting health systems interventions directed to improve the management of type 1 diabetes using PubMed, EMBASE and CENTRAL. Information on the outcomes was extracted and classified according to a COS: self-management, level of clinical engagement, perceived control over diabetes, diabetes-related quality of life, diabetes burden, diabetes ketoacidosis, severe hypoglycemia, and glycated hemoglobin (HbA1C). RESULTS 187 studies were included. Most of the studies included either children (n = 82/187) or adults (n = 82/187) living with type 1 diabetes. The most common outcome measured was HbA1C (n = 149/187), followed by self-management (n = 105/187). While the least measured ones were diabetes ketoacidosis (n = 15/187), and clinical engagement (n = 0/187). None of the studies measured all the outcomes recommended in the COS. Additionally, different tools were found to be used in measuring the same outcome. CONCLUSIONS This study provides a description of what researchers are measuring when assessing health systems interventions to improve type 1 diabetes management. In contrast to a COS, it was found that there is a predominance of clinical-based outcomes over patient-reported outcome measures.
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Affiliation(s)
- Jessica Hanae Zafra-Tanaka
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Adela Del Valle
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Antonio Bernabé-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Universidad Científica del Sur, Lima, Peru
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
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13
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Rebollo-Román Á, Tabernero-Urbieta MC, Villaécija J, Luque-Salas B. Mediterranean diet adherence and glycemic control in children and adolescents with type 1 diabetes. Eur J Pediatr 2024; 183:453-460. [PMID: 37930397 DOI: 10.1007/s00431-023-05325-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
To effectively manage type 1 diabetes (T1D) insulin is essential, with dosages based on lifestyle. The Mediterranean diet has demonstrated its advantages in preventing and enhancing the management of chronic diseases. Our objective was to investigate the potential mediation of sensor activity on the relationship between adherence to the Mediterranean diet and glycemic control in children and adolescents. A total of 150 children and adolescents (mean age = 13.09, SD = 3.54; 44% female) with T1D were recruited. Adherence to the Mediterranean diet was assessed using the KIDMED questionnaire which evaluates 16 items and gives higher scores when adherence is higher. Glycemic control and the duration of sensor activity were evaluated with data from flash glucose monitoring. The data confirmed our hypothesis by revealing that adherence to the Mediterranean diet positively influenced glycemic control (direct effect = 1.505; P < 0.01) and that this relationship was mediated by the duration of sensor activity (indirect effect = 0.531; P < 0.01). Conclusions: Our results support the increased utilization of glycemic control devices, as they contribute to improve glycemic control and mediate on the positive relationship between adherence to the Mediterranean diet and adequate glycemic control. Furthermore, our findings highlight the importance of incorporating Mediterranean diet recommendations to achieve better glycemic control in children and adolescents with T1D. What is Known: • The Mediterranean diet and glycemic control have proven benefits in improving cardiovascular health in the general population. Scarce evidence exists of these benefits among children and adolescents with T1D. What is New: • Adherence to the Mediterranean diet and greater use of glucose monitoring devices in children and adolescents with T1D are related to better glycemic control. These variables can be enhanced by psychoeducational interventions such as structured diabetes education programs or peer group-based sessions, which highlights the importance of focusing on these aspects.
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Affiliation(s)
- Ángel Rebollo-Román
- Department of Endocrinology and Nutrition, University Hospital Reina Sofía, Avda. Menéndez Pidal S/N, 14004, Córdoba, Spain.
- Department of Psychology, Faculty of Education Sciences and Psychology, Córdoba University, Córdoba, Spain.
| | - Mª Carmen Tabernero-Urbieta
- Department of Psychology, Faculty of Education Sciences and Psychology, Córdoba University, Córdoba, Spain
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córdoba, Spain
- Department of Social Psychology and Anthropology, University of Salamanca, Salamanca, Spain
- Institute of Neurosciences of Castilla y León (INCYL), University of Salamanca, Salamanca, Spain
| | - Joaquín Villaécija
- Department of Psychology, Faculty of Education Sciences and Psychology, Córdoba University, Córdoba, Spain
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córdoba, Spain
| | - Bárbara Luque-Salas
- Department of Psychology, Faculty of Education Sciences and Psychology, Córdoba University, Córdoba, Spain
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córdoba, Spain
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14
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Marx A, Di Stefano F, Leutheuser H, Chin-Cheong K, Pfister M, Burckhardt MA, Bachmann S, Vogt JE. Blood glucose forecasting from temporal and static information in children with T1D. Front Pediatr 2023; 11:1296904. [PMID: 38155742 PMCID: PMC10752933 DOI: 10.3389/fped.2023.1296904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Background The overarching goal of blood glucose forecasting is to assist individuals with type 1 diabetes (T1D) in avoiding hyper- or hypoglycemic conditions. While deep learning approaches have shown promising results for blood glucose forecasting in adults with T1D, it is not known if these results generalize to children. Possible reasons are physical activity (PA), which is often unplanned in children, as well as age and development of a child, which both have an effect on the blood glucose level. Materials and Methods In this study, we collected time series measurements of glucose levels, carbohydrate intake, insulin-dosing and physical activity from children with T1D for one week in an ethics approved prospective observational study, which included daily physical activities. We investigate the performance of state-of-the-art deep learning methods for adult data-(dilated) recurrent neural networks and a transformer-on our dataset for short-term (30 min) and long-term (2 h) prediction. We propose to integrate static patient characteristics, such as age, gender, BMI, and percentage of basal insulin, to account for the heterogeneity of our study group. Results Integrating static patient characteristics (SPC) proves beneficial, especially for short-term prediction. LSTMs and GRUs with SPC perform best for a prediction horizon of 30 min (RMSE of 1.66 mmol/l), a vanilla RNN with SPC performs best across different prediction horizons, while the performance significantly decays for long-term prediction. For prediction during the night, the best method improves to an RMSE of 1.50 mmol/l. Overall, the results for our baselines and RNN models indicate that blood glucose forecasting for children conducting regular physical activity is more challenging than for previously studied adult data. Conclusion We find that integrating static data improves the performance of deep-learning architectures for blood glucose forecasting of children with T1D and achieves promising results for short-term prediction. Despite these improvements, additional clinical studies are warranted to extend forecasting to longer-term prediction horizons.
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Affiliation(s)
- Alexander Marx
- Department of Computer Science, ETH Zurich, Zurich, Switzerland
| | | | | | | | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Marie-Anne Burckhardt
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Pediatric Endocrinolgy and Diabetology, University Children’s Hospital Basel, Basel, Switzerland
| | - Sara Bachmann
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Pediatric Endocrinolgy and Diabetology, University Children’s Hospital Basel, Basel, Switzerland
| | - Julia E. Vogt
- Department of Computer Science, ETH Zurich, Zurich, Switzerland
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15
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Olsson S, Otten J, Blusi M, Lundberg E, Hörnsten Å. Experiences of transition to adulthood and transfer to adult care in young adults with type 1 diabetes: A qualitative study. J Adv Nurs 2023; 79:4621-4634. [PMID: 37357405 DOI: 10.1111/jan.15740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/29/2023] [Accepted: 06/10/2023] [Indexed: 06/27/2023]
Abstract
AIM To explore young adults' experiences of living with type 1 diabetes in the transition to adulthood, including experiences of the transfer from paediatric to adult care. DESIGN A qualitative approach was used. METHOD Ten young adults, six women and four men, aged 19-29 years, participated. Participants were recruited at their regular diabetes clinic from spring 2021 to spring 2022. Semi-structured interviews were transcribed and analysed using qualitative content analysis. FINDINGS Dreaming of being nurtured towards self-reliance was the overarching theme. Personal experiences of the transition to adulthood, including the transfer from paediatric to adult care, were described in terms of struggling to find balance in daily life, dealing with feelings of being different, being gradually supported to achieve independence, and wishing to be approached as a unique person in healthcare. CONCLUSION In healthcare, it is important to emphasize not only diabetes-related factors but also emotional and psychosocial aspects of life connected to the transition to adulthood, including the transfer to adult care. The young adults wished to be seen as unique persons in healthcare during their emerging adulthood and should therefore be supported to achieve self-reliance through personal preparations for new challenges and for the consequences of transitioning to adulthood. Specialist nurses can provide appropriate knowledge and leadership. IMPLICATIONS FOR THE PROFESSION These findings can guide nurse specialists in support for emerging adults to achieve self-reliance and indicate the importance of person-centred care when experiencing transition and transfer. REPORTING METHOD The study adhered to EQUATOR guidelines, and the COREQ checklist for qualitative studies was used as the reporting method.
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Affiliation(s)
- Sara Olsson
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Julia Otten
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Elena Lundberg
- Department of Pediatrics, Institution of Clinical Science, Umeå University, Umeå, Sweden
| | - Åsa Hörnsten
- Department of Nursing, Umeå University, Umeå, Sweden
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16
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Vallmark M, Brorsson AL, Sparud-Lundin C, Bratt EL, Moons P, Saarijärvi M, Mora MA. Development and psychometric evaluation of TEXP-Q: a questionnaire measuring transition and transfer experiences in emerging adults with type 1 diabetes. J Patient Rep Outcomes 2023; 7:111. [PMID: 37938469 PMCID: PMC10632333 DOI: 10.1186/s41687-023-00652-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 10/31/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND During transition to adulthood and transfer to adult healthcare, emerging adults with chronic conditions are at risk of deteriorating disease control, well-being, and acute, as well as long-term complications. Despite an increasing call for person-centred healthcare services attuned to young peoples' needs, few validated instruments exist pinpointing adolescents' and emerging adults' experiences of preparation for transition and transfer. Thus, the overarching purpose of this study was to develop a person-centred, clinically applicable instrument (Transitional care EXPeriences Questionnaire, TEXP-Q) adjustable to different chronic conditions, although the focus in the present study was Type 1 Diabetes. The specific aim was, therefore, to describe the development and psychometric evaluation of TEXP-Q in emerging adults with Type 1 Diabetes. METHODS Initial development of the TEXP-Q was inspired by existing research. Items were formulated in accordance with consensus recommendations for developing patient-reported measures, and extra consideration was taken to ensure person-centredness. Psychometric evaluation comprised two phases: In phase I, data from cognitive interviews, content validity indexing, and judgement of an expert panel provided information on face and content validity. In phase II, data from a cross-sectional study conducted at eight adult diabetes outpatient clinics in Sweden (n = 163) allowed for explorative factor analysis (EFA), as well as calculation of content validity, reliability and responsiveness. RESULTS Combining results from cognitive interviews, content validity index values and expert panel judgement, a test version of TEXP-Q was developed, the content and face validity of which were considered good. This version consisted of 17 items answered on a five-point Likert scale, and three open-ended questions answered in free text. During EFA, four items were removed, and a three-factor solution was recognised as most adequate, accounting for 60% cumulative variance and one single cross-loading. After EFA, the instrument comprised 13 questions, divided into three latent factors. Cronbach's alpha for the complete instrument was 0.866, which indicates good internal consistency. Crohnbach's alpha approximated to 0.8 for all factors respectively. CONCLUSION TEXP-Q is a newly developed, person-centred instrument which has proven to be both valid and reliable when applied to youths with T1D. The questionnaire fills a need for instruments focusing on emerging adults' experiences of preparation for transition and transfer.
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Affiliation(s)
- Mikaela Vallmark
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Anna Lena Brorsson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Gothenburg Centre for Person-Centred Care (GPCC) at University of Gothenburg, Gothenburg, Sweden
| | - Carina Sparud-Lundin
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Gothenburg Centre for Person-Centred Care (GPCC) at University of Gothenburg, Gothenburg, Sweden
| | - Ewa-Lena Bratt
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Children's Heart Center, Gothenburg, Sweden
| | - Philip Moons
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Markus Saarijärvi
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Gothenburg Centre for Person-Centred Care (GPCC) at University of Gothenburg, Gothenburg, Sweden
| | - Mariela Acuña Mora
- Institute of Healthcare Sciences, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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17
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Framme JR, Kim-Dorner SJ, Heidtmann B, Kapellen TM, Lange K, Kordonouri O, Saßmann H. Health-related quality of life among adolescents with type 1 diabetes since the second wave of the COVID-19 pandemic in Germany. Fam Med Community Health 2023; 11:e002415. [PMID: 37967993 PMCID: PMC10660822 DOI: 10.1136/fmch-2023-002415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVE The COVID-19 pandemic had an impact on everyday life and in general, reduced the health-related quality of life (HRQoL) of adolescents. In this study, we assess the HRQoL of adolescents with type 1 diabetes (T1D) in Germany since the second wave of the COVID-19 pandemic by using self-report and parent-proxy reports, to identify risk factors, to compare to peers and to examine the agreement of HRQoL between parents and their children. METHODS A total of 445 adolescents (12-18 years) and 413 parents participated in an anonymous cross-sectional survey conducted at three German diabetes centres from January 2021 to June 2022. Inclusion criteria were diabetes duration ≥1 year and German-speaking. Teen HRQoL was assessed by using self-report and parent-proxy report versions of the KIDSCREEN-10 index. RESULTS The majority of adolescents reported average (75.5%) HRQoL. Approximately 11.3% of teens reported high and 13.2% low HRQoL. Teen's female gender, older age, higher diabetes burden and parental depression symptoms contributed to lower self-reported HRQoL among teens. For parent-proxy reports, increasing diabetes burdens, parental depression symptoms, non-migrant status, high education and ketoacidosis contributed to lower scores on teen HRQoL. The mean scores of the KIDSCREEN-10 index for adolescents did not differ from the German norm. In comparison to healthy peers during the first wave of the pandemic, adolescents in the current study reported higher HRQoL. The overall teen-parent agreement was fair although parents reported significantly lower teen HRQoL than adolescents did. CONCLUSIONS HRQoL of most adolescents with T1D during the COVID-19 pandemic was average with parents reporting significantly lower scores. Self-reported and parent-proxy-reported HRQoL and the level of agreement due to different perspectives can provide important information for clinical care and intervention planning.
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Affiliation(s)
| | | | - Bettina Heidtmann
- Paediatric Endocrinology and Diabetology, Catholic Childrens Hospital Wilhelmstift, Hamburg, Germany
| | - Thomas Michael Kapellen
- Hospital for Children and Adolescents, University of Leipzig Medical Center, Leipzig, Germany
- Department of Paediatrics, MEDIAN Children's Hospital "Am Nicolausholz", Bad Kösen, Germany
| | - Karin Lange
- Medical Psychology, Hannover Medical School, Hannover, Germany
| | - Olga Kordonouri
- Diabetes Center for Children and Adolescents, Auf der Bult Children's Hospital, Hannover, Germany
| | - Heike Saßmann
- Medical Psychology, Hannover Medical School, Hannover, Germany
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18
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Schweizer R, Lösch-Binder M, Hayn C, Friz S, Uber J, Ziegler J, Liebrich F, Neu A. Transition From Childhood to Adult Care in Patients with Type 1 Diabetes: 20 Years of Experience From the Tübinger Transition Study. Exp Clin Endocrinol Diabetes 2023; 131:532-538. [PMID: 37467782 DOI: 10.1055/a-2132-9585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
AIMS Transition from pediatric to adult care is difficult for patients with chronic diseases. In this study, factors associated with metabolic control in childhood-onset type 1 diabetes (T1D) after transfer to adult care were analyzed. METHODS Overall, 224 persons with T1D were contacted yearly from 1998 to 2019. They voluntarily answered a questionnaire about their current hemoglobin A1c (HbA1c) levels, diabetes-associated complications, kind of care, living conditions, and family situation. Then, mixed longitudinal-cross-sectional analyses were carried out. RESULTS Overall, 190 patients answered at least once (mean age: 26.6 years). Diabetes complications were mentioned by 10 patients (5 microalbuminuria, 5 retinopathy). Most patients (92.6%) were in diabetes-specific care during the first year after transfer, with a trend to leave diabetes-specific care during the observation period. Patients in diabetes-specific care displayed lower HbA1c levels (%/mmol/mol) (7.1/54 vs. 7.5/58). An important predictor for HbA1c after transfer was HbA1c during the year before transfer (r=0.67, p <0.001). Patients living alone showed no difference in HbA1c levels from those living with their parents. Married patients had lower HbA1c levels (7.0/53 vs. 7.3/56, p<0.05) than unmarried ones. Patients with children (15.8%) presented lower HbA1c levels (6.9/52 vs. 7.3/56, p <0.01) than those without. CONCLUSIONS Good metabolic results are favored in patients followed-up in specialized care, are married, and are parents. We recommend transfer to a diabetologist with experience in T1D at an individual age.
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Affiliation(s)
- Roland Schweizer
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | | | - Clara Hayn
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Silas Friz
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Julia Uber
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Julian Ziegler
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Franziska Liebrich
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
| | - Andreas Neu
- Pediatric Diabetology, University Children's Hospital, Tübingen, Germany
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19
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de Beaufort C, Gomber A, Sap S, Laffel L. From paediatric to adult diabetes care: lost in transition. Lancet Diabetes Endocrinol 2023; 11:446-448. [PMID: 37209705 PMCID: PMC10851110 DOI: 10.1016/s2213-8587(23)00091-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Carine de Beaufort
- Diabetes & Endocrine Care Clinique Pédiatrique, Centre Hospitalier de Luxembourg, Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette 4356, Luxembourg.
| | - Apoorva Gomber
- Center for Integration Science, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Suzanne Sap
- Department of Paediatrics, Faculty of Medicine, University of Yaounde, Yaounde, Cameroon
| | - Lori Laffel
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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20
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Bruggeman BS, Schatz DA. The ISPAD Clinical Practice Consensus Guidelines 2022: how far we have come and the distance still to go. Lancet Diabetes Endocrinol 2023; 11:304-307. [PMID: 36972713 DOI: 10.1016/s2213-8587(23)00083-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Brittany S Bruggeman
- Division of Endocrinology, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
| | - Desmond A Schatz
- Division of Endocrinology, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA.
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21
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The Impact of a Low-Carbohydrate Diet on Micronutrient Intake and Status in Adolescents with Type 1 Diabetes. Nutrients 2023; 15:nu15061418. [PMID: 36986149 PMCID: PMC10051868 DOI: 10.3390/nu15061418] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Objective: The aim of this study was to evaluate the macronutrient and micronutrient intake and status in youth with type 1 diabetes mellitus (T1DM) following the consumption of a low-carbohydrate diet (LCD). Research Methods and Procedures: In a prospective intervention clinical trial, adolescents with T1DM using a continuous glucose monitoring device were enrolled. Following a cooking workshop, each participant received a personalized diet regime based on LCD (50–80 g carbohydrate/day). A Food Frequency Questionnaire was administered, and laboratory tests were taken before and 6 months following the intervention. Twenty participants were enrolled. Results: The median age was 17 years (15; 19), and the median diabetes duration was 10 years (8; 12). During the six-months intervention, carbohydrate intake decreased from 266 g (204; 316) to 87 g (68; 95) (p = 0.004). Energy intake, the energy percent from ultra-processed food, and fiber intake decreased (p = 0.001, p = 0.024, and p < 0.0001, respectively). These changes were accompanied by declines in BMI z-score (p = 0.019) and waist-circumference percentile (p = 0.007). Improvement was observed in the median HbA1c from 8.1% (7.5; 9.4) to 7.7% (6.9; 8.2) (p = 0.021). Significant declines below the DRI were shown in median intake levels of iron, calcium, vitamin B1, and folate. Conclusions: The LCD lowered ultra-processed food consumption, BMI z-scores and the indices of central obesity. However, LCDs require close nutritional monitoring due to the possibility of nutrient deficiencies.
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Stahl-Pehe A, Bächle C, Bódis K, Zaharia OP, Lange K, Holl RW, Roden M, Rosenbauer J. Comparison of diabetes distress and depression screening results of emerging adults with type 1 diabetes onset at different ages: findings from the German early-onset T1D study and the German Diabetes Study (GDS). Diabetol Metab Syndr 2023; 15:24. [PMID: 36803876 PMCID: PMC9940340 DOI: 10.1186/s13098-023-00994-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/08/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Diabetes distress is increasingly considered one of the most important psychosocial issues in the care of people with type 1 diabetes (T1D). We analyse whether diabetes distress and depression screening results of emerging adults are associated with the age at T1D onset. METHODS Data were taken from two cohort studies conducted at the German Diabetes Center, Düsseldorf, Germany. The 18-30-year-old participants had an age at onset either before the age of 5 years (childhood-onset long-term T1D study group, N = 749) or during adulthood (adult-onset short-term T1D study group from the German Diabetes Study (GDS), N = 163). Diabetes distress and depression screening were analysed by means of the 20-item Problem Areas in Diabetes (PAID-20) scale and the nine-item depression module from the Patient Health Questionnaire (PHQ-9). The average causal effect of age at onset was estimated by a doubly robust causal inference method. RESULTS The PAID-20 total scores were increased in the adult-onset study group [potential outcome mean (POM) 32.1 (95% confidence interval 28.0; 36.1) points] compared to the childhood-onset study group [POM 21.0 (19.6; 22.4) points, difference 11.1 (6.9; 15.3) points, p<0.001] adjusted for age, sex and haemoglobin A1c (HbA1c) levels. Moreover, more participants in the adult-onset group [POM 34.5 (24.9; 44.2) %] than in the childhood-onset group [POM 16.3 (13.3; 19.2) %] screened positive for diabetes distress [adjusted difference 18.3 (8.3; 28.2) %, p<0.001]. The PHQ-9 total score [difference 0.3 (-1.1; 1.7) points, p=0.660] and the proportion of participants with a positive screening result for depression [difference 0.0 (-12.7; 12.8) %, p=0.994] did not differ between the groups in the adjusted analyses. CONCLUSIONS Emerging adults with short-term type 1 diabetes screened positive for diabetes distress more often than adults with type 1 diabetes onset during early childhood when age, sex and HbA1c values were considered confounding factors. Accounting for age at onset or the duration of diabetes may help explain the heterogeneity in the data when psychological factors are examined.
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Affiliation(s)
- Anna Stahl-Pehe
- Institute for Biometrics and Epidemiology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany.
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany.
| | - Christina Bächle
- Institute for Biometrics and Epidemiology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Kálmán Bódis
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Oana-Patricia Zaharia
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Karin Lange
- Medical Psychology Unit, Hannover Medical School, Hannover, Germany
| | - Reinhard W Holl
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - Michael Roden
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Joachim Rosenbauer
- Institute for Biometrics and Epidemiology, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Auf'm Hennekamp 65, 40225, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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23
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Rami-Merhar B, Fröhlich-Reiterer E, Hofer SE, Fritsch M. [Diabetes mellitus in childhood and adolescence (Update 2023)]. Wien Klin Wochenschr 2023; 135:106-114. [PMID: 37101031 PMCID: PMC10132915 DOI: 10.1007/s00508-023-02169-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
In contrast to adults, type 1 diabetes mellitus (T1D) is the most frequent form of diabetes in childhood and adolescence (> 90%). After diagnosis the management of children and adolescents with T1D should take place in highly specialized pediatric units experienced in pediatric diabetology. The lifelong substitution of insulin is the cornerstone of treatment whereby modalities need to be individually adapted for patient age and the family routine. In this age group the usage of diabetes technology (glucose sensors, insulinpumps and recently hybrid-closed-loop-systems) is recommended. An optimal metabolic control right from the start of therapy is associated with an improved long-term prognosis. Diabetes education is essential in the management of patients with diabetes and their families and needs to be performed by a multidisciplinary team consisting of a pediatric diabetologists, diabetes educator, dietitian, psychologist and social worker. The Austrian working group for pediatric endocrinology and diabetes (APEDÖ) and the ISPAD (International Society for Pediatric and Adolescent Diabetes) recommend a metabolic goal of HbA1c ≤ 7.0%, ((IFCC) < 53 mmol/mol), and a "Time in range" > 70% for all pediatric age groups without the presence of severe hypoglycemia. Age-related physical, cognitive and psychosocial development, screening for associated diseases, avoidance of acute diabetes-related complications (severe hypoglycemia, diabetic ketoacidosis) and prevention of diabetes-related late complications to ensure high quality of life are the main goals of diabetes treatment in all pediatric age groups.
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Affiliation(s)
- Birgit Rami-Merhar
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Elke Fröhlich-Reiterer
- Universitätsklinik für Kinder- und Jugendheilkunde, Abteilung für allgemeine Pädiatrie, Medizinische Universität Graz, Graz, Österreich
| | - Sabine E Hofer
- Universitätsklinik für Kinder- und Jugendheilkunde, Department für Pädiatrie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Maria Fritsch
- Universitätsklinik für Kinder- und Jugendheilkunde, Abteilung für allgemeine Pädiatrie, Medizinische Universität Graz, Graz, Österreich
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24
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Arslan M, Ünsal EN, Durmaz N, Akin O, Güneş SO, Balamtekin N. Evaluation of the nutritional status of children with type 1 diabetes and their healthy siblings. Pediatr Endocrinol Diabetes Metab 2023; 29:225-230. [PMID: 38318788 PMCID: PMC10826688 DOI: 10.5114/pedm.2023.131161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/20/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Although there are studies evaluating the psychological adjustment of healthy children when their siblings have type 1 diabetes mellitus (T1DM), no study evaluating their nutritional status exists. Thus, this study aimed to determine the nutritional status of children with T1DM and their healthy siblings. MATERIAL AND METHODS Data from a control group, healthy siblings, and patients who were followed and treated for T1D in the Paediatric Gastroenterology and Paediatric Endocrinology outpatient clinics of the Health Sciences University Gülhane Medical Faculty between November 2019 and November 2020 were analysed and compared. The groups were compared in terms of nutritional characteristics, daily macro and micronutrient intakes and classified according to their body mass index (BMI) Z-scores. RESULTS The study population consisted of 29 children with T1DM (51.7% female, 48.3% male; age: 11.00 ±3.66 years), 36 healthy siblings of children with T1D (50% female, 50% male; age: 9.61 ±4.84 years), and a control group of 58 healthy children (51.7% female, 48.3% male; age: 10.68 ±3.01years).The BMI Z-score of 28.6%of healthy siblings and 25% of children with T1D was > 1 SD or overweight. All of the control group children were of normal weight. None of the children were obese; however, the overweight rate was significantly higher in the healthy siblings and diabetes groups compared to the control group (p = 0.012). Daily energy intake (%) was significantly higher in the control group than in the healthy siblings (p < 0.001). CONCLUSIONS A quarter of the children with T1D over five years of age were overweight. In addition, healthy siblings were found to have higher BMI Z-scores than controls. This is the first study to evaluate the nutritional status of siblings of patients with T1D and will hopefully lead to more comprehensive studies that will also assess their daily exercise and physical activity.
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Affiliation(s)
- Melike Arslan
- Division of Paediatric Gastroenterology, Department of Child Health and Diseases, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Emine Nüket Ünsal
- Department of Dietetics, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Nihal Durmaz
- Department of Child Health and Diseases, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Onur Akin
- Division of Paediatric Endocrinology, Department of Child Health and Diseases, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Sevinç Odabaşi Güneş
- Division of Paediatric Endocrinology, Department of Child Health and Diseases, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Necati Balamtekin
- Division of Paediatric Gastroenterology, Department of Child Health and Diseases, Gülhane Training and Research Hospital, Ankara, Turkey
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