Identification of minimal clinically important difference scores of the PedsQL in children, adolescents, and young adults with type 1 and type 2 diabetes

Interventions for High Body Mass Index in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

Importance

Approximately 19.7% of children and adolescents aged 2 to 19 years in the US have a body mass index (BMI) at or above the 95th percentile for age and sex, based on Centers for Disease Control and Prevention growth charts from 2000. The prevalence of high BMI increases with age and is higher among Hispanic/Latino, Native American/Alaska Native, and non-Hispanic Black children and adolescents and children from lower-income families.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on interventions (behavioral counseling and pharmacotherapy) for weight loss or weight management in children and adolescents that can be provided in or referred from a primary care setting.

Population

Children and adolescents 6 years or older.

Evidence Assessment

The USPSTF concludes with moderate certainty that providing or referring children and adolescents 6 years or older with a high BMI to comprehensive, intensive behavioral interventions has a moderate net benefit.

Recommendation

The USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high BMI (≥95th percentile for age and sex) to comprehensive, intensive behavioral interventions. (B recommendation).

Interventions for Weight Management in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Body mass index (BMI) of the 95th or greater percentile for age and sex is common among young people, and its prevalence has increased in recent decades.

Objective

To examine the benefits and harms of weight management interventions initiated in health care settings among children and adolescents with high BMI.

Data Sources

MEDLINE via Ovid, PsycINFO via Ovid, and the Cochrane Central Registry of Controlled Trials through January 12, 2023; ongoing surveillance through January 26, 2024.

Study Selection

English-language studies of weight management interventions (behavioral and pharmacologic, including liraglutide, semaglutide, orlistat, and phentermine/topiramate) among children aged 2 to 18 years with high BMI (eg, ≥85th or ≥95th percentile for age and sex) conducted in or recruited from health care settings.

Data Extraction and Synthesis

One investigator abstracted data; a second checked for accuracy. Outcomes with sufficient evidence for meta-analysis were pooled using random-effects models.

Main Outcomes and Measures

BMI and other weight-related outcomes, cardiometabolic measures, quality of life, physical activity, dietary pattern scores, and harms.

Results

Fifty-eight randomized clinical trials (RCTs) were included (N = 10 143). Behavioral interventions were associated with small reductions in BMI and other weight outcomes after 6 to 12 months (28 RCTs [n = 4494]; mean difference in change between groups, -0.7 [95% CI, -1.0 to -0.3]). Larger effects were seen in interventions with higher contact hours and that offered physical activity sessions. Reporting was sparse for outcomes other than BMI, with few significant findings. Semaglutide and phentermine/topiramate had the largest effects on BMI (eg, 1 RCT [n = 201] for semaglutide; mean difference, -6.0 [95% CI, -7.3 to -4.6]). The very few studies that evaluated outcomes after medication discontinuation showed immediate weight regain. Gastrointestinal adverse effects were common with liraglutide, semaglutide, and orlistat. Serious adverse effects were rare, but no studies had follow-up longer than 17 months.

Conclusions and Relevance

In the short term, weight management interventions led to lower BMI in children and adolescents, with no evidence of serious harm. Evidence is lacking about how weight management interventions affect BMI beyond 1 year and after medication discontinuation and about longer-term effects on other outcomes.

Exploring the Influence of Preexisting Conditions and Infection Factors on Pediatric Long COVID Symptoms and Quality of Life

OBJECTIVE

Pediatric postacute sequelae of SARS-CoV-2 or "long COVID" is a multisystemic disease with a wide range of symptoms more than 4 wks after initial infection. This study explores the quality of life in children with long COVID and how preexisting conditions affect symptoms and quality of life.

DESIGN

A retrospective single-center study of 97 patients was completed to analyze PedsQL quality of life in pediatric patients with long COVID and associations between preexisting conditions, long COVID symptoms, and PedsQL scores.

RESULTS

Children with long COVID had significantly lower quality of life compared with previously published normative samples (PedsQL Core: P < 0.001; Fatigue: P < 0.001; Family Impact: P < 0.001). Number of long COVID symptoms, age, and preexisting history of depression, allergies, and developmental delay affected the overall fatigue PedsQL scores. Preexisting mood disorders were associated with a higher prevalence of worsening mental health symptoms (anxiety, P = 0.01; depression, P = 0.04), dizziness/lightheadedness/vertigo ( P = 0.02), and change in appetite ( P = 0.04).

CONCLUSIONS

Long COVID has a significant impact on the quality of life of children and their families. Children with long COVID can benefit from multidisciplinary care addressing fatigue, mental health, and family coping.

Factors Affecting Quality of Life in Adolescents Living With Type 2 Diabetes: A Substudy of the Improving Renal Complications in Adolescents With Type 2 Diabetes Through REsearch (iCARE) Cohort

OBJECTIVES

Type 2 diabetes (T2D) disproportionately impacts adolescents living in challenging socioeconomic conditions. However, the impacts of T2D on quality of life (QOL) in this context are unknown. Our aim in this study was to evaluate QOL and identify its biological, psychological, and social determinants among adolescents living with and without T2D from similar sociodemographic backgrounds. Relationships between glycemic stability, early complications, and treatments of T2D and QOL were also examined.

METHODS

Ninety-two adolescents with T2D and 59 at-risk controls were included from the Improving Renal Complications in Adolescents With Type 2 Diabetes Through Research (iCARE) cohort. The main outcome was QOL (Pediatric QOL Inventory [PedsQL]). Biological covariates included age, sex, body mass index z score, glycated hemoglobin, estimated glomerular filtration rate, and urine albumin-to-creatinine ratio. Psychological factors included perceived stress (14-item Perceived Stress Scale) and mental distress (6-item Kessler scale). Social factors included food security (Household Food Security Survey Module) and income quintile. Multivariate linear regression analyses were used to identify factors associated with QOL between adolescents with and without T2D, and within the T2D cohort.

RESULTS

Mean total QOL scores among adolescents with T2D were lower than in controls (67.0±14.8 vs 71.7±16.2, p=0.04). Age, sex, and percent Indigenous ethnicity were not significantly different between groups. Mean duration of T2D was 2.3±2.0 years. In the multivariate analysis, QOL was not associated with diabetes status, but negative associations were seen between mental distress (β=-1.46, p<0.001) and food insecurity QOL (β=-6.26, p=0.037). No differences were seen between biological factors and QOL in either analysis.

CONCLUSIONS

Significant factors associated with decreased QOL in adolescents living with T2D include mental distress and food insecurity, indicating areas for targeted intervention.

Association of stigma, diabetes distress and self-efficacy with quality of life in adolescents with type 1 diabetes preparing to transition to adult care

AIMS

In type 1 diabetes (T1D), psychosocial factors may impact quality of life (QOL) and clinical outcomes, but remain understudied, particularly during late adolescence. Our aim was to determine whether stigma, diabetes distress and self-efficacy are associated with QOL in adolescents with T1D as they are preparing to transition to adult care.

METHODS

We conducted a cross-sectional study of adolescents (ages 16-17 years) with T1D participating in the Group Education Trial to Improve Transition (GET-IT) in Montreal, Canada. Participants completed validated questionnaires on stigma using the Barriers to Diabetes Adherence (BDA) stigma subscale, self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1-10), diabetes distress (Diabetes Distress Scale for Adults with type 1 diabetes) and QOL (Pediatric Quality of Life Inventory [PedsQL] 4.0 Generic Core Scale and PedsQL 3.2 Diabetes Module). We examined associations of stigma, diabetes distress and self-efficacy with QOL using multivariate linear regression models adjusted for sex, diabetes duration, socioeconomic status and HbA1c.

RESULTS

Of 128 adolescents with T1D, 76 (59%) self-reported having the diabetes-related stigma and 29 (22.7%) reported experiencing diabetes distress. Those with stigma had lower diabetes-specific and general QOL scores compared with those without stigma, and stigma and diabetes distress were both associated with lower diabetes-specific QOL and lower general QOL. Self-efficacy was associated with higher diabetes-specific and general QOL.

CONCLUSIONS

Stigma and diabetes distress are associated with lower QOL, whereas self-efficacy is associated with higher QOL in adolescents with T1D preparing to transfer to adult care.

Developmental motor problems and health-related quality of life in 5-year-old children born extremely preterm: A European cohort study

AIM

To measure the association between cerebral palsy (CP) and non-CP-related movement difficulties and health-related quality of life (HRQoL) among 5-year-old children born extremely preterm (<28 weeks gestational age).

METHOD

We included 5-year-old children from a multi-country, population-based cohort of children born extremely preterm in 2011 to 2012 in 11 European countries (n = 1021). Children without CP were classified using the Movement Assessment Battery for Children, Second Edition as having significant movement difficulties (≤5th centile of standardized norms) or being at risk of movement difficulties (6th-15th centile). Parents reported on a clinical CP diagnosis and HRQoL using the Pediatric Quality of Life Inventory. Associations were assessed using linear and quantile regressions.

RESULTS

Compared to children without movement difficulties, children at risk of movement difficulties, with significant movement difficulties, and CP had lower adjusted HRQoL total scores (β [95% confidence interval] = -5.0 [-7.7 to -2.3], -9.1 [-12.0 to -6.1], and - 26.1 [-31.0 to -21.2]). Quantile regression analyses showed similar decreases in HRQoL for all children with CP, whereas for children with non-CP-related movement difficulties, reductions in HRQoL were more pronounced at lower centiles.

INTERPRETATION

CP and non-CP-related movement difficulties were associated with lower HRQoL, even for children with less severe difficulties. Heterogeneous associations for non-CP-related movement difficulties raise questions for research about mitigating and protective factors.

Ascertainment of Minimal Clinically Important Differences in the Diabetes Distress Scale-17: A Secondary Analysis of a Randomized Clinical Trial

Importance

The Diabetes Distress Scale-17 (DDS-17) is a common measure of diabetes distress. Despite its popularity, there are no agreed-on minimal clinically important difference (MCID) values for the DDS-17.

Objective

To establish a distribution-based metric for MCID in the DDS-17 and its 4 subscale scores (interpersonal distress, physician distress, regimen distress, and emotional distress).

Design, Setting, and Participants

This secondary analysis of a randomized clinical trial used baseline and postintervention data from a hybrid (implementation-effectiveness) trial evaluating Empowering Patients in Chronic Care (EPICC) vs an enhanced form of usual care (EUC). Participants included adults with uncontrolled type 2 diabetes (glycated hemoglobin A1c [HbA1c] level >8.0%) who received primary care during the prior year in participating Department of Veterans Affairs clinics across Illinois, Indiana, and Texas. Data collection was completed in November 2018, and data analysis was completed in June 2023.

Interventions

Participants in EPICC attended 6 group sessions led by health care professionals based on collaborative goal-setting theory. EUC included diabetes education.

Main Outcomes and Measures

The main outcome was distribution-based MCID values for the total DDS-17 and 4 DDS-17 subscales, calculated using the standard error of measurement. Baseline to postintervention changes in DDS-17 and its 4 subscale scores were grouped into 3 categories: improved, no change, and worsened. Multilevel logistic and linear regression models examined associations between treatment group and MCID change categories and whether improvement in HbA1c varied in association with MCID category.

Results

A total of 248 individuals with complete DDS-17 data were included (mean [SD] age, 67.4 [8.3] years; 235 [94.76%] men), with 123 participants in the EPICC group and 125 participants in the EUC group. The MCID value for DDS-17 was 0.25 and MCID values for the 4 distress subscales were 0.38 for emotional and interpersonal distress and 0.39 for physician and regimen distress. Compared with EUC, more EPICC participants were in the MCID improvement category on DDS-17 (63 participants [51.22%] vs 40 participants [32.00%]; P = .003) and fewer EPICC participants were in the worsened category (20 participants [16.26%] vs 39 participants [31.20%]; P = .008). There was no direct association of DDS-17 MCID improvement (β = -0.25; 95% CI, -0.59 to 0.10; P = .17) or worsening (β = 0.18; 95% CI, -0.22 to 0.59; P = .38) with HbA1c levels among all participants.

Conclusions and Relevance

In this secondary analysis of data from a randomized clinical trial, an MCID improvement or worsening of more than 0.25 on the DDS-17 was quantitatively significant and patients in the EPICC group were more likely to experience improvement than those in the EUC group.

Trial Registration

ClinicalTrials.gov Identifier: NCT01876485.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care.

METHODS

We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity.

RESULTS

One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted β=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted β=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted β=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted β=-0.01; 95% CI, -0.03 to -0.00).

CONCLUSION

Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Health-related quality of life of children born very preterm: a multinational European cohort study

PURPOSE

This study aims to (1) describe the health-related quality of life (HRQoL) outcomes experienced by children born very preterm (28-31 weeks' gestation) and extremely preterm (< 28 weeks' gestation) at five years of age and (2) explore the mediation effects of bronchopulmonary dysplasia (BPD) and severe non-respiratory neonatal morbidity on those outcomes.

METHODS

This investigation was based on data for 3687 children born at < 32 weeks' gestation that contributed to the EPICE and SHIPS studies conducted in 19 regions across 11 European countries. Descriptive statistics and multi-level ordinary linear squares (OLS) regression were used to explore the association between perinatal and sociodemographic characteristics and PedsQL^™ GCS scores. A mediation analysis that applied generalised structural equation modelling explored the association between potential mediators and PedsQL^™ GCS scores.

RESULTS

The multi-level OLS regression (fully adjusted model) revealed that birth at < 26 weeks' gestation, BPD status and experience of severe non-respiratory morbidity were associated with mean decrements in the total PedsQL^™ GCS score of 0.35, 3.71 and 5.87, respectively. The mediation analysis revealed that the indirect effects of BPD and severe non-respiratory morbidity on the total PedsQL^™ GCS score translated into decrements of 1.73 and 17.56, respectively, at < 26 weeks' gestation; 0.99 and 10.95, respectively, at 26-27 weeks' gestation; and 0.34 and 4.80, respectively, at 28-29 weeks' gestation (referent: birth at 30-31 weeks' gestation).

CONCLUSION

The findings suggest that HRQoL is particularly impaired by extremely preterm birth and the concomitant complications of preterm birth such as BPD and severe non-respiratory morbidity.

Minimal important difference in childhood interstitial lung diseases

Background

Monitoring disease progression in childhood interstitial lung diseases (chILD) is essential. No information for the minimal important difference (MID), which is defined as the smallest change in a parameter that is perceived as important prompting a clinician to change the treatment, is available. We calculated MIDs for vital signs (respiratory rate, peripheral oxygen saturation in room air, Fan severity score) and health-related quality of life (HrQoL) scores.

Methods

This study used data from the Kids Lung Register, which is a web-based management platform that collects data of rare paediatric lung disorders with a focus on chILD. Data of vital signs and HrQoL scores (Health Status Questionnaire, chILD-specific questionnaire and PedsQL V.4.0) were collected. MIDs were calculated according to distribution-based (one-third SD) and anchor-based methods (using forced expiratory volume in 1 s and forced vital capacity) as anchors.

Results

Baseline data of 774 children were used to calculate the following MIDs: respiratory rate 1.3 (z-score), O2saturation in room air 3.0%, Fan severity score 0.2–0.4, Health Status Questionnaire 0.4–0.8, chILD-specific questionnaire 4.4%–8.2%, physical health summary score 7.8%–8.9%, psychosocial health summary score 3.4%–6.9% and total score 5.1%–7.4%. Results of the responsiveness analysis generally agreed with the MIDs calculated.

Conclusions

For the first time, we provide estimates of MIDs for vital signs and HrQoL scores in a large cohort of chILD using different methods.

Innovative Designs and Logistical Considerations for Expedited Clinical Development of Combination Disease-Modifying Treatments for Type 1 Diabetes

It has been 100 years since the life-saving discovery of insulin, yet daily management of type 1 diabetes (T1D) remains challenging. Even with closed-loop systems, the prevailing need for persons with T1D to attempt to match the kinetics of insulin activity with the kinetics of carbohydrate metabolism, alongside dynamic life factors affecting insulin requirements, results in the need for frequent interventions to adjust insulin dosages or consume carbohydrates to correct mismatches. Moreover, peripheral insulin dosing leaves the liver underinsulinized and hyperglucagonemic and peripheral tissues overinsulinized relative to their normal physiologic roles in glucose homeostasis. Disease-modifying therapies (DMT) to preserve and/or restore functional β-cell mass with controlled or corrected autoimmunity would simplify exogenous insulin need, thereby reducing disease mortality, morbidity, and management burdens. However, identifying effective DMTs for T1D has proven complex. There is some consensus that combination DMTs are needed for more meaningful clinical benefit. Other complexities are addressable with more innovative trial designs and logistics. While no DMT has yet been approved for marketing, existing regulatory guidance provides opportunities to further "de-risk" development. The T1D development ecosystem can accelerate progress by using more innovative ways for testing DMTs for T1D. This perspective outlines suggestions for accelerating evaluation of candidate T1D DMTs, including combination therapies, by use of innovative trial designs, enhanced logistical coordination of efforts, and regulatory guidance for expedited development, combination therapies, and adaptive designs.

A new perspective on diabetes distress using the type 2 diabetes distress assessment system (T2-DDAS): Prevalence and change over time

AIMS

To establish cut-points and thresholds for elevated diabetes distress; document change over time; and define minimal clinically important differences (MCID) using the new Type 2 Diabetes Distress Assessment System (T2-DDAS).

METHODS

A national sample of adults with type 2 diabetes completed the T2-DDAS CORE distress scale and the 7 T2-DDAS SOURCE distress scales at baseline and 6-months. Scores were computed separately for insulin- and non-insulin users. Spline regression models defined CORE cut-points and SEM formulas defined MCID. A rational "threshold" approach defined elevated SOURCE scores.

RESULTS

471 participants (205 insulin, 266 non-insulin) completed both assessments. Analyses yielded ≥2.0 as the cut-point for both elevated CORE and elevated SOURCE. Prevalence of elevated CORE was 61.8 % (69.9 % over 6 months). Elevated SOURCE scores varied from 30.6 % (Stigma/Shame) to 76.4 % (Management); 87.5 % indicated at least 1 elevated SOURCE score. Most (77.1 %) reported multiple elevated SOURCES. 81.8 % with elevated CORE distress at baseline remained elevated at 6 months. MCID analyses yielded +/- 0.25 as significant change. Few differences between insulin- and non-insulin users occurred.

CONCLUSIONS

Elevated CORE distress is highly prevalent and persistent over time; most participants reported multiple SOURCES of distress. Findings highlight the need for comprehensive assessment of diabetes distress.

Gastrointestinal Symptoms Profile in Pediatric Patients With Gastroparesis Compared to Healthy Controls

OBJECTIVES

The primary objective was to compare the patient-reported gastrointestinal symptoms profiles of pediatric patients with gastroparesis to matched healthy controls using the Pediatric Quality of Life Inventory™ (PedsQL™) Gastrointestinal Symptoms Scales. The secondary objectives were to compare pediatric patients with gastroparesis to pediatric patients with gastroparesis-like symptoms and normal gastric emptying and to compare pediatric patients with gastroparesis-like symptoms and normal gastric emptying to matched healthy controls.

METHODS

The PedsQL™ Gastrointestinal Symptoms Scales were completed by 64 pediatric patients with gastroparesis, 59 pediatric patients with gastroparesis-like symptoms and normal gastric emptying, and 200 age, gender, and race/ethnicity matched healthy controls. The PedsQL™ Gastrointestinal Symptoms Scales encompass 10 individual multi-item scales which measure stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea/fecal incontinence. Based on gastric emptying scintigraphy testing, those with abnormal gastric retention were classified as having gastroparesis.

RESULTS

The gastrointestinal symptoms profile analysis identified large differences between those with gastroparesis compared to healthy controls (most P <0.001), with the largest effect sizes for upper gastrointestinal symptoms including stomach pain, stomach discomfort when eating, food and drink limits, nausea, and vomiting. Those with gastroparesis self-reported similar gastrointestinal symptoms to those with normal gastric emptying, except for increased constipation.

CONCLUSIONS

Pediatric patients with gastroparesis self-reported broad multidimensional gastrointestinal symptoms profiles in comparison to healthy controls with large differences, indicating the critical need for more highly efficacious interventions to bring patient functioning within the normal range of healthy functioning.

Trajectories, Risk Factors, and Impact of Persistent Pain After Major Musculoskeletal Surgery in Adolescents: A Replication Study

Studies have identified high rates of chronic postsurgical pain in adolescents. Characterizing patterns of pain in the transition from acute to chronic following major surgery may pinpoint critical periods of recovery. This observational study modelled pain trajectories over 1-year following surgery to attempt replication of prior work and evaluate baseline psychosocial factors and 12-month health outcomes. Adolescents 10 to 18 years completed electronic daily pain reporting for 7 days and self-reported health outcomes, at 5 assessment timepoints. Group-based trajectory modelling identified two trajectories with similar starting points in-hospital but distinct recovery courses at home. Pain declined steadily in one group across the study period ("Declining Pain"; estimated probability,18.9%), but pain increased after hospital discharge and remained high through 12-months in the other group ("High and Persistent Pain"; estimated probability,81.1%). Pre-surgery pain (Aor = 1.86, P = .001) and sleep quality (Aor = 0.49, P = .029) were associated with the High and Persistent pain trajectory in multivariate regressions. This trajectory was associated with lower total quality of life (B=-9.79, P = .002), physical health (B = -15.93, P < .001), psychosocial health (B = -6.73, P = .06), and greater fatigue (B = -13.61, P = .001). This study replicated prior findings identifying two post-surgical pain trajectories with diverging pain in the first two weeks. Clinical detection of those with increasing pain and early intervention may interrupt persistence of pain. PERSPECTIVE: This article replicates a prior study identifying distinct post-surgical pain trajectories, Declining Pain and High and Persistent Pain. The High and Persistent pain trajectory is associated with pre-surgery pain, pre-surgery sleep quality, and lower quality of life (total, physical, and psychosocial health as well as fatigue) at 12-month follow-up.

The Relationships Between Sport Specialization, Sleep, and Quality of Life in Female Youth Volleyball Athletes

BACKGROUND

Although sport specialization may be associated with stress and burnout among youth athletes, the relationship with quality of life (QOL) remains unknown. The purpose of this study was to evaluate the relationship between sport specialization, sleep, and QOL in female youth athletes.

HYPOTHESIS

Higher levels of specialization are associated with increased daytime sleepiness and worse QOL.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Female high school volleyball players completed preseason surveys to determine sport specialization (low, moderate, high), injury history, QOL, sleep duration, and daytime sleepiness. QOL and sleep variables were compared across specialization groups. Multivariable linear regression models were developed to evaluate the associations between sleepiness, QOL, specialization, grade in school, and injury history.

RESULTS

Of 1482 participants, 591 (40%), 436 (29%), and 455 (31%) were categorized as low, moderate, and high specialization, respectively. Highly specialized athletes demonstrated worse QOL (median 91.3 [interquartile range 86-96]) than low (92.4 [88-97], P = 0.05) and moderate (93.5 [88-99], P = 0.05) specialization groups and greater daytime sleepiness (11 [7-15]) than low (10 [6-14], P < 0.001) and moderate (10 [6-14], P < 0.001) specialization groups. In the multivariable model, QOL was negatively associated with prior injury occurrence (β = -1.1 ± 0.5, P = 0.02), but not grade in school (β = -0.08 ± 0.2, P = 0.71) or specialization (moderate: β = 0.08 ± 0.5, P = 0.88; high: β = -0.70 ± 0.5, P = 0.18). Daytime sleepiness increased with high specialization (β = 1.12 ± 0.3, P < 0.001) and grade (β = 0.76 ± 0.1, P < 0.001), but not prior injury (β = 0.51 ±0.3, P = 0.10).

CONCLUSION

Highly specialized female volleyball athletes demonstrate decreased QOL, perhaps because of higher rates of prior injury. Specialization is also associated with increased daytime sleepiness.

CLINICAL RELEVANCE

Sport participation patterns and injury may have implications for QOL in youth athletes.

Type 2 diabetes mellitus and its effect on quality of life in adolescents: A retrospective cohort study in Saudi Arabia

INTRODUCTION

Quality of life (QoL) in adolescent patients suffering from type 2 diabetes mellitus (T2DM) has not been thoroughly explored in Saudi Arabia. Herein, we aimed to measure the health-related quality of life (HRQoL) in adolescent patients suffering from T2DM and explore the correlation between adolescents' self- and parent-reporting of QoL scores, and glycaemic control (HbA1c).

MATERIAL AND METHODS

A retrospective multi-centre cohort study was conducted at 4 hospitals in Riyadh, Saudi Arabia. The Paediatric Quality of Life Inventory (PedsQLTM) Diabetes Module 3.0 was completed by children and their parents in a confidential and anonyms manner through a phone interview.

RESULTS

We recruited 49 paediatric patients for this study (mean age: 18.45 years; male: 55%). Both children and parents reported low cumulative mean scores for PedsQL™ (58.65 and 57.38, respectively) as compared to previous international studies. The lowest obtained score was noted for the diabetes symptoms domain (53.4). Comparing the magnitude of discrepancy between the adolescents' and parents' subscale scores revealed a non-significant difference, except for the 'worry' subscale, in which parents reported significantly higher mean scores (76.73 vs. 60.54, p = 0.02). Comparison of mean scores reported by adolescents who met the target HbA1c goal (<7%) and their counterparts revealed a non-significant difference, suggesting an irrelevant impact of this parameter on their perspectives or experiences.

CONCLUSIONS

The study findings emphasized the need to initiate further intensive awareness programs concerning this disease and its clinical implications in T2DM children to improve treatment adherence and symptoms, and consequently improve the perception of the patient and the family for HRQoL.

Antioxidants to prevent respiratory decline in people with Duchenne muscular dystrophy and progressive respiratory decline

BACKGROUND

Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterised by progressive muscle weakness beginning in early childhood. Respiratory failure and weak cough develop in all patients as a consequence of muscle weakness leading to a risk of atelectasis, pneumonia, or the need for ventilatory support. There is no curative treatment for DMD. Corticosteroids are the only pharmacological intervention proven to delay the onset and progression of muscle weakness and thus respiratory decline in DMD. Antioxidant treatment has been proposed to try to reduce muscle weakness in general, and respiratory decline in particular.  OBJECTIVES: To assess the effects of antioxidant agents on preventing respiratory decline in people with Duchenne muscular dystrophy during the respiratory decline phase of the condition.  SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers to 23 March 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that met our inclusion criteria. We included male patients with a diagnosis of DMD who had respiratory decline evidenced by a forced vital capacity (FVC%) less than 80% but greater than 30% of predicted values, receiving any antioxidant agent compared with other therapies for the management of DMD or placebo.  DATA COLLECTION AND ANALYSIS: Two review authors screened studies for eligibility, assessed risk of bias of studies, and extracted data. We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. The primary outcomes were FVC and hospitalisation due to respiratory infections. Secondary outcomes were quality of life, adverse events, change in muscle function, forced expiratory volume in the first second (FEV1), and peak expiratory flow (PEF).  MAIN RESULTS: We included one study with 66 participants who were not co-treated with corticosteroids, which was the only study to contribute data to our main analysis. We also included a study that enrolled 255 participants treated with corticosteroids, which was only available as a press release without numerical results. The studies were parallel-group RCTs that assessed the effect of idebenone on respiratory function compared to placebo. The trial that contributed numerical data included patients with a mean (standard deviation) age of 14.3 (2.7) years at the time of inclusion, with a documented diagnosis of DMD or severe dystrophinopathy with clinical features consistent with typical DMD. The overall risk of bias across most outcomes was similar and judged as 'low'.  Idebenone may result in a slightly less of a decline in FVC from baseline to one year compared to placebo (mean difference (MD) 3.28%, 95% confidence interval (CI) -0.41 to 6.97; 64 participants; low-certainty evidence), and probably has little or no effect on change in quality of life (MD -3.80, 95% CI -10.09 to 2.49; 63 participants; moderate-certainty evidence) (Pediatric Quality of Life Inventory (PedsQL), range 0 to 100, 0 = worst, 100 = best quality of life). As a related but secondary outcome, idebenone may result in less of a decline from baseline in FEV1 (MD 8.28%, 95% CI 0.89 to 15.67; 53 participants) and PEF (MD 6.27%, 95% CI 0.61 to 11.93; 1 trial, 64 participants) compared to placebo. Idebenone was associated with fewer serious adverse events (RR 0.42, 95% CI 0.09 to 2.04; 66 participants; low-certainty evidence) and little to no difference in non-serious adverse events (RR 1.00, 95% CI 0.88 to 1.13; 66 participants; low-certainty evidence) compared to placebo. Idebenone may result in little to no difference in change in arm muscle function (MD -2.45 N, 95% CI -8.60 to 3.70 for elbow flexors and MD -1.06 N, 95% CI -6.77 to 4.65 for elbow extensors; both 52 participants) compared to placebo. We found no studies evaluating the outcome hospitalisation due to respiratory infection.  The second trial, involving 255 participants, for which data were available only as a press release without numerical data, was prematurely discontinued due to futility after an interim efficacy analysis based on FVC. There were no safety concerns. The certainty of the evidence was low for most outcomes due to imprecision and publication bias (the lack of a full report of the larger trial, which was prematurely terminated).

AUTHORS' CONCLUSIONS

Idebenone is the only antioxidant agent tested in RCTs for preventing respiratory decline in people with DMD for which evidence was available for assessment. Idebenone may result in slightly less of a decline in FVC and less of a decline in FEV1 and PEF, but probably has little to no measurable effect on change in quality of life. Idebenone is associated with fewer serious adverse events than placebo. Idebenone may result in little to no difference in change in muscle function. Discontinuation due to the futility of the SIDEROS trial and its expanded access programmes may indicate that idebenone research in this condition is no longer needed, but we await the trial data. Further research is needed to establish the effect of different antioxidant agents on preventing respiratory decline in people with DMD during the respiratory decline phase of the condition.

Antioxidants to prevent respiratory decline in people with Duchenne muscular dystrophy and progressive respiratory decline

BACKGROUND

Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterised by progressive muscle weakness beginning in early childhood. Respiratory failure and weak cough develop in all patients as a consequence of muscle weakness leading to a risk of atelectasis, pneumonia, or the need for ventilatory support. There is no curative treatment for DMD. Corticosteroids are the only pharmacological intervention proven to delay the onset and progression of muscle weakness and thus respiratory decline in DMD. Antioxidant treatment has been proposed to try to reduce muscle weakness in general, and respiratory decline in particular.  OBJECTIVES: To assess the effects of antioxidant agents on preventing respiratory decline in people with Duchenne muscular dystrophy during the respiratory decline phase of the condition.  SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trials registers to 23 March 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that met our inclusion criteria. We included male patients with a diagnosis of DMD who had respiratory decline evidenced by a forced vital capacity (FVC%) less than 80% but greater than 30% of predicted values, receiving any antioxidant agent compared with other therapies for the management of DMD or placebo.  DATA COLLECTION AND ANALYSIS: Two review authors screened studies for eligibility, assessed risk of bias of studies, and extracted data. We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. The primary outcomes were FVC and hospitalisation due to respiratory infections. Secondary outcomes were quality of life, adverse events, change in muscle function, forced expiratory volume in the first second (FEV1), and peak expiratory flow (PEF).  MAIN RESULTS: We included one study with 66 participants who were not co-treated with corticosteroids, which was the only study to contribute data to our main analysis. We also included a study that enrolled 255 participants treated with corticosteroids, which was only available as a press release without numerical results. The studies were parallel-group RCTs that assessed the effect of idebenone on respiratory function compared to placebo. The trial that contributed numerical data included patients with a mean (standard deviation) age of 14.3 (2.7) years at the time of inclusion, with a documented diagnosis of DMD or severe dystrophinopathy with clinical features consistent with typical DMD. The overall risk of bias across most outcomes was similar and judged as 'low'.  Idebenone may result in a slightly less of a decline in FVC from baseline to one year compared to placebo (mean difference (MD) 3.28%, 95% confidence interval (CI) -0.41 to 6.97; 64 participants; low-certainty evidence), and probably has little or no effect on change in quality of life (MD -3.80, 95% CI -10.09 to 2.49; 63 participants; moderate-certainty evidence) (Pediatric Quality of Life Inventory (PedsQL), range 0 to 100, 0 = worst, 100 = best quality of life). As a related but secondary outcome, idebenone may result in less of a decline from baseline in FEV1 (MD 8.28%, 95% CI 0.89 to 15.67; 53 participants) and PEF (MD 6.27%, 95% CI 0.61 to 11.93; 1 trial, 64 participants) compared to placebo. Idebenone was associated with fewer serious adverse events (RR 0.42, 95% CI 0.09 to 2.04; 66 participants; low-certainty evidence) and little to no difference in non-serious adverse events (RR 1.00, 95% CI 0.88 to 1.13; 66 participants; low-certainty evidence) compared to placebo. Idebenone may result in little to no difference in change in arm muscle function (MD -2.45 N, 95% CI -8.60 to 3.70 for elbow flexors and MD -1.06 N, 95% CI -6.77 to 4.65 for elbow extensors; both 52 participants) compared to placebo. We found no studies evaluating the outcome hospitalisation due to respiratory infection.  The second trial, involving 255 participants, for which data were available only as a press release without numerical data, was prematurely discontinued due to futility after an interim efficacy analysis based on FVC. There were no safety concerns. The certainty of the evidence was low for most outcomes due to imprecision and publication bias (the lack of a full report of the larger trial, which was prematurely terminated).

AUTHORS' CONCLUSIONS

Idebenone is the only antioxidant agent tested in RCTs for preventing respiratory decline in people with DMD for which evidence was available for assessment. Idebenone may result in slightly less of a decline in FVC and less of a decline in FEV1 and PEF, but probably has little to no measurable effect on change in quality of life. Idebenone is associated with fewer serious adverse events than placebo. Idebenone may result in little to no difference in change in muscle function. Discontinuation due to the futility of the SIDEROS trial and its expanded access programmes may indicate that idebenone research in this condition is no longer needed, but we await the trial data. Further research is needed to establish the effect of different antioxidant agents on preventing respiratory decline in people with DMD during the respiratory decline phase of the condition.

Is It Worth It? A Comparison of an Intensive Interdisciplinary Pain Treatment and a Multimodal Treatment for Youths With Pain-related Disability

OBJECTIVE

The objective of this study was to evaluate the effectiveness of an intensive interdisciplinary pain treatment (IIPT) day-hospital program as compared with an outpatient multimodal treatment (MMT) for youth with chronic pain.

MATERIALS AND METHODS

A nonrandomized pretest posttest with control group design was used. A battery of patient-oriented measures assessing pain interference, quality of life, and depressive symptoms were completed at treatment commencement and at 3, 6, and 12 months after treatment by 44 youths enrolled in the IIPT and 138 youths engaged in the MMT, with various chronic pain conditions. Data were analyzed using longitudinal mixed-effects models.

RESULTS

The main outcomes were the score difference from baseline of patient-oriented measures across 3 timepoints within 12 months of intervention initiation for both treatment groups. IIPT participants demonstrated greater improvement in pain interference, as compared with MMT at 3 and 12 months. Initially, health-related quality of life scores improved similarly in both groups, but greater improvement was seen in the MMT group at 12 months. Depressive symptom scores did not improve with either intervention. Only pain interference scores reached statistically and clinically significant difference levels.

DISCUSSION

This study supports the benefits of specialized rehabilitation interventions, including both MMT and IIPT programs, for youths with chronic pain. The findings also suggest that IIPT might have a greater long-term effect for helping youths, in particular those with high pain interference scores.

Twenty years of pediatric diabetes surveillance: what do we know and why it matters

SEARCH for Diabetes in Youth (SEARCH) was initiated in 2000 as a multicenter study to address major gaps in the understanding of childhood diabetes in the United States. An active registry of youth diagnosed with diabetes at age <20 years since 2002 assessed prevalence, annual incidence, and trends by age, race/ethnicity, sex, and diabetes type. An observational cohort nested within the population-based registry was established to assess the natural history and risk factors for acute and chronic diabetes-related complications, as well as the quality of care and quality of life of children and adolescents with diabetes from diagnosis into young adulthood. SEARCH findings have contributed to a better understanding of the complex and heterogeneous nature of youth-onset diabetes. Continued surveillance of the burden and risk of type 1 and type 2 diabetes is important to track and monitor incidence and prevalence within the population. SEARCH reported evidence of early diabetes complications highlighting that continuing the long-term follow-up of youth with diabetes is necessary to further our understanding of its natural history and to develop the most appropriate approaches to primary, secondary, and tertiary prevention of diabetes and its complications. This review summarizes two decades of research and suggests avenues for further work.

Responsivity to Problem-Solving Skills Training in Mothers of Children With Cancer

OBJECTIVE

Bright IDEAS (BI) is a problem-solving skills training (PSST) program that has been demonstrated in earlier randomized controlled trials (RCTs) to be an effective and specific intervention for improving problem-solving skills and reducing negative affect in caregivers of children with cancer. The objectives of this study were to (a) offer an approach to defining meaningful treatment response and to determine the rates of responsivity to PSST; and (b) identify characteristics of PSST responders and nonresponders.

METHODS

Data from 154 mothers receiving the BI intervention were analyzed. Drawing on the literature on minimal clinically important differences, two criteria for determining responsivity were calculated for the primary outcome of problem-solving skills: (a) The reliable change index (RCI) based on group data, and; (b) The effect size (ES) of each participant's pre/postintervention change score as a function of the group's baseline SD.

RESULTS

Thirty-three percent of the sample met both responsivity criteria immediately posttreatment (39% at follow-up) and 38% (39% at follow-up) met neither. An additional 29% demonstrated a small or greater ES (≥ 0.2) but did not meet the RCI criteria, suggesting possible benefit. The single consistent predictor of responsivity was participants' pretreatment problem-solving skills, with lower skills at baseline predicting greater improvement (p < .001).

CONCLUSIONS

These findings highlight the need to go beyond group data in interpreting RCTs and to incorporate measures of meaningful treatment response. Our ability to predict and screen for meaningful treatment response is critical to more precise targeting, enhanced outcomes, and better resource allocation.

Impact of in-season injury on quality of life and sleep duration in female youth volleyball athletes: a prospective study of 2073 players

OBJECTIVES

The psychological impacts of injuries in youth athletes remain poorly defined. The purpose of this study was to evaluate the influence of injury on quality of life (QOL) and sleep in female high school volleyball athletes.

METHODS

2073 female high school volleyball players (15.6±1.1 years) completed the Pediatric Quality of Life survey (total QOL, physical, social, school, emotional and psychosocial function) and reported average sleep duration at the start and end of the season. Injury data were collected by school athletic trainers. Mixed effects linear regression models were used to compare changes in QOL and sleep duration during the season between (1) injured and uninjured athletes and (2) injured athletes who did or did not suffer a season-ending injury.

RESULTS

Time-loss injuries were reported in 187 athletes with complete preseason and postseason data. During the season, injured athletes demonstrated a greater decrease in total QOL (β=-1.3±0.5, p=0.012), as well as physical function (β=-1.6±0.6, p=0.012), school function (β=-2.0±0.76, p=0.01) and psychosocial function domains (β=-1.2±0.6, p=0.039) compared with uninjured athletes. Athletes who sustained a season-ending injury had a significantly greater decrease in total QOL (β=-6.8±2.0, p=0.006) and physical function (β=-17±2.9, p<0.001) compared with injured athletes who were able to return to play during the season.

CONCLUSION

In-season injuries are associated with significant decreases in total QOL as well as physical and psychosocial function. Healthcare providers should consider the impacts of injuries on QOL and sleep in youth athletes in order to optimise management and improve overall health.

Youth and Parent Health-Related Quality of Life and Association With Glycemic Outcomes in Preadolescents and Adolescents With Type 1 Diabetes

INTRODUCTION

We explored differences in Health-Related Quality of Life (HRQOL) and the youth's glycosylated hemoglobin (A1c) of preadolescent and adolescent youths with type 1 diabetes (T1D) by individual (age, sex, race) and family (socioeconomic status) factors, and associations between youths' HRQOL, their parents' HRQOL, and youth's A1c.

METHOD

Correlational secondary analysis of baseline data from a randomized controlled trial testing a developmental intervention for youths with T1D and their parents from two diabetes clinics.

RESULTS

Better adolescent HRQOL was associated with better glycemic control. Better preadolescent HRQOL was associated with better parent HRQOL. Non-White adolescents had worse HRQOL than White adolescents; whereas Non-White preadolescents had worse glycemic control than White preadolescents.

DISCUSSION

Addressing HRQOL may promote better glycemic control in adolescents with T1D. For preadolescents with T1D, parent HRQOL support may impact preadolescent HRQOL and improve glycemic control moving into adolescence. Further study is warranted for non-White youths with T1D HRQOL and A1c outcomes.

An intervention to improve the quality of life in children of parents with serious mental illness: the Young SMILES feasibility RCT

BACKGROUND

Quality of life for children and adolescents living with serious parental mental illness can be impaired, but evidence-based interventions to improve it are scarce.

OBJECTIVE

Co-production of a child-centred intervention [called Young Simplifying Mental Illness plus Life Enhancement Skills (SMILES)] to improve the health-related quality of life of children and adolescents living with serious parental mental illness, and evaluating its acceptability and feasibility for delivery in NHS and community settings.

DESIGN

Qualitative and co-production methods informed the development of the intervention (Phase I). A feasibility randomised controlled trial was designed to compare Young SMILES with treatment as usual (Phase II). Semistructured qualitative interviews were used to explore acceptability among children and adolescents living with their parents, who had serious mental illness, and their parents. A mixture of semistructured qualitative interviews and focus group research was used to examine feasibility among Young SMILES facilitators and referrers/non-referrers.

SETTING

Randomisation was conducted after baseline measures were collected by the study co-ordinator, ensuring that the blinding of the statistician and research team was maintained to reduce detection bias.

PARTICIPANTS

Phase I: 14 children and adolescents living with serious parental mental illness, seven parents and 31 practitioners from social, educational and health-related sectors. Phase II: 40 children and adolescents living with serious parental mental illness, 33 parents, five referrers/non-referrers and 16 Young SMILES facilitators.

INTERVENTION

Young SMILES was delivered at two sites: (1) Warrington, supported by the National Society for the Prevention of Cruelty to Children (NSPCC), and (2) Newcastle, supported by the NHS and Barnardo's. An eight-session weekly group programme was delivered, with four to six children and adolescents living with serious parental mental illness per age-appropriate group (6-11 and 12-16 years). At week 4, a five-session parallel weekly programme was offered to the parents/carers. Sessions lasted 2 hours each and focused on improving mental health literacy, child-parent communication and children's problem-solving skills.

MAIN OUTCOME MEASURES

Phase ll children and parents completed questionnaires at randomisation and then again at 4 and 6 months post randomisation. Quality of life was self-reported by children and proxy-reported by parents using the Paediatric Quality of Life questionnaire and KIDSCREEN. Semistructured interviews with parents (n = 14) and children (n = 17) who participated in the Young SMILES groups gathered information about their motivation to sign up to the study, their experiences of participating in the group sessions, and their perceived changes in themselves and their family members following intervention. Further interviews with individual referrers (n = 5) gathered information about challenges to recruitment and randomisation. Two focus groups (n = 16) with practitioners who facilitated the intervention explored their views of the format and content of the Young SMILES manual and their suggestions for changes.

RESULTS

A total of 35 families were recruited: 20 were randomly allocated to Young SMILES group and 15 to treatment as usual. Of those, 28 families [15/20 (75%) in the intervention group and 13/15 (87%) in the control group] gave follow-up data at the primary end point (4 months post baseline). Participating children had high adherence to the intervention and high completion rates of the questionnaires. Children and adolescents living with their parents, who had serious mental illness, and their parents were mainly very positive and enthusiastic about Young SMILES, both of whom invoked the benefits of peer support and insight into parental difficulties. Although facilitators regarded Young SMILES as a meaningful and distinctive intervention having great potential, referrers identified several barriers to referring families to the study. One harm was reported by a parent, which was dealt with by the research team and the NSPCC in accordance with the standard operating procedures.

LIMITATIONS

The findings from our feasibility study are not sufficient to recommend a fully powered trial of Young SMILES in the near future. Although it was feasible to randomise children and adolescents living with serious parental mental illness of different ages to standardised, time-limited groups in both NHS and non-NHS settings, an intervention like Young SMILES is unlikely to address underlying core components of the vulnerability that children and adolescents living with serious parental mental illness express as a population over time.

CONCLUSIONS

Young SMILES was widely valued as unique in filling a recognised gap in need. Outcome measures in future studies of interventions for children and adolescents living with serious parental mental illness are more likely to capture change in individual risk factors for reduced quality of life by considering their unmet need, rather than on an aggregate construct of health-related quality of life overall, which may not reflect these young people's needs.

FUTURE WORK

A public health approach to intervention might be best. Most children and adolescents living with serious parental mental illness remain well most of the time, so, although their absolute risks are low across outcomes (and most will remain resilient most of the time), consistent population estimates find their relative risk to be high compared with unexposed children. A public health approach to intervention needs to be both tailored to the particular needs of children and adolescents living with serious parental mental illness and agile to these needs so that it can respond to fluctuations over time.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN36865046.

FUNDING

This project was funded by the National Institute of Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 59. See the NIHR Journals Library website for further project information.

The DISABKIDS generic and diabetes-specific modules are valid but not directly comparable between Denmark, Sweden, and Norway

BACKGROUND/OBJECTIVES

Government guidance promote benchmarking comparing quality of care including both clinical values and patient reported outcome measures in young persons with type 1 diabetes. The aim was to test if the Nordic DISABKIDS health-related quality of life (HrQoL) modules were construct valid and measurement comparable within the three Nordic countries.

METHODS

Data from three DISABKIDS validation studies in Sweden, Denmark, and Norway were compared using Rasch and the graphical log-linear Rasch modeling. Monte Carlo methods were used to estimate reliability coefficient and target was defined as the point with the lowest SE of the mean. Self-report data were available from 99 Danish (8-18 years), 103 Norwegian (7-19 years), and 131 Swedish (8-18 years) young people.

RESULTS

For the DISABKIDS higher scores on most subscales were noted in the Norwegian population. The Swedish sample had a significantly higher score on the "Diabetes treatment" subscale and scores closer to optimal target than the other countries. For each country, construct validity and sensitivity were acceptable when accounting for differential item function (DIF) and local dependency (LD). Less LD and DIF were found if only Denmark and Norway were included. The combined model was reliable; however, some differences were noted in the scale translations relating to the stem and response alternatives, which could explain the discrepancies.

CONCLUSION

The Nordic versions of the DISABKIDS questionnaires measures valid and reliable HrQoL both within and between countries when adjusted for DIF and LD. Adjusting the Likert scales to the same respond categories may improve comparability.

Young Adults With Type 1 Diabetes Preparing to Transition to Adult Care: Psychosocial Functioning and Associations With Self-Management and Health Outcomes

BACKGROUND | Young adulthood is a vulnerable developmental period associated with increased risk for suboptimal health outcomes in youth with type 1 diabetes. Psychosocial factors have been associated with self-management and glycemic control in younger populations, but the extent to which these associations exist among young adults is poorly understood. This study aimed to examine the psychosocial functioning of young adults with type 1 diabetes and associated clinical outcomes. METHODS | Participants included young adults (n = 44) between the ages of 18 and 23 years in a pediatric setting who were preparing to transition to adult care. All participants completed self-report measures of psychosocial functioning at baseline as part of this longitudinal observational study. Outcome data included glycemic control, frequency of blood glucose monitoring, and self-management ratings at baseline and 1-year follow-up. RESULTS | Young adults with type 1 diabetes reported higher levels of depressive symptoms, lower self-efficacy, and more risk behaviors compared with previously published scores for adolescents. Young adults also reported greater resilience and transition readiness than their younger counterparts. Psychosocial variables were differentially related to glycemic control and frequency of blood glucose monitoring both cross-sectionally and longitudinally. CONCLUSION | This study provides key information about the psychosocial functioning of young adults with type 1 diabetes. It identifies relevant psychosocial factors that are associated with meaningful health outcomes during the transition preparation period. These findings may inform the development of clinical programs aimed at promoting transition preparation and health outcomes in young adults with type 1 diabetes.

The effects of intervening with physical activity in the early years (ages 3-5) on health-related quality of life: a secondary analysis of the Activity Begins in Childhood (ABC) trial

PURPOSE

Limited research has measured the effect of physical activity (PA) interventions on health-related quality of life (HRQoL) among pre-school-aged children. This study evaluates the effect of the Activity Begins in Childhood (ABC) cluster-randomized controlled trial designed to increase PA in the ages 3-5 years on HRQoL.

METHODS

This was a cluster-randomized controlled trial where the intervention group included PA education delivered to daycare providers only, or daycare providers and parents. In the current study, the two PA intervention groups were combined. The comparator group received standard daycare curriculum (COM). A total of 215 children were included (PA n = 161, COM n = 54). Parents completed the proxy Pediatric Quality of Life Inventory Generic Core Scale (PedsQL™ 4.0) to measure HRQoL at baseline and the end of the 6-month trial. HRQoL scores were analyzed as physical, psychosocial, and total domains. Baseline and 6-months measurements were compared for PA and COM groups, and mean changes in scores (95% confidence intervals) were measured using absolute values.

RESULTS

No between-group differences were observed for the physical (p = 0.17), psychosocial (p = 0.95) or total scores (p = 0.20). Paired comparisons showed that only the PA group improved psychosocial- (PA mean difference = 2.18 (0.20, 4.15), p = 0.03; COM mean difference = 2.05 (- 1.03, 5.13), p = 0.19) and total-HRQoL scores (PA mean difference = 2.83 (1.83, 3.84), p < 0.001; COM mean difference = 0.19 (- 1.78, 2.16), p = 0.84) after 6 months.

CONCLUSION

Although the within-PA group analysis showed an improvement in psychosocial and total HRQoL scores from baseline, no between-group differences were observed in the HRQoL over time among children aged 3-5 years.

How is the minimal clinically important difference established in health-related quality of life instruments? Review of anchors and methods

Background

The aim of this systematic review is to describe the different types of anchors and statistical methods used in estimating the Minimal Clinically Important Difference (MCID) for Health-Related Quality of Life (HRQoL) instruments.

Methods

PubMed and Google scholar were searched for English and French language studies published from 2010 to 2018 using selected keywords. We included original articles (reviews, meta-analysis, commentaries and research letters were not considered) that described anchors and statistical methods used to estimate the MCID in HRQoL instruments.

Results

Forty-seven papers satisfied the inclusion criteria. The MCID was estimated for 6 generic and 18 disease-specific instruments. Most studies in our review used anchor-based methods (n = 41), either alone or in combination with distribution-based methods. The most common applied anchors were non-clinical, from the viewpoint of patients. Different statistical methods for anchor-based methods were applied and the Change Difference (CD) was the most used one. Most distributional methods included 0.2 standard deviations (SD), 0.3 SD, 0.5 SD and 1 standard error of measurement (SEM). MCID values were very variable depending on methods applied, and also on clinical context of the study.

Conclusion

Multiple anchors and methods were applied in the included studies, which lead to different estimations of MCID. Using several methods enables to assess the robustness of the results. This corresponds to a sensitivity analysis of the methods. Close collaboration between statisticians and clinicians is recommended to integrate an agreement regarding the appropriate method to determine MCID for a specific context.

Fitness as a Mediator of the Enhancement of Quality of Life after a 6-Months Exercise Program

Purpose: The study aimed to test whether improvement in fitness components, mediates the changes in Health-related Quality of Life (HRQoL) after exercise intervention in overweight and obese children. Methods and design: 170 obese and overweight children (121 exercise group and 49 control group) participated in a public exercise program based on sports practice for 6 months, 2 h per week. Anthropometry, physical fitness, and HRQoL were measured. Magnitude-based inferences and Cohen's effect size were performed to analyze the program effect. To know which physical fitness components mediated the improvement on children's HRQoL, multiple mediation analyses were performed. Results: the analysis showed a moderate effect on some fitness components and a moderate and small effect on HRQoL. The improvement of agility or cardiorespiratory fitness showed a significant indirect effect on the enhancements in some HRQoL dimensions. Conclusion: after a 6-months exercise program in overweight and obese children, all physical fitness components improved, being responsible for the improvement of the HRQoL, agility and cardiorespiratory fitness.

PedsQL™ Cognitive Functioning Scale in youth with epilepsy: Reliability and validity

OBJECTIVE

The objective of the study was to report on the internal consistency reliability and discriminant, concurrent and construct validity of the Pediatric Quality of Life Inventory™ (PedsQL™) Cognitive Functioning Scale as a brief generic cognitive functioning measure in youth with epilepsy.

METHODS

The 6-item PedsQL™ Cognitive Functioning Scale and 23-item PedsQL™ 4.0 Generic Core Scales were completed by 221 pediatric patients ages 5-18 years with epilepsy and 336 parents of patients ages 2-18 years in a national field test study for the PedsQL™ Epilepsy Module. Parents also completed the 86-item Behavior Rating Inventory of Executive Function (BRIEF), a widely validated measure of executive functioning.

RESULTS

The PedsQL™ Cognitive Functioning Scale evidenced excellent reliability (patient self-report α = 0.88; parent proxy-report α = 0.96), distinguished between youth with epilepsy and an age, gender, and race/ethnicity-matched healthy sample supporting discriminant validity with large effect sizes (~20-30 point score differences, P < 0.001), and demonstrated concurrent and construct validity, respectively, through large effect size intercorrelations with the BRIEF (Behavioral Regulation Index, Metacognition Index, Global Executive Composite Summary Scores rs = 0.43-0.67, P < 0.001) and the PedsQL™ Generic Core Scales (Total Scale Scores rs = 0.67-0.74, P < 0.001). Minimal clinically important difference (MCID) scores ranged from 5.92 to 8.80.

CONCLUSIONS

The PedsQL™ Cognitive Functioning Scale demonstrated excellent internal consistency reliability, discriminant, concurrent, and construct validity in youth with epilepsy and may be suitable as a brief generic patient-reported outcome (PRO) measure for clinical research, clinical trials, and routine clinical practice in pediatric epilepsy.

Alcohol consumption patterns in young adults with type 1 diabetes: The SEARCH for diabetes in youth study

AIMS

The objective of this study is to describe alcohol consumption behaviors of young adults with T1D and to examine associations between alcohol consumption and diabetes-related clinical markers.

METHODS

Data from 602 SEARCH for Diabetes in Youth Study participants age ≥ 18 yrs. with T1D were collected from 12/2011 to 6/2015 (50% female, mean age 21.3(SD 2.4), 22% race/ethnic minority). Participants were characterized as alcohol non-drinkers (n = 269), drinkers but non-binge drinkers (n = 167), or binge drinkers (n = 166) based on reported consumption in the past 30 days. Analyses were conducted using one-way ANOVAs, chi-square tests, and logistic regression modeling to examine associations between drinking and clinical markers.

RESULTS

Fifty-five percent of participants reported alcohol consumption; 27.6% of participants reported binge drinking. After adjusting for demographic characteristics, neither binge drinking nor non-binge drinking were associated with HbA1c or severe hypoglycemic events relative to non-drinkers. Binge drinking was associated with higher HDL (p = 0.008), lower systolic blood pressure (p = 0.011), and a lower waist:height ratio compared to non-drinkers (p = 0.013).

CONCLUSIONS

Young adults with T1D in the SEARCH cohort reported similar alcohol use but higher rates of binge drinking compared to the general United States population and previously reported rates in adults with T1D.

Does Kyphectomy Improve the Quality of Life of Patients With Myelomeningocele?

BACKGROUND

Lumbar kyphosis is a complex spinal deformity occurring in approximately 8% to 20% of patients with myelomeningocele. The resulting gibbosity may cause pressure ulcers, difficulty lying down in the supine position and sitting on the ischia without support, decreasing quality of life (QOL). Surgery is generally performed to correct kyphosis and maintain vertebral alignment, but high complication rates have been reported. Despite satisfactory radiological results, the impact of surgery and its complications on health-related QOL (HRQOL) has not yet been established.

QUESTIONS/PURPOSES

Among children with myelomeningocele undergoing corrective surgery for lumbar kyphosis: (1) What is the risk of complications and reoperation after this procedure? (2) Does this procedure improve HRQOL scores in these patients?

METHODS

Between 2012 and 2013, five surgeons at three centers treated 32 patients for myelomeningocele-related kyphosis with kyphectomy and posterior instrumentation. During that period, all surgeons used the same indications for the procedure, which were progressive postural decompensation and chronic ulceration at the apex of the deformity. Data were prospectively collected, and all patients who underwent surgery were considered in this retrospective study. The legal guardians of one patient declined to sign the informed consent form, resulting in 31 patients included. A total of 9.7% (3 of 31) were lost to follow-up before the 2-year period, and the remaining 90.3% (28 of 31) were seen at a mean of 3 years (± 9 months) after surgery. The average age was 10 years, 7 months (± 21 months) at the time of surgery. The patients had a mean kyphosis angle of 130° ± 36° before surgery. This technique involved posterior fixation using S-shaped rods inserted through the foramina of S1 and pedicle screws inserted in the thoracic spine. The patients' caregivers answered both the generic and specific (neuromuscular module) Pediatric Quality of Life Inventory questionnaires preoperatively and 2 years postoperatively. The minimum clinically important difference (MCID) considered for the instruments used was 5.

RESULTS

Reoperation was performed in 68% of patients (19 of 28), mostly to treat deep infection. In all, 18% of patients (five of 28) underwent implant removal to control infection. Eleven percent (three of 28) had a loss of reduction and pseudarthrosis. The HRQOL increased from 71 ± 11 preoperatively to 76 ± 10 postoperatively (p < 0.001), resulting in a 5-point increase (95% CI 3 to 7) in the generic questionnaire score and from 71 ± 13 to 79 ± 11 (p < 0.001), resulting in an 8-point increase (95% CI 5 to 10) in the neuromuscular Paediatric Quality of Life Inventory questionnaire score, mainly in the physical health domain on both questionnaires.

CONCLUSIONS

Kyphectomy was associated with a high risk of complications and reoperations and did not seem to deliver a substantial clinical benefit for patients who underwent the procedure. Most of our HRQOL score improvements were below the minimum clinically important difference for the Pediatric Quality of Life Inventory questionnaires. Although it seems that surgeons lack a better surgical alternative when facing the challenging health impairments these patients suffer, efforts should be made to improve the technique and reduce surgical complications. Additionally, patients and caregivers should be advised of the high reoperation rate and notified that the procedure may not result in a better QOL and should thus be avoided when possible. Future studies should verify whether decreasing the complication rate could imply improvement in the HRQOL of these patients after surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Flash Glucose Monitoring System for People with Type 1 or Type 2 Diabetes: A Health Technology Assessment

BACKGROUND

People with diabetes manage their condition by monitoring the amount of glucose (a type of sugar) in their blood, typically using a method called self-monitoring of blood glucose. Flash glucose monitoring is another method of assessing glucose levels; it uses a sensor placed under the skin and a separate touchscreen reader device. We conducted a health technology assessment of flash glucose monitoring for people with type 1 or type 2 diabetes, which included an evaluation of effectiveness and safety, the budget impact of publicly funding flash glucose monitoring, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool for randomized controlled trials and the Cochrane ROBINS-I tool for nonrandomized studies, and we assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search, and we analyzed the net budget impact of publicly funding flash glucose monitoring in Ontario for people with type 1 diabetes and for people with type 2 diabetes requiring intensive insulin therapy who are eligible for coverage under the Ontario Drug Benefit program. To contextualize the potential value of flash glucose monitoring, we spoke with adults with diabetes and parents of children with diabetes.

RESULTS

Six publications met the eligibility criteria for the clinical evidence review. Compared with self-monitoring of blood glucose, people who used flash glucose monitoring spent on average 1 hour more in the target glucose range (95% confidence interval [CI] 0.41-1.59) and 0.37 hours (22 minutes) less in a high glucose range (95% CI -0.69 to -0.05) (GRADE: Moderate). Among adults with well-controlled type 1 diabetes, flash glucose monitoring was more effective than self-monitoring of blood glucose in reducing glucose variability (GRADE: Moderate). Flash glucose monitoring was more effective than self-monitoring of blood glucose in reducing the average time spent in hypoglycemia (-0.47 h [95% CI -0.73 to -0.21]) and the average number of hypoglycemia events (-0.16 [95% CI -0.29 to -0.03]) among adults with type 2 diabetes requiring intensive insulin therapy (GRADE: Moderate). Our certainty in the evidence for the effectiveness of flash glucose monitoring for other clinical outcomes, such as quality of life and severe hypoglycemia events, is low or very low. We identified no studies on flash glucose monitoring that included pregnant people, people with diabetes who did not use insulin, or children younger than 13 years of age.We identified two studies for the economic evidence review: one cost analysis and one cost-utility analysis. The cost analysis study, conducted from the perspective of United Kingdom's National Health Service, found that flash glucose monitoring reduced costs when self-monitoring of blood glucose was performed 10 times daily but was more expensive when self-monitoring of blood glucose was performed 5.6 times daily. The cost-utility analysis had methodological limitations and was not applicable to the context of Ontario's health care system.Our 5-year budget impact analysis found that flash glucose monitoring may lead to a net budget increase ranging from $14.6 million ($2.9 million for type 1 diabetes and $11.7 million for type 2 diabetes) in year 1, at an uptake rate of 15%, to $38.6 million ($7.7 million for type 1 diabetes and $30.9 million for type 2 diabetes) in year 5, at an uptake rate of 35%. In this analysis, we assumed that people with type 1 diabetes who self-monitor their blood glucose levels would perform six blood glucose tests daily and that people with type 2 diabetes would perform four blood glucose tests daily. For people switching from self-monitoring of blood glucose using the maximum number of blood glucose test strips for reimbursement (3,000 strips yearly) to flash glucose monitoring, the net budget impact of using flash glucose monitoring is likely to be small.Adults with diabetes and parents of children with diabetes with whom we spoke reported positively on their experiences with flash glucose monitoring, reporting they believed that flash glucose monitoring helped them control their blood glucose levels, resulting in physical, social, and emotional benefits. The cost of flash glucose monitoring was the largest barrier to its use.

CONCLUSIONS

Based on an assessment of several glycemic outcomes, moderate-quality evidence shows that flash glucose monitoring improves diabetes management among adults with well-controlled type 1 diabetes and adults with type 2 diabetes requiring intensive insulin therapy. We estimate that publicly funding flash glucose monitoring in Ontario for people with type 1 diabetes and for people with type 2 diabetes requiring intensive insulin therapy who are eligible for coverage under the Ontario Drug Benefit program would result in additional costs of between $14.6 million and $38.6 million annually over the next 5 years. Adults with diabetes and parents of children with diabetes with whom we spoke reported that flash glucose monitoring helped them or their children control their blood glucose levels, resulting in physical, social, and emotional benefits.

Health trajectories of children with severe obesity attending a weight management program

Purpose

The objective of the present study is to examine physical and mental health trajectories of change in youth with severe obesity attending a tertiary care weight management program. It was predicted that younger children would show favourable changes in body mass index (BMI), markers of cardiovascular health, quality of life, and mental health.

Methods

This 2-year longitudinal study examined health trajectories of children referred to a weight management program at a Canadian paediatric tertiary care centre from November 2010 to December 2013. Participants were 209 of 217 consecutive referred paediatric patients (families) aged 3 to 17 years who met criteria for severe obesity and consented to participate. To maximize generalizability of results, there were no exclusion criteria. Primary outcomes were children's quality of life and BMI. Secondary outcomes included anxiety, depression, and non-high-density lipoprotein cholesterol levels.

Results

The findings suggest an improvement in mental health, quality of life, and cardiometabolic health of children and adolescents of all ages over the 2 years of programming. These positive findings were consistent across gender, age, and distance to the program. BMI trajectory changes varied across age cohorts such that younger children showed more favourable outcomes. The retention rate over the 2 years was high at 82.9%.

Conclusions

This is the first study to show improvements in both physical and mental health outcomes beyond 1 year in a tertiary care setting with a high-risk population of children and youth with severe obesity. Findings highlight the need to examine both mental and physical health outcomes beyond 1 year.

Randomized Trial of a Positive Psychology Intervention for Adolescents With Type 1 Diabetes

OBJECTIVE

To evaluate the effects of a positive psychology intervention for adolescents with type 1 diabetes (T1D) on adherence, glycemic control, and quality of life.

METHODS

Adolescents with T1D (n = 120) and their caregivers were randomized to either an Education (EDU) (n = 60) or Positive Affect (PA) intervention (n = 60). Adolescents in the PA group received the intervention reminders (gratitude, self-affirmation, parental affirmation, and small gifts) via text messages or phone calls over 8 weeks. Questionnaires were completed by adolescents and caregivers and clinical data (glucometer and HbA1c) were collected at baseline 3 and 6 months. Data were analyzed using generalized linear modeling.

RESULTS

After adjusting for covariates, adolescents in the PA group demonstrated significant improvement in quality of life at 3 months, compared to the EDU group, but this was not sustained at 6 months. Similarly, the PA group showed a significant decrease in disengagement coping at 3 months but not at 6 months. There was no significant intervention effect on blood glucose monitoring, but the odds of clinically significantly improvement (checking at least one more time/day) were about twice as high in the PA group as the EDU group. No significant effects were found for glycemic control.

CONCLUSIONS

A positive psychology intervention had initial significant, positive effects on coping and quality of life in adolescents with T1D. A more intensive or longer-lasting intervention may be needed to sustain these effects and to improve adherence and glycemic control.

Continuous subcutaneous insulin infusion versus multiple daily injection regimens in children and young people at diagnosis of type 1 diabetes: pragmatic randomised controlled trial and economic evaluation

OBJECTIVE

To compare the efficacy, safety, and cost utility of continuous subcutaneous insulin infusion (CSII) with multiple daily injection (MDI) regimens during the first year following diagnosis of type 1 diabetes in children and young people.

DESIGN

Pragmatic, multicentre, open label, parallel group, randomised controlled trial and economic evaluation.

SETTING

15 paediatric National Health Service (NHS) diabetes services in England and Wales. The study opened to recruitment in May 2011 and closed in January 2017.

PARTICIPANTS

Patients aged between 7 months and 15 years, with a new diagnosis of type 1 diabetes were eligible to participate. Patients who had a sibling with the disease, and those who took drug treatments or had additional diagnoses that could have affected glycaemic control were ineligible.

INTERVENTIONS

Participants were randomised, stratified by age and treating centre, to start treatment with CSII or MDI within 14 days of diagnosis. Starting doses of aspart (CSII and MDI) and glargine or detemir (MDI) were calculated according to weight and age, and titrated according to blood glucose measurements and according to local clinical practice.

MAIN OUTCOME MEASURES

Primary outcome was glycaemic control (as measured by glycated haemoglobin; HbA1c) at 12 months. Secondary outcomes were percentage of patients in each treatment arm with HbA1c within the national target range, incidence of severe hypoglycaemia and diabetic ketoacidosis, change in height and body mass index (as measured by standard deviation scores), insulin requirements (units/kg/day), partial remission rate (insulin dose adjusted HbA1c <9), paediatric quality of life inventory score, and cost utility based on the incremental cost per quality adjusted life year (QALY) gained from an NHS costing perspective.

RESULTS

294 participants were randomised and 293 included in intention to treat analyses (CSI, n=144; MDI, n=149). At 12 months, mean HbA1c was comparable with clinically unimportant differences between CSII and MDI participants (60.9 mmol/mol v 58.5 mmol/mol, mean difference 2.4 mmol/mol (95% confidence interval -0.4 to 5.3), P=0.09). Achievement of HbA1c lower than 58 mmol/mol was low among the two groups (66/143 (46%) CSII participants v 78/142 (55%) MDI participants; relative risk 0.84 (95% confidence interval 0.67 to 1.06)). Incidence of severe hypoglycaemia and diabetic ketoacidosis were low in both groups. Fifty four non-serious and 14 serious adverse events were reported during CSII treatment, and 17 non-serious and eight serious adverse events during MDI treatment. Parents (but not children) reported superior PedsQL scores for those patients treated with CSII compared to those treated with MDI. CSII was more expensive than MDI by £1863 (€2179; $2474; 95% confidence interval £1620 to £2137) per patient, with no additional QALY gains (difference -0.006 (95% confidence interval -0.031 to 0.018)).

CONCLUSION

During the first year following type 1 diabetes diagnosis, no clinical benefit of CSII over MDI was identified in children and young people in the UK setting, and treatment with either regimen was suboptimal in achieving HbA1c thresholds. CSII was not cost effective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29255275; European Clinical Trials Database 2010-023792-25.

Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for youth with Type 2 diabetes: reliability and validity

AIM

To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes.

METHODS

The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA_1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes.

Psychiatric symptom rate of patients with Diabetes Mellitus: A case control study

AIMS

The aim of the study is comparing the psychiatric symptom in Type1 DM, Type 2 DM and controls.

METHODS

The study was designed as case control study and conducted between September 2011 and April 2012 to the Diabetes Clinic. Age, gender and education level matched 70 type 1 diabetics, 68 type 2 diabetics and 70 controls included to the study. SCL-90-R [Symptom Check List-90 (Revised)] test is used for determining the psychiatric symptom rates.

RESULTS

It was found that the rate of somatization, interpersonal sensitivity, anger-hostility and additional scales were significantly different in type 1, type 2 diabetics and controls ((p = 0.023, p = 0.008, p = 0.018 and p = 0.039, respectively). Compared to control group, being a patient with type 1 or type 2 Diabetes found as a risk factor for somatization, depression, anger-hostility and additional scales. Moreover being a patient with type 1 DM was found as a risk factor for having OBS symptoms (p = 0.039) and type 1 DM was protective against having interpersonal sensitivity symptoms (p = 0.006).

CONCLUSION

In diabetic patient groups, an increase in the rate of psychiatric symptoms was observed. Therefore a careful psychiatric examination is required in DM.

Impact of Comorbid Chronic Conditions to Quality of Life among Elderly Patients with Diabetes Mellitus in Vietnam

Type 2 diabetes mellitus (T2DM) is a major cause of disease burden in the elderly population. This study aimed to measure the quality of life (QOL) among patients with T2DM and the associations between co-morbidities and QOL. A cross-sectional study was conducted on 194 patients with T2DM. The minimal clinically important difference (MCID) scores were used to indicate the clinically meaningful differences of comorbidities on quality of life. A Tobit regression was employed to find relationships between QOL and comorbidities. The mean scores of QOL domains were 50.8 (SD = 13.2) in physical, 62.4 (SD = 11.5) in psychological, 52.3 (SD = 10.2) in social relationship, and 64.3 (SD = 10.1) in environmental. Digestive and neuropsychiatric diseases had the strongest negative associations with physical QOL of patients. Neuropsychiatric diseases also had the biggest effect on psychological and environmental QOL. Meanwhile, in the social domain, respiratory diseases had the greatest effect. In conclusion, patients with T2DM struggled to perform physical functions. In addition, comorbidities significantly reduced the QOL of T2DM patients.

The relationship of Type 1 diabetes self-management barriers to child and parent quality of life: a US cross-sectional study

AIM

Families of children and adolescents with Type 1 diabetes experience self-management challenges that negatively impact diabetes control. This study assesses whether self-management challenges are also associated with quality of life (QOL) for children and adolescents with Type 1 diabetes and their parents.

METHODS

Children aged 8-12 years (n = 135), adolescents aged 13-16 years (n = 132) and their parents completed QOL assessments (diabetes-specific QOL from the PedsQL Diabetes Module or the Family Impact Module, both scaled 0-100) and a validated survey of up to six self-management barriers [PRISM; scaled 1 (low) to 5 (high)]. Regression coefficients were calculated to assess the association of self-management barriers with child and adolescent diabetes-specific QOL or parent QOL, including interaction effects to assess the stability of the associations.

RESULTS

Mean duration of diabetes was 4.7 years for children and 6.1 years for adolescents. The majority of children and adolescents did not meet target values for glycaemic control. All barriers but one (Healthcare Team Interactions) were associated with lower diabetes-specific QOL for children and adolescents, as well as lower QOL for parents (all P < 0.05). Barrier scores that were 1 unit higher were associated with diabetes-specific QOL that was 3.7-5.1 points lower for children and 5.8-8.8 points lower for adolescents, as well as QOL that was 6.0-12.6 points lower for parents. Diabetes-specific QOL was most strongly associated with 'Denial of Disease and Its Consequences' for children and with 'Regimen Pain and Bother' for adolescents. Parent QOL was most strongly associated with 'Understanding and Organizing Care'. Associations were stable across numerous demographic and disease factors.

CONCLUSIONS

Single-unit differences in self-management barrier scores are associated with clinically meaningful differences in QOL for children and parents. Interventions specifically tailored to address individual self-management barriers may improve both diabetes control and QOL.

Diabetes management mediating effects between diabetes symptoms and health-related quality of life in adolescents and young adults with type 1 diabetes

OBJECTIVES

The primary objective was to investigate the mediating effects of diabetes management in the relationship between diabetes symptoms and generic health-related quality of life (HRQOL) in adolescents and young adults (AYAs) with type 1 diabetes. The secondary objective explored patient health communication and perceived treatment adherence barriers as mediators in a serial multiple mediator model.

METHODS

The PedsQL 3.2 Diabetes Module 15-item diabetes symptoms summary score, 18-item diabetes management summary score, and PedsQL 4.0 generic core scales were completed in a 10-site national field test study by 418 AYA aged 13 to 25 years with type 1 diabetes. Diabetes symptoms and diabetes management were tested for bivariate and multivariate linear associations with overall generic HRQOL. Mediational analyses were conducted to test the hypothesized mediating effects of diabetes management as an intervening variable between diabetes symptoms and generic HRQOL.

RESULTS

The predictive effects of diabetes symptoms on HRQOL were mediated in part by diabetes management. In predictive analytics models utilizing multiple regression analyses, demographic and clinical covariates, diabetes symptoms, and diabetes management significantly accounted for 53% of the variance in generic HRQOL (P < 0.001), demonstrating a large effect size. Patient health communication and perceived treatment adherence barriers were significant mediators in an exploratory serial multiple mediator model.

CONCLUSIONS

Diabetes management explains in part the effects of diabetes symptoms on HRQOL in AYA with type 1 diabetes. Patient health communication to healthcare providers and perceived treatment adherence barriers further explain the mechanism in the relationship between diabetes symptoms and overall HRQOL.

PedsQL 3.2 Diabetes Module for Children, Adolescents, and Young Adults: Reliability and Validity in Type 1 Diabetes

OBJECTIVE

The objective of the study was to report on the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for children, adolescents, and young adults with type 1 diabetes.

RESEARCH DESIGN AND METHODS

The 33-item PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were completed in a 10-site national field test study by 656 families of patients ages 2-25 years with type 1 diabetes.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 18-item Diabetes Management Summary Score were derived from the factor analysis of the items. The Diabetes Symptoms and Diabetes Management Summary Scores evidenced excellent reliability (patient self-report α = 0.88-0.90; parent proxy report α = 0.89-0.90). The Diabetes Symptoms and Diabetes Management Summary Scores demonstrated construct validity through medium to large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.43-0.67, P < 0.001). HbA1c was significantly correlated with the Diabetes Symptoms and Diabetes Management Summary Scores (r = -0.21 to -0.29, P < 0.001). Minimal clinically important difference scores ranged from 5.05 to 5.55.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms and Diabetes Management Summary Scores demonstrated excellent measurement properties and may be useful as standardized patient-reported outcomes of diabetes symptoms and diabetes management in clinical research, clinical trials, and practice in children, adolescents, and young adults with type 1 diabetes.

Efficacy of the Flexible Lifestyles Empowering Change intervention on metabolic and psychosocial outcomes in adolescents with type 1 diabetes (FLEX): a randomised controlled trial

BACKGROUND

Adolescents with type 1 diabetes commonly have poor glycaemic control. We aimed to test the efficacy of a newly developed adaptive behavioral intervention (Flexible Lifestyles Empowering Change; FLEX) on metabolic and psychosocial outcomes in adolescents with type 1 diabetes.

METHODS

Young people (13-16 years, type 1 diabetes duration >1 year, HbA1c of 64-119 mmol/mol [8·0-13·0%], and without other serious medical conditions or pregnancy) from two clinical sites (Colorado and Ohio, USA) were eligible for enrolment. One caregiver was required to participate actively in the study. Adolescent participants were randomly assigned to the FLEX intervention, which used motivational interviewing and problem-solving skills training to enhance patients' self-management, or usual care control. Intervention fidelity was assessed by a behavioral psychologist with specific expertise in motivational interviewing and who was not otherwise involved in the study via audiotaped sessions. The primary outcome was measurement of glycated haemoglobin A1c (HbA1c) at 18 months. Secondary outcomes included motivation and intention, problem solving skills, self-management behaviors, symptoms of depression, health related quality of life, fear of hypoglycemia, diabetes family conflict, risk factors for T1D complications (BMI, blood pressure, and plasma lipids), and hypoglycemia derived from continuous glucose monitoring (percent time below 3·0 and 3·9 mmol/l [54 and 70 mg/dl]). Intention-to-treat analyses used mixed effects models, with fixed effects including site, timepoint, intervention group, intervention by timepoint, and baseline level of primary (HbA1c) or secondary outcomes (α=0·05). FLEX is registered on clinicaltrials.gov, number NCT01286350.

FINDINGS

Young people recruited from May 1, 2014 to April 4, 2016 were randomly assigned to FLEX (n=130) or usual care control (n=128). Mean diabetes duration was 6·4 (SD 3·8) years, and 71% (181 out of 256) of patients used insulin pump therapy. Retention was 93%, with 241 out of 258 completing the 18-month assessment. The intervention fidelity score was 4·40 of 5·00 for motivational interviewing and 97% for session content. At 18 months, HbA1c was not significantly different between intervention (83 [13] mmol/mol at baseline; 84 [19] mmol/mol at follow-up); and control (80 [14] mmol/mol at baseline; 82 [17] mmol/mol at follow-up); change in intervention versus control was -0·7 mmol/mol (95% CI -4·7 to 3·4, p=0·75). The intervention was associated with improved scores for motivation (p=0·011), problem solving (p=0·024), diabetes self-management profile (p=0·013), youth report of overall quality of life (p=0·0089), selected domains related to fear of hypoglycaemia (p=0·036 for youth's helplessness or worry; p=0·0051 for parent's efforts to maintain high blood glucose), parent report of diabetes family conflict (p=0·0001), total cholesterol (p=0·038), and diastolic blood pressure (p=0·015). A total of 54 serious adverse events were identified; 34 of these were diabetes-related, including low blood glucose requiring assistance (n=3) and high blood glucose with diabetic ketoacidosis and emergency response (n=25).

INTERPRETATION

The FLEX intervention did not significantly change HbA1c among these adolescents with elevated HbA1c, but did positively affect several psychosocial outcomes over 18 months. Further analyses will provide information regarding drivers of positive response to the intervention and will point to future directions for improvement in the approach.

FUNDING

National Institutes of Health and National Institute of Diabetes Digestive Diseases and Kidney and the Helmsley Charitable Trust.

Health-Related Quality of Life for Patients With Genetically Determined Leukoencephalopathy

BACKGROUND

We attempted to characterize the health-related quality of life in patients with genetically determined leukoencephalopathies as it relates to the severity of clinical features and the presence or absence of a precise molecular diagnosis.

METHODS

Health-related quality of life was assessed using the Pediatric Quality of Life Inventory model (Pediatric Quality of Life Inventory 4.0 Self- and Proxy-reports) on 59 patients diagnosed with genetically determined leukoencephalopathies. In total, 38 male and 21 female patients ranging from one to 32 years of age (mean nine years), as well as their parents, completed the Pediatric Quality of Life Inventory health-related quality of life measures. In addition, participants completed detailed standardized clinical assessments or questionnaires. The correlation between health-related quality of life results and the severity of the clinical features, as well as the presence or absence of a molecular diagnosis, were analyzed.

RESULTS

Patients with more severe clinical features showed statistically significant lower total Pediatric Quality of Life Inventory scores. More specifically, lower health-related quality of life was noted in children with sialorrhea, gastrostomy, and dystonia and in children who use a wheelchair.

CONCLUSIONS

Patients with more severe clinical features experience a lower quality of life. Our study further highlights the importance of addressing both physical and psychosocial issues and discussing perception of quality of life with both parents and children. A larger multicenter prospective study will be needed to further define the burden of these diseases and to identify modifiable factors.