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Allen V, Mahieu A, Kasireddy E, Shouman W, Pourrahmat MM, Collet JP, Cherkas A. Humanistic burden of pediatric type 1 diabetes on children and informal caregivers: systematic literature reviews. Diabetol Metab Syndr 2024; 16:73. [PMID: 38515123 PMCID: PMC10956250 DOI: 10.1186/s13098-024-01310-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Diagnosis of children with type 1 diabetes (T1D) imposes an unprecedented burden on children and their caregivers. OBJECTIVE To assess the burden of T1D on children and their informal caregivers, both after a recent diagnosis or after a longer duration of disease. METHODS A series of systematic literature reviews were performed to explore the burden of T1D on children with the disease and their primary informal caregivers, based on the time of diagnosis. After the extraction of the qualitative and quantitative data from the included studies, two literature-based conceptual frameworks were developed: on the burden of pediatric T1D on children, and on informal caregivers. A third conceptual framework on the shared burden of pediatric T1D on both children and informal caregivers as part of the same family unit was also developed. RESULTS The review of literature has identified a series of factors that affect the quality of life of children with T1D and their informal caregivers, with a direct impact on physical, emotional, and social outcomes. Generally, female patients and older adolescents experience more worry and stress that affects their quality of life. Other categories of factors affecting the child's and caregiver's burden include social, emotional, and physical factors, treatment-related and disease-related factors, as well as their coping abilities. Anxiety, depression, stress, and worry were commonly found among children and caregivers, starting with the diagnosis of T1D and continuing over time in relation to new challenges pertaining to aging or the disease duration. CONCLUSION T1D causes a significant burden to affected children and their caregivers, both independently and through transactional interaction within the family unit. Disease burden can be reduced by strengthening individuals for the benefit of the whole family.
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Affiliation(s)
| | | | | | - Walid Shouman
- Evidinno Outcomes Research Inc., Vancouver, BC, Canada
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Almeida AC, Tavares F, Pereira MG. Metabolic control and quality of life in type 1 diabetes: Do adherence, family support, and school support matter? Nurs Health Sci 2023; 25:456-465. [PMID: 37640532 DOI: 10.1111/nhs.13042] [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: 04/01/2022] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/31/2023]
Abstract
This study analyzed the relationship between clinical and demographic variables, family support, school support, and adherence on adolescents' metabolic control and quality of life (QoL) based on Adaptation to Chronic Disease in Childhood's model. The sample included 100 adolescents and 100 parents. Adolescents were assessed on adherence, family support, school support, and QoL. Parents were assessed on family functioning and parental coping. A path analysis was performed to assess the adequacy of the theoretical model to the sample. Daily glycemic monitoring was associated with better metabolic control and diabetes hospitalizations with worse metabolic control. The final model showed adherence, family support, school support, and family functioning having an indirect effect on the relationship between adolescence stage, number of daily glycemic monitorings, number of hospitalizations, and metabolic control/QoL. Adherence had an indirect effect on the relationship between glycemic monitoring and family and school support, suggesting that adolescents need both types of support to perform diabetes self-care tasks. QoL showed a direct effect on metabolic control revealing the importance of QoL in the design of interventions to promote metabolic control in adolescents.
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Affiliation(s)
- Ana C Almeida
- Psychology Research Centre (CIPsi), School of Psychology, University of Minho, Braga, Portugal
| | | | - M Graça Pereira
- Psychology Research Centre (CIPsi), School of Psychology, University of Minho, Braga, Portugal
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Wagner G, Zeiler M, Karwautz A, Schneider A, Rami-Merhar B, Berger G. Personality, Coping and Developmental Conditions in Female Adolescents and Young Adults with Type 1 Diabetes: Influence on Metabolic Control and Quality of Life. Front Psychiatry 2022; 12:809015. [PMID: 35356383 PMCID: PMC8960069 DOI: 10.3389/fpsyt.2021.809015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/06/2021] [Indexed: 01/09/2023] Open
Abstract
Objective To assess personality factors, coping, developmental conditions and quality of life in female adolescents and young adults with type 1 diabetes (T1D) and high vs.low HbA1c. Methods Patients were approached at the Department for Pediatrics, Medical University of Vienna; n = 129 female adolescents (10 to 23 years, mean age 15.21 ± 2.91) with type 1 diabetes were included. HIGH-A1c was defined as HbA1c > 7.5%, LOW-A1c as HbA1c ≤ 7.5% and compared to a sample of 56 age-matched female healthy controls. Self-rating questionnaires were used to assess psychosocial factors: Children's Depression Inventory (CDI); Junior Temperament and Character Inventory (J-TCI); Eating Disorders Inventory-2 (EDI-2); KIDCOPE; Subjective Family Image Test (SFIT) and Inventory of Life Quality in Children and Adolescents(ILC). Results T1D patients with HIGH-A1c were younger at the age of diabetes onset, had a longer diabetes duration, a higher maximum BMI, higher depression score, and higher frequency of diabetic ketoacidosis in the last year. They showed significantly higher levels of fatigue, lower levels of taking responsibility, lower ability to set goals and lower self-acceptance, as well as higher levels of ineffectiveness, lower levels of emotional attachment within the family, in particular with the fathers, and used negative coping strategies more often compared to patients with LOW-A1c. Furthermore, they reported significantly higher burden of illness and lower quality of life. Conclusions Disadvantageous personality and coping styles as well as developmental conditions should be addressed in the treatment of female adolescents with T1D with management problems.
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Affiliation(s)
- Gudrun Wagner
- Eating Disorders Unit at the Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Michael Zeiler
- Eating Disorders Unit at the Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Andreas Karwautz
- Eating Disorders Unit at the Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Andrea Schneider
- Eating Disorders Unit at the Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Birgit Rami-Merhar
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Gabriele Berger
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Pediatric Diabetes Outpatient Clinic, Health Care Centre Vienna Floridsdorf, Vienna, Austria
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Lukács A, Bettina Zagraj V, Bartkóné Kovács A, Soós A, Török A, Barkai L. Health-related quality of life of preschool-aged children with type 1 diabetes in the context of family and maternal functioning. J Child Health Care 2022; 26:31-41. [PMID: 33599524 DOI: 10.1177/1367493521995320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In this study, generic health-related quality of life (HRQoL) of young children with type 1 diabetes (T1D) was compared to healthy peers taken in consideration of family functioning and psychological well-being of mothers. A total of 113 mothers provided data (28 mothers had a preschool-aged child with T1D). There were no significant differences in background parameters of two investigated groups. No significant differences between children with and without T1D were detected either in HRQoL or in family functioning. Moreover, mothers of children with diabetes reported lower levels of resilience and more depressive symptoms than mothers of healthy peers. In the regression analysis, mothers' depressive symptoms and the family functioning significantly affected children's HRQoL regardless of the presence of diabetes. These results suggest that parents of children with T1D handle the burden of diabetes well and integrate into the daily activities of the families. Mothers experience distress, presumably because diabetes management is burdensome; however, the family can function well and the young children can live in a similar way to their healthy peers.
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Affiliation(s)
- Andrea Lukács
- Faculty of Healthcare, Institute of Theoretical Health Sciences, 547530University of Miskolc, Hungary
| | - Veronika Bettina Zagraj
- Faculty of Healthcare, Institute of Applied Health Sciences, 547530University of Miskolc, Miskolc, Hungary
| | - Anett Bartkóné Kovács
- 125749Borsod-Abaúj-Zemplén County Central and University Teaching Hospital, Miskolc, Hungary
| | - Andrea Soós
- 125749Borsod-Abaúj-Zemplén County Central and University Teaching Hospital, Miskolc, Hungary
| | - András Török
- 125749Borsod-Abaúj-Zemplén County Central and University Teaching Hospital, Miskolc, Hungary
| | - László Barkai
- Faculty of Healthcare, Institute of Theoretical Health Sciences, 547530University of Miskolc, Hungary.,Department of Paediatrics and Adolescent Medicine, Faculty of Medicine, 37862Pavol Jozef Šafárik University, Kosice, Slovakia
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Nikitina IL, Kelmanson IA. Health-related quality of life in 4-to-6-year-old children with type 1 diabetes mellitus estimated by children and their mothers. Eur J Pediatr 2022; 181:549-560. [PMID: 34424400 PMCID: PMC8380516 DOI: 10.1007/s00431-021-04239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/29/2021] [Accepted: 08/10/2021] [Indexed: 02/07/2023]
Abstract
Administration of pediatric Health Related Quality of Life (HRQoL) inventories frequently assesses both the child and parent perspectives in young children with type 1 diabetes mellitus (T1DM), but parent-proxy and child self-reports may differ, and little is known on these discrepancies. The aim is to evaluate HRQoL estimated by young children with T1DM and by their mothers, potential discrepancies in the children-maternal estimates and the factors influencing these discrepancies. Thirty-five 4-to-6-year-old children (19 boys) with T1DM admitted to the Pediatric Endocrinology Department were approached with the self-report KINDL questionnaire for children aged 4-6 years (Kiddy-KINDL for children). Their mothers were approached with the parental version (Kiddy-KINDL for parents). Both versions enable measuring child HRQoL in physical, emotional wellbeing, self-esteem, family, friends, everyday functioning, and the disease dimensions, as well as KINDL total on a 0-100 scale. Statistically significant differences were found between children's and maternal estimates on the KINDL total and "Disease" scales, in that the maternal proxy-reports produced lower values. A statistically significant difference between self- and proxy-reports was found for the KINDL "Emotional wellbeing" scale values, and the maternal proxy-reports yielded higher estimates compared with children's self-reports. These associations remained significant after adjustment for major potential confounders. Maternal education, maternal marital status, insulin regimen, and achievement of glycemic control modified the effect of child-maternal discrepancies.Conclusion: Attempts should be made to improve parental understanding of child problems related to his/her disease with due account to individual family social and demographic characteristics. What is Known: • HRQoL in children with T1DM has been advocated as an important complementary outcome to clinical and laboratory markers. • Self-and parental proxy-reports on HRQoL may differ, but little is known on these discrepancies and on the factors influencing them in young children with T1DM. What is New: • Mothers tend to underestimate general and disease-related components of HRQoL but likely to overestimate psychological wellbeing of their ill young children with T1DM. • Maternal education, marital status, insulin regimen, and achievement of glycemic control modify estimations of HRQoL and child-maternal discrepancies.
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Affiliation(s)
- Irina L. Nikitina
- Department of Children’s Diseases, Institute for Medical Education of the V.A.Almazov National Medical Research Centre, Akkuratova Str., 2, 197341 St. Petersburg, Russia
| | - Igor A. Kelmanson
- Department of Children’s Diseases, Institute for Medical Education of the V.A.Almazov National Medical Research Centre, Akkuratova Str., 2, 197341 St. Petersburg, Russia
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Susilowati S, Arto KS, Lubis AD. The Relationship between Glycated Hemoglobin Levels and the Quality of Life among Type 1 Diabetes Mellitus in Children. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia that occurs due to impaired both in insulin secretion and insulin action. Children with type 1 diabetes mellitus should be targeted to achieve a glycated hemoglobin (HbA1C) level ≤7.0% to reduce the risk of complications and improve quality of life. The majority of children with type 1 diabetes mellitus exhibit poor self-care and Health-related Quality of life behavior.
AIM: The objective of the study was to determine the relationship between HbA1C level and the quality of life among type 1 diabetes mellitus in children.
METHODS: A cross-sectional study was conducted among 30 children with type 1 diabetes mellitus who attended at pediatric endocrine clinic Haji Adam Malik general hospital and Universitas Sumatera Utara hospital Medan. Sampling was carried out in April 2020–July 2020. HbA1C level and self-administered questionnaire were used to assess the quality of life. Spearman correlation test was conducted to assess the correlation between HbA1C levels and the quality of life.
RESULTS: The mean of HbA1C level was 10.35 ± 2.68. No significant correlation between HbA1C level and the quality of life of children with type 1 diabetes mellitus (r = 0.264, p > 0.05)
CONCLUSIONS: There was no significant correlation between HbA1C levels and the quality of life of children with type 1 diabetes mellitus.
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Marques RDMB, Rodrigues MLDM, Marini ACB, Santos CRDC, Schincaglia RM. Associated factors with the quality of life of adolescents with type 1 diabetes. Clin Nutr ESPEN 2021; 42:387-392. [PMID: 33745610 DOI: 10.1016/j.clnesp.2020.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND & AIMS The impact of Type 1 diabetes on adolescence can have consequences on the quality of life (QoL), which can affect its growth, development and management of the disease. Thus, the objective of this study was to evaluate the QoL related to the health of adolescents with type 1 diabetes and if socioeconomic, demographic, clinical and anthropometric factors can be associated with it. METHODS Cross-sectional study with adolescents with Type 1 diabetes mellitus (T1DM) of both sexes and between 10 and 18 years old. QoL was assessed by the Quality of Life Instrument for Young Diabetics (total score and its dimensions - Satisfaction, Impact and Concerns) and socioeconomic and demographic, clinical and anthropometric data were evaluated. RESULTS Among 53 adolescents with T1DM, more than 13% of adolescents rated QoL as poor. The worst QoL in the Satisfaction dimension was associated with overweight, assessed by the body mass index; the increased cardiometabolic risk, assessed by waist circumference; the adolescent's later age at diagnosis (11-17 years); and the adolescent's older age (15-18 years). The worst QoL assessed in the Impact dimension was associated with the female sex. The Concerns dimension and the Total QoL score were not associated with socioeconomic and demographic, clinical, and anthropometric variables. CONCLUSIONS We conclude that the QoL Satisfaction dimension of adolescents with T1DM is associated with their age, age at diagnosis, overweight and increased waist circumference, while the Impact dimension is associated with sex, and the Concerns dimension and the Total QoL score were not associated with the factors studied. Knowing the importance of QoL and its related factors, it is necessary to propose health activities and strategies for the all-around improvement of these patients.
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Affiliation(s)
- Rosana de Morais Borges Marques
- Nutrition Course at the Federal University of Goiás, Rua 227 s / n - Setor Leste Universitário, Goiânia, GO, 74605-080, Brazil.
| | - Maria Luiza de Moura Rodrigues
- Nutrition Course at the School of Social and Health Sciences at the Pontifical Catholic University of Goiás. Praça Universitária, 1440 - Setor Universitário, Goiânia, GO, 74605-010, Brazil.
| | - Ana Clara Barreto Marini
- Faculty of Medicine, Federal University of Goiás, Rua 235, s / n, Setor Leste Universitário, CEP: 74605-050, Brazil.
| | - Camila Rodrigues da Cunha Santos
- Urgencies State Hospital of Goiânia Doctor Valdemiro Cruz, Av. 31 de Março with 5 radial, s / n, Setor Pedro Ludovico, CEP: 74820-200, Brazil.
| | - Raquel Machado Schincaglia
- Nutrition Course at the School of Social and Health Sciences at the Pontifical Catholic University of Goiás. Praça Universitária, 1440 - Setor Universitário, Goiânia, GO, 74605-010, Brazil.
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Papadakis JL, Anderson LM, Garza K, Feldman MA, Shapiro JB, Evans M, Thompson LG, Weissberg-Benchell J. Psychosocial Aspects of Diabetes Technology Use: The Child and Family Perspective. Endocrinol Metab Clin North Am 2020; 49:127-141. [PMID: 31980113 DOI: 10.1016/j.ecl.2019.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This article offers a systematic review of the literature on psychosocial aspects of technology use in children and adolescents with type 1 diabetes and their families, searching for relevant articles published the past 5 years. Topics included continuous subcutaneous insulin infusion, continuous glucose monitoring, predictive low-glucose suspend, and artificial pancreas systems. The review indicates there are positive and negative psychosocial aspects to diabetes technology use among youth and their families. Although consistent findings were revealed, contradictions exist. Discussed are recommendations for future research and implications for how health care providers can collaborate with families to discuss and manage diabetes technology.
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Affiliation(s)
- Jaclyn Lennon Papadakis
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA.
| | - Lindsay M Anderson
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA
| | - Kimberly Garza
- Department of Anthropology, University of Illinois at Chicago, 1007 West Harrison Street, M/C 027, Chicago, IL 60607, USA
| | - Marissa A Feldman
- Child Development and Rehabilitation Center, Johns Hopkins All Children's Hospital, 880 6th Street South, #170, Saint Petersburg, FL 33701, USA
| | - Jenna B Shapiro
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA
| | - Meredyth Evans
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 446 East Ontario Street, #7-200, Chicago, IL 60611, USA
| | - Laurie Gayes Thompson
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 446 East Ontario Street, #7-200, Chicago, IL 60611, USA
| | - Jill Weissberg-Benchell
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 10, Chicago, IL 60611, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 446 East Ontario Street, #7-200, Chicago, IL 60611, USA
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Lee I, Kim S, Kang H. Non-Exercise Based Estimation of Cardiorespiratory Fitness Mediates Associations between Comorbidities and Health-Related Quality of Life in Older Korean Adults with Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1164. [PMID: 32059584 PMCID: PMC7068497 DOI: 10.3390/ijerph17041164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/06/2020] [Accepted: 02/08/2020] [Indexed: 11/16/2022]
Abstract
This study investigated whether non-exercise-based estimation of cardiorespiratory fitness (eCRF) mediates the association between health-related quality of life (HRQoL) and comorbidities in older Korean adults with diabetes. A total of 1371 Korean adults (56% women) aged 60 years and older with diabetes was drawn from those who participated in the 2008-2011 Korea National Health and Nutrition Examination Surveys IV and V. Data on comorbidities included hypertension, heart disease (acute myocardial infarction or angina), stroke, arthritis, and chronic renal disease. HRQoL was assessed using the EuroQoL group, which consists of a health-status descriptive system and a visual analogue scale. eCRF was determined with sex-specific algorithms. Age, sex, household income, education level, marital status, smoking, alcohol consumption, and regular exercise were additionally measured as covariates. HRQoL found to be inversely associated with number of comorbidities and positively associated with increasing eCRF category (from low to high) in older Korean patients with diabetes. The Sobel mediation test showed a significant indirect effect (Z = -4.632, p < 0.001), and the result of a bootstrap procedure corroborated the Sobel test result: a non-zero range in the 95% bias-corrected confidence interval (95% CI -1.104 to -0.453) indicated that eCRF mediates the impact of comorbidities on HRQoL. Overall, the current findings suggest that enhancing CRF can facilitate positive outcomes, including better HRQoL, for patients with diabetes.
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Affiliation(s)
- Inhwan Lee
- College of Sport Science, Sungkyunkwan University, Suwon 16419, Korea;
| | - Shinuk Kim
- College of Kyedang General Education, Sangmyung University, Cheonan 31066, Korea;
| | - Hyunsik Kang
- College of Sport Science, Sungkyunkwan University, Suwon 16419, Korea;
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Lech LVJ, Jónsdóttir ED, Niclasen J, Treldal C, Graabæk T, Almarsdóttir AB. Translation and psychometric validation of a Danish version of the medication-related quality of life scale. Int J Clin Pharm 2020; 42:667-676. [PMID: 32026349 DOI: 10.1007/s11096-020-00979-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/22/2020] [Indexed: 11/29/2022]
Abstract
Background Generic and disease specific health-related quality of life scales have been found to be non-responsive to changes in medications in polypharmacy patients. The Taiwanese medication-related quality of life (MRQoL) scale aims to measure the effect of medication use on patients' quality of life. Objective To evaluate the psychometric properties of the Danish translation of MRQoL in a population of patients with polypharmacy. Setting Polypharmacy patients waiting for services at a community pharmacy or hospital in Denmark. Method The original MRQoL included 14 items. It was forward-translated into Danish and backward-translated into Chinese according to a modified translation protocol proposed by Sousa and Rojjanasrirrat et al. The translation was pre-tested, adjusted, and administered to polypharmacy patients. The factor structure was examined using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Internal consistency reliability was evaluated, and criterion validity assessed using the beliefs about medicines questionnaire (BMQ) and SF-12v2. Known-group validity was carried out on age, number of medicines and setting. Main outcome measure Validity of the Danish version of the MRQoL-scale. Results 164 patients completed the questionnaire. EFA of all 14 items resulted in a two-factor structure, accounting for 72.8% of the total variance. The two factors were named "Energy/Concentration" (7 items) and "Feelings/Social" (7 items). Items correlating over 0.80 were removed leaving 11 items (Model 1). This model was further reduced to 8 items (Model 2) based on Cronbach's alpha. CFA confirmed the two-factor structure of both models. Model 2 fitted data without having to define covariations between error terms. Both factors showed high internal consistency reliability (Cronbachs' alpha 0.901-0.932). Ceiling effects were detected for both factors. Criterion validity was demonstrated via its significant correlations with SF-12vs2 subscales (Spearman's rho 0.340-0.353) and BMQ Concern (Spearman's rho - 0.451 to - 0.347). There was a statistically significant difference in relation to total scores of the MRQoL for age and number of drugs taken, indicating known-group validity. Conclusion The Danish translation of the MRQoL instrument showed measurement properties indicating a well-defined two-factor structure with high internal reliability, concurrent criterion validity, and known group validity. However, challenges remain with ceiling effects and efforts should be put into further development of the instrument.
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Affiliation(s)
- Laura Victoria Jedig Lech
- The Social and Clinical Pharmacy Research Group, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, Copenhagen, Denmark.
| | - Elín Dröfn Jónsdóttir
- Faculty of Pharmaceutical Sciences, University of Iceland, Hagi, Hofsvallagata 53, 107, Reykjavík, Iceland
| | - Janni Niclasen
- Frederikshøj Skole og dagbehandling, Primulavej 2, Vanløse, Denmark
- Steno Diabetes Center Copenhagen, Capital Region of Denmark, Niels Steensens Vej 6, Gentofte, Denmark
| | - Charlotte Treldal
- Clinical Research Center, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Hvidovre, Denmark
- Capital Region Pharmacy, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Hvidovre, Denmark
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, Copenhagen, Denmark
| | - Trine Graabæk
- The Social and Clinical Pharmacy Research Group, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, Copenhagen, Denmark
- The Research Unit, Hospital Pharmacy Funen, Odense University Hospital, Solfaldsvej 38, Odense C, Denmark
| | - Anna Birna Almarsdóttir
- The Social and Clinical Pharmacy Research Group, Department of Pharmacy, University of Copenhagen, Universitetsparken 2, Copenhagen, Denmark
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Validation of Cardiorespiratory Fitness Measurements in Adolescents. J Funct Morphol Kinesiol 2019; 4:jfmk4030044. [PMID: 33467359 PMCID: PMC7739358 DOI: 10.3390/jfmk4030044] [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: 06/28/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 11/16/2022] Open
Abstract
Cardiorespiratory fitness (CRF) is an important indicator of adolescent cardiovascular well-being and future cardiometabolic health but not always feasible to measure. The purpose of this study was to estimate the concurrent validity of the non-exercise test (NET) for adolescents against the Progressive Aerobic Capacity Endurance Run (PACER®) and direct measures of VO2max as well as to examine the concurrent validity of the PACER® with a portable metabolic system (K4b2™). Forty-six adolescents (12-17 years) completed the NET prior to performing the PACER® while wearing the K4b2™. The obtained VO2max values were compared using linear regression, intra-class correlation (ICC), and Bland-Altman plots, and α was set at 0.05. The VO2max acquired directly from the K4b2™ was significantly correlated to the VO2max indirectly estimated from the NET (r = 0.73, p < 0.001, r2 = 0.53, ICC = 0.67). PACER® results were significantly related to the VO2max estimates from the NET (r = 0.81, p < 0.001, r2 = 0.65, ICC = 0.72). Direct measures from the K4b2™ were significantly correlated to the VO2max estimates from the PACER® (r = 0.87, p < 0.001, r2 = 0.75, ICC = 0.93). The NET is a valid measure of CRF in adolescents and can be used when an exercise test is not feasible.
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Munkácsi B, Papp G, Felszeghy E, Nagy BE, Kovács KE. The associations between mental health, health-related quality of life and insulin pump therapy among children and adolescents with type 1 diabetes. J Pediatr Endocrinol Metab 2018; 31:1065-1072. [PMID: 30291785 DOI: 10.1515/jpem-2018-0130] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/13/2018] [Indexed: 11/15/2022]
Abstract
Background Diabetes has previously been linked to mental health problems in children and adolescents, but more recent studies have yielded mixed findings. The aim of the current study was to compare symptoms of mental health problems in children and adolescents with and without type 1 diabetes (T1DM). Methods Life quality, subjective well-being, self-rated health, depression and somatic symptoms in children and adolescents with diabetes (n=130) were measured and compared to the results of a socio-demographically joined control group (n=177) which consists of healthy children and adolescents. Results A significant difference could be observed between the groups in well-being and depressive symptoms as according to the results, the research sample namely the children with T1DM could be described with significantly higher subjective well-being and mood, but with less physical symptoms and lower level of depression as those in the control group. Conclusions These findings suggest that T1DM is not associated with an increased risk of psychosocial problems, and confirm that even a severe disease of a child can lead to personal growth.
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Affiliation(s)
- Brigitta Munkácsi
- University of Debrecen, Faculty of Public Health, Doctoral School of Health Sciences, Debrecen, Hungary
| | - Gábor Papp
- University of Debrecen, Faculty of Arts, Institute of Psychology, Debrecen, Hungary
| | - Enikő Felszeghy
- University of Debrecen, Faculty of Medicine, Departement of Pediatrics, Debrecen, Hungary
| | - Beáta Erika Nagy
- University of Debrecen, Faculty of Medicine, Departement of Pediatrics, Debrecen, Hungary
| | - Karolina Eszter Kovács
- University of Debrecen, Faculty of Arts, Doctoral School of Human Sciences, Debrecen, Hungary
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Mozzillo E, Zito E, Maffeis C, De Nitto E, Maltoni G, Marigliano M, Zucchini S, Franzese A, Valerio G. Unhealthy lifestyle habits and diabetes-specific health-related quality of life in youths with type 1 diabetes. Acta Diabetol 2017; 54:1073-1080. [PMID: 28914364 DOI: 10.1007/s00592-017-1051-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/06/2017] [Indexed: 02/05/2023]
Abstract
AIMS Management of type 1 diabetes mellitus (T1DM) influences several aspects of life, such as adherence to healthy lifestyle habits and health-related quality of life (HRQoL). Our aim was to evaluate the association between unhealthy lifestyle habits and HRQoL in adolescents and young adults with T1DM. METHODS Two hundred and forty-two Caucasian patients (13-19 years) consecutively enrolled over a 12-month period in three Regional Pediatric Diabetes Centers in Italy. Demographics, clinical, and laboratory parameters, adherence to lifestyle habits (Mediterranean Diet assessed by KIDMED, Physical Activity levels and sedentary behavior by questionnaire) considered either separately or in cluster, and HRQoL by Pediatric Quality of Life Inventory Diabetes Module (PedsQL 3.0 DM) were collected. Metabolic control was determined by HbA1cmean of previous year. RESULTS Only 15 (6.2%) patients fulfilled the cluster of three healthy lifestyle habits without gender differences (p = 0.353); 62 (25.6%) had 1 unhealthy lifestyle habit, and 165 (68.2%) had ≥2. Adolescents meeting physical activity recommendations had better PedsQL scores than those who did not meet. PedsQL total score and specific sub-scales decreased in patients with unhealthy lifestyle habits. High PedsQL was significantly associated with being male, living in South Italy, having lower HbA1c mean levels, and reporting lower adherence to unhealthy lifestyle habits. CONCLUSIONS The clustering of unhealthy lifestyle habits is associated with reduced HRQoL in adolescents and young adults with T1DM. Promoting multiple behavior changes may be a useful approach to improve the health status and the HRQoL in youths with T1DM.
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Affiliation(s)
- Enza Mozzillo
- Department of Translational Medical Science, Section of Pediatrics, Regional Center for Pediatric Diabetes, University of Naples Federico II, Naples, Italy
- Department of Movement Sciences and Wellbeing, University of Naples Parthenope, via Medina 40, 80133, Naples, Italy
| | - Eugenio Zito
- Department of Translational Medical Science, Section of Pediatrics, Regional Center for Pediatric Diabetes, University of Naples Federico II, Naples, Italy
| | - Claudio Maffeis
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital of Verona, Verona, Italy
| | - Elena De Nitto
- Department of Translational Medical Science, Section of Pediatrics, Regional Center for Pediatric Diabetes, University of Naples Federico II, Naples, Italy
| | - Giulio Maltoni
- Endocrine Unit, Department of Pediatrics, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Marco Marigliano
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital of Verona, Verona, Italy
| | - Stefano Zucchini
- Endocrine Unit, Department of Pediatrics, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Adriana Franzese
- Department of Translational Medical Science, Section of Pediatrics, Regional Center for Pediatric Diabetes, University of Naples Federico II, Naples, Italy
| | - Giuliana Valerio
- Department of Movement Sciences and Wellbeing, University of Naples Parthenope, via Medina 40, 80133, Naples, Italy.
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Braham R, Robert AA, Musallam MA, Alanazi A, Swedan NB, Al Dawish MA. Reproductive disturbances among Saudi adolescent girls and young women with type 1 diabetes mellitus. World J Diabetes 2017; 8:475-483. [PMID: 29204256 PMCID: PMC5700384 DOI: 10.4239/wjd.v8.i11.475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/08/2017] [Accepted: 10/17/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To identify reproductive disturbances among adolescent girls and young women with type 1 diabetes mellitus (T1DM) in Saudi Arabia.
METHODS This cross sectional study was conducted among 102 female with T1DM, (aged 13-29 years) who attended the Diabetes Clinic at Diabetes Treatment Center, Prince Sultan Military Medical City, Saudi Arabia between April 2015 to March 2016. Clinical history, anthropometric characteristics and reproductive disturbance were collected through a questionnaire.
RESULTS Of 102 patients included in this analysis, 26.5% (27/102) were reported that they experienced an irregular menses. Of these patients, when compared to whose diabetes was diagnosed before menarche (35.4%, 17/48), patients diagnosed with diabetes after menarche (18.5%, 10/54) showed significantly less irregular menses (difference 16.9%, P = 0.04). Similarly, compared to patients diagnosed with diabetes prior to menarche (mean age 12.9 years; n = 48), patients diagnosed with diabetes after menarche (mean age 12.26 years; n = 54) were found to have 0.64 years delay in the age of menarche (P = 0.04). Among the studied patients, 15.7% (16/102) had polycystic ovary syndrome (PCOS). Of these PCOS patients, 37.5% (6/16) had irregular menses, 6.3% (1/16) had Celiac disease, 37.5% (6/16) had Hashimoto thyroiditis and 18.7% (3/16) had acne.
CONCLUSION More than one fourth of the study population with T1DM experiencing an irregular menses. Adolescent girls and young women diagnosed with diabetes prior to menarche showed higher menstrual irregularity and a delay in the age of menarche.
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Affiliation(s)
- Rim Braham
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Asirvatham Alwin Robert
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Maha Ali Musallam
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Abdulaziz Alanazi
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Nawaf Bin Swedan
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
| | - Mohamed Abdulaziz Al Dawish
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh 11159, Saudi Arabia
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Özyazıcıoğlu N, Avdal EÜ, Sağlam H. A determination of the quality of life of children and adolescents with type 1 diabetes and their parents. Int J Nurs Sci 2017; 4:94-98. [PMID: 31406726 PMCID: PMC6626105 DOI: 10.1016/j.ijnss.2017.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 01/26/2017] [Indexed: 11/09/2022] Open
Abstract
Objective Type 1 diabetes is a chronic illness which can have a negative effect on the health care and development of children and can put their lives in danger. This descriptive study aimed to determine the quality of life and the factors affecting it of children and adolescents with type 1 diabetes using the Pediatric Quality of Life Inventory (PedsQL). Methods The study was conducted in the Child Endocrinology Unit of a University Hospital in Bursa, Turkey. Totally 64 children eight-12 years and 85 adolescents aged 13–18 with type 1 diabetes and their parents were recruited. HbA1c measurements were obtained from the records of the endocrinology clinicare, which were made once every three months, and the average of the last three measurements was taken in the study. The PedsQL was used to measure quality of life of the children and adolescents. The data was analyzed using SPSS version 20.0 and P < 0.05 was considered significant. The demographic data of the children and parents were analyzed using means and percentiles. Pearson's correlation analysis was used to assess the relationship between two averages. Results Of the sub-groups on the scale, affective and school function scores were somewhat low, and social function scores were high. The quality of life scores of the children and adolescents were found to correlate with those of their parents. A negative correlation was found between HbA1c levels and adolescent quality of life, a positive correlation was found between the child's age and the quality of life of the child and parents, and a negative correlation was found between the number of children in the family and the quality of life of the child and parents. Conclusions An evaluation of the quality of life after a diagnosis of diabetes can be used to assess the problems which may be faced by children and adolescents and to combat these problems.
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Affiliation(s)
- Nurcan Özyazıcıoğlu
- Department of Pediatric Nursing, Faculty of Health Sciences, Uludağ University, Bursa, Turkey
| | - Elif Ünsal Avdal
- Department of Internal Medicine Nursing, Faculty of Health Science, Katip Çelebi University, Izmir, Turkey
| | - Halil Sağlam
- Department of Pediatrics, Pediatric Endocrinology Division, Faculty of Medicine, Uludağ University, Bursa, Turkey
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Al Hayek AA, Robert AA, Braham RB, Al Dawish MA. Frequency of Lipohypertrophy and Associated Risk Factors in Young Patients with Type 1 Diabetes: A Cross-Sectional Study. Diabetes Ther 2016; 7:259-67. [PMID: 26979975 PMCID: PMC4900971 DOI: 10.1007/s13300-016-0161-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The objective of this study was to investigate the frequency of lipohypertrophy (LH) and the associated risk factors in young patients with type 1 diabetes mellitus (T1DM). METHODS This cross-sectional study was conducted on a sample of 174 patients with T1DM (aged 13-18 years) treated with multiple daily insulin injections for a minimum duration of 1 year. The study was performed at the Diabetes Treatment Center, Prince Sultan Military Medical City (Riyadh, Saudi Arabia), between July 2015 and September 2015. Information regarding patients' age, weight, height, adjusted body mass index (BMI), period of the diabetic condition, length of needle used, number of injections per day, injection locations, insulin regimen, and glycosylated hemoglobin (HbA1c) were recorded. LH was assessed using the palpation technique. RESULTS Nearly 46% of patients were found to reuse needles, while 42.5% failed to alternate the injection site and 23% revealed unexplained hypoglycemic events. A substantial percentage of patients (approximately 47%) showed grade 1 LH, followed by 33.7% with grade 2 and 19.3% with grade 3 LH. A higher frequency of LH was observed in the thigh region (n = 28, 33.7%) than in the arm, which was second highest (n = 23, 27.7%). Patients aged ≥16 years showed a higher frequency of LH than those aged <16 years. Patients with uncontrolled diabetes mellitus had a greater likelihood of having LH (59.5%) than those with controlled diabetes (20.8%). Significant differences in LH were observed based on needle length, needle reuse, and rotation of the injection sites. On performing regression analysis, the independent risk factors for LH were found to be as follows: higher BMI, higher HbA1c, a higher number of injection sites, a higher rate of needle reuse and failed to alternate the injection site. CONCLUSION As the frequency of LH was found to be high in Saudi patients with T1DM, it is essential to educate patients on the risk factors for LH and on diabetic control.
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Affiliation(s)
- Ayman A Al Hayek
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Asirvatham A Robert
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Rim B Braham
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohamed A Al Dawish
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Al Hayek AA, Robert AA, Braham RB, Issa BA, Al Sabaan FS. Predictive Risk Factors for Fear of Hypoglycemia and Anxiety-Related Emotional Disorders among Adolescents with Type 1 Diabetes. Med Princ Pract 2015; 24:222-30. [PMID: 25766305 PMCID: PMC5588232 DOI: 10.1159/000375306] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 01/19/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To explore the fear of hypoglycemia (FOH) and anxiety-related emotional disorders and their risk factors among adolescents with type 1 diabetes mellitus (T1DM). SUBJECTS AND METHODS A cross-sectional study was conducted among 187 adolescents (aged 13-18 years; 92 males, 95 females) with T1DM at the Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia, from June 2013 to February 2014. The participants were interviewed using FOH and Screen for Child Anxiety-Related Disorders (SCARED) scales. RESULTS Females had significantly higher scores on all FOH and SCARED subscales compared to males. The mean scores for many subscales of FOH and SCARED were higher in the older age group (16-18 years), in those under multiple-dose injection (MDI) treatment (compared with the insulin pump treatment), and in those with a longer duration of T1DM. Similarly, significant differences were observed in those with high frequencies of hypoglycemia, passing out, hypoglycemia while asleep and awake, and hypoglycemia in front of friends and at school. Regression analysis revealed that higher age, female gender, MDI treatment, longer duration of T1DM, higher frequencies of hypoglycemia, passing out, hypoglycemia while asleep and awake, and hypoglycemia in front of friends and at school were the risk factors associated with the majority of the FOH and SCARED subscales. The behavior of the FOH subscale correlated with all the subscales of SCARED except the subscale of generalized anxiety disorder. Similarly, the FOH subscale of worry significantly correlated with all the subscales of SCARED. CONCLUSION The strongest determinants of higher risk for the majority of the FOH and SCARED subscales were higher age, female gender, MDI treatment, longer duration of T1DM, higher frequency of hypoglycemia, passing out due to hypoglycemia, hypoglycemia while asleep and awake, and hypoglycemia in front of friends and at school.
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Affiliation(s)
- Ayman A. Al Hayek
- *Ayman A. Al Hayek, Senior Diabetes Educator, Department of Endocrinology and Diabetes, Diabetes Treatment Center, Diabetes Education Unit, Prince Sultan Military Medical City, PO Box 7897, Riyadh 11159 (Saudi Arabia), E-Mail
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Terlizzi V, Zito E, Mozzillo E, Raia V, Franzese A. Can continuous subcutaneous insulin infusion improve health-related quality of life in patients with Shwachman-Bodian-Diamond syndrome and diabetes? Diabetes Technol Ther 2015; 17:64-7. [PMID: 25269020 DOI: 10.1089/dia.2014.0184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report the first case of the use of continuous subcutaneous insulin infusion (CSII) in a patient with Shwachman-Bodian-Diamond syndrome (SBDS) and diabetes. An Italian boy received diagnosis of SBDS at the age of 7 months (SBDS gene mutation: c.183-184TA → CT and c.258 + 2 T → C in compound heterozygous). The patient presented an impaired psychosocial functioning with difficulties in mental health, body pain experiences, attention deficit disorder, somatic complaints, behavioral and social problems. Total Intelligence Quotient (T-IQ) was within the normal range for age (T-IQ = 109). The patient developed clinical diabetes at the age of 13 years (glycemia 282 mg/dL at 120 min of oral glucose tolerance test, glycosylated hemoglobin level of 7.5%, anti-β-cell antibodies negative; glucagon test yielding a C peptide level at zero-time of 1.5 ng/mL and at 6 min of 2.0 ng/mL). Multiple daily injection therapy with insulin was started. Nevertheless, because of a relevant needle phobia and the recurrent hypoglycemia due to poor nutrition secondary to depression, after 3 years the patient started CSII. After 12 months a new evaluation showed (1) better social adaptation, (2) meliorated self-esteem and self-efficacy, (3) reduced psychosocial suffering, and (4) improved health-related quality of life, assessed by the Pediatric Quality of Life Inventory version 3.0 Diabetes Module. Thus CSII seems to be crucial to improve health-related quality of life in patients affected by diabetes and genetic disorders.
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Affiliation(s)
- Vito Terlizzi
- Department of Traslational Medical Sciences, Federico II University of Naples , Naples, Italy
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