Dyad and group-based interventions in physical activity, diet, and weight loss: a systematic review of the evidence

Studies show that interpersonal relations impact behavior change. Yet, a comprehensive review of their efficacy remains unclear. This systematic review examines the efficacy of dyadic and group-based studies that intervened on primary endpoints: diet, PA, and weight loss in adults and their networks. We searched five databases for eligible articles published from 1980 to present. Final inclusion and risk of bias were independently determined and agreed upon by two of the paper's co-authors. Nine dyads and twelve group-based studies were eligible. Of the studies, 36% (4/11) of PA studies, 60% (3/5) of diet studies and 57% (8/14) of studies with weight loss as primary outcomes, reported significant findings. Compared to dyadic interventions, a greater proportion of group-based interventions demonstrated efficacy in PA gain and weight loss as outcomes. Approximately 43% of studies demonstrated low to moderate methodological quality. This systematic review synthesized the evidence of dyadic and group studies that intervened on PA, diet, and weight in adults from the same network. Moderately-high risk of bias and lack of diverse representation restricts inferences around efficacy. High-quality rigorous research is needed to understand the efficacy of dyadic and group-based interventions in addressing these co-occurring endpoints of interest.

Vertebral Body Reshaping after Fractures: An Important Index of Recovery in Glucocorticoid-Treated Children

PURPOSE

In this 6-year study we identified factors associated with spontaneous vertebral body reshaping in glucocorticoid (GC)-treated children with leukemia, rheumatic disorders, and nephrotic syndrome.

METHODS

Subjects were 79 children (mean age 7.4 years) who had vertebral fracture (VF) evaluation on lateral spine radiographs at least 1 year after VF detection. VF were graded using the modified Genant semiquantitative method and fracture burden for individuals was quantified using the spinal deformity index (SDI; sum of grades from T4 to L4).

RESULTS

Sixty-five children (82.3%) underwent complete vertebral body reshaping (median time from VF detection to complete reshaping 1.3 years by Cox proportional hazard modeling). Of 237 VF, the majority (83.1%) ultimately reshaped, with 87.2% reshaping in the thoracic region vs 70.7% in the lumbar region (P = .004). Cox models showed that (1) every g/m2 increase in GC exposure in the first year after VF detection was associated with a 19% decline in the probability of reshaping; (2) each unit increase in the SDI at the time of VF detection was associated with a 19% decline in the probability of reshaping [hazard ratio (HR) = 0.81; 95% confidence interval (CI) = 0.71, 0.92; P = .001]; (3) each additional VF present at the time of VF detection reduced reshaping by 25% (HR = 0.75; 95% CI = 0.62, 0.90; P = .002); and (4) each higher grade of VF severity decreased reshaping by 65% (HR = 0.35; 95% CI = 0.21, 0.57; P < .001).

CONCLUSION

After experiencing a VF, children with higher GC exposure, higher SDI, more severe fractures, or lumbar VF were at increased risk for persistent vertebral deformity.

Multiomics atlas-assisted discovery of transcription factors enables specific cell state programming

The same types of cells can assume diverse states with varying functionalities. Effective cell therapy can be achieved by specifically driving a desirable cell state, which requires the elucidation of key transcription factors (TFs). Here, we integrated epigenomic and transcriptomic data at the systems level to identify TFs that define different CD8 + T cell states in an unbiased manner. These TF profiles can be used for cell state programming that aims to maximize the therapeutic potential of T cells. For example, T cells can be programmed to avoid a terminal exhaustion state (Tex Term ), a dysfunctional T cell state that is often found in tumors or chronic infections. However, Tex Term exhibits high similarity with the beneficial tissue-resident memory T states (T RM ) in terms of their locations and transcription profiles. Our bioinformatic analysis predicted Zscan20 , a novel TF, to be uniquely active in Tex Term . Consistently, Zscan20 knock-out thwarted the differentiation of Tex Term in vivo , but not that of T RM . Furthermore, perturbation of Zscan20 programs T cells into an effector-like state that confers superior tumor and virus control and synergizes with immune checkpoint therapy. We also identified Jdp2 and Nfil3 as powerful Tex Term drivers. In short, our multiomics-based approach discovered novel TFs that enhance anti-tumor immunity, and enable highly effective cell state programming.

One sentence summary

Multiomics atlas enables the systematic identification of cell-state specifying transcription factors for therapeutic cell state programming.

A Randomized Trial of Closed-Loop Insulin Delivery Postpartum in Type 1 Diabetes

OBJECTIVE

This study aimed to evaluate the efficacy of closed-loop insulin delivery postpartum.

RESEARCH DESIGN AND METHODS

In this open-label, randomized controlled trial, postpartum individuals with type 1 diabetes were randomized to hybrid closed-loop insulin delivery with the MiniMed 670G/770G system in automode or sensor-augmented pump therapy in the first 12-weeks postpartum followed by a continuation phase with closed-loop insulin delivery for all until 24 weeks postpartum.

RESULTS

Eighteen participants (mean ± SD age 32 ± 3.5 years, diabetes duration 22 ± 7.3 years, and early pregnancy HbA1c 52 ± 6.8 mmol/mol [6.9 ± 0.9%]) completed 24 weeks of postpartum follow-up. In the randomized phase, percent time in range 70-180 mg/dL (3.9-10 mmol/L) did not differ between groups (79.2 ± 8.7% vs. 78.2 ± 6.0%; P = 0.41). Participants randomized to closed-loop insulin delivery spent less time <70 mg/dL (3.9 mmol/L) and <54 mg/dL (3.0 mmol/L) (1.7 ± 0.8% vs. 5.5 ± 3.3% [P < 0.001] and 0.3 ± 0.2% vs. 1.1 ± 0.9% [P = 0.008]). Time >180 mg/dL (10 mmol/L) was not different between groups (18.7 ± 8.8% vs. 15.9 ± 7.7%; P = 0.21). In the continuation phase, those initially randomized to sensor-augmented pump therapy had less time <70 mg/dL after initiation of closed-loop insulin delivery (5.5 ± 3.3% vs. 3.3 ± 2.2%; P = 0.039). The closed-loop group maintained similar glycemic metrics in both study phases. There were no episodes of diabetic ketoacidosis or severe hypoglycemia in the randomized or continuation phase in either group.

CONCLUSIONS

Women randomized to closed-loop insulin delivery postpartum had less hypoglycemia than those randomized to sensor-augmented pump therapy. There were no safety concerns. These findings are reassuring for use of closed-loop insulin delivery postpartum because of its potential to reduce hypoglycemia.

Reported barriers to physical activity and the role of built environment among overweight and obese youth attending a Canadian pediatric weight management clinic

Objective

To assess activity levels and role of the built environment among overweight and obese youth referred to a pediatric weight management clinic.

Design

A cross-sectional study using a caregiver-administered survey was completed from October 2017 to February 2018.

Results

The study analyzed 210 surveys. Participants were 52 % male and average age was 11.6 years (3-18 years). Of those surveyed, 73 % of respondents reported ≥ 2 h of average daily screen time in the past 3 months, and 74 % of children partook in < 60 min of daily physical activity of any intensity. The most common location for physical activity was a recreational facility. The least common was nearby green spaces. Moreover, 77 % of caregivers felt that their child did not engage in enough physical activity, and the most common cited barrier was motivation. The built environment, however, was not cited as a barrier to active living as 90 % of caregivers reported their community was safe, and greater than 80 % of caregivers agreed their community was aesthetically beautiful, well connected with good infrastructure. The majority of commonly used spaces were located within 2 km of their home, however, it was uncommon for children to walk or bike to them.

Conclusion

Overweight and obese children referred to our clinic are not meeting national recommendations for physical activity and screen time. The built environment does not appear to be a large contributing factor to decreased physical activity in this population and the most common reason cited for lack of physical activity was motivation.

24-h ambulatory blood pressure readings and associations with albuminuria in youth with type 2 diabetes: A cross sectional analysis from the iCARE cohort

AIMS

To evaluate associations between 24-h ambulatory blood pressure monitor (ABPM) data vs. single casual blood pressure (BP) and albuminuria in youth with type 2 diabetes.

METHODS

A cross-sectional analysis of youth with type 2 diabetes 10-<18 yrs. from the iCARE cohort.

MAIN EXPOSURES

daytime HTN (+/- nocturnal), isolated nocturnal HTN and single casual BP.

MAIN OUTCOME

non-orthostatic urine albumin: creatinine ratio (ACR) ≥ 3 mg/mmol and log-transformed urine ACR. Regressions evaluated associations between 1. HTN status based on ABPM and log-transformed urine ACR (continuous) and 2. ABPM-derived BP z-scores and casual BPcentiles and albuminuria status (categorical).

RESULTS

Of 281 youth included, 19.6 % had daytime HTN (+/- nocturnal), and 28.5 % isolated nocturnal HTN on 24-h ABPM. In multivariate linear regression, HTN (ABPM) (ß = 0.553; p = 0.001), duration of diabetes (ß = 0.857; p = 0.02), HbA1c (ß = 1.172; p ≤0.0001) and ACEI/ARB use (ß = 3.94; p < 0.0001) were positively associated with log-transformed ACR; (R2 = 0.184). In logistic regression analysis, all ABPM LMS z-scores were positively associated with albuminuria; casual BPcentile was not significant.

CONCLUSIONS

Youth with type 2 diabetes have high rates of HTN based on 24-ABPM data. ABPM-derived measures of BP are associated with albuminuria. These data support the routine use of ABPM devices to diagnose hypertension in youth with type 2 diabetes.

Assessment of maternal knowledge of infant movement and nutrition guidelines in Canada: The survey study (hysical activity, est, xercise and nutrition alues for ducation of ew moms with ype 2 diabetes/gestational diabetes)

Infants born to mothers with type 2 diabetes (T2D) and gestational diabetes (GDM) are at an increased risk of being overweight/obese. Modifiable lifestyle factors play a role in prevention of overweight and obesity. In 2017, the Canadian 24 h Movement Guidelines for the Early Years (CMG) were released. Alongside physical activity recommendations, sweetened beverage consumption (SBC) recommendations were also released by the American Academy of Pediatrics in 2017. The objective of this study was to determine the knowledge pregnant women with T2D and GDM have on the CMG and SBC recommendations, and to determine what factors affect this. A survey with questions regarding demographics, socioeconomic variables and the CMG and SBC recommendations was administered to pregnant women at Diabetes in Pregnancy clinics in Calgary, Alberta from July 2019 to January 2020. Surveys were analyzed utilizing the non-parametric Kruskall-Wallis Rank-Sum test, chi-square test and linear regression. A total of 79 respondents with T2D and GDM were collected. Respondents had the highest knowledge of SBC recommendations and the lowest knowledge of CMG recommendations. A bachelor's or higher degree was associated with significantly higher knowledge scores than a high-school education or less. In conclusion, pregnant women with T2D and GDM in this study had overall poor knowledge of the CMG and SBC recommendations, with less knowledge regarding the CMG. Level of education was found to be associated with knowledge regarding these recommendations. Future programs to improve education around infant and toddler physical activity and SBC recommendations may be beneficial for this patient population.

Do Individual Characteristics and Social Support Increase Children's Use of an MHealth Intervention? Findings from the Evaluation of a Behavior Change MHealth App, Aim2Be

Purpose: Mobile health (mHealth) apps may support improved health behavior practice among youth living in larger bodies. However, long-term use is low, limiting effectiveness. This study evaluated whether youths' motivation, satisfaction, engagement with social features, or parent co-participation supported long-term use of an app named Aim2Be. Methods: A secondary analysis of two versions of Aim2Be (preteen and teen versions) using covariate-adjusted multivariable regression was conducted. We evaluated associations between social support features (a virtual coach, a social poll, or a social wall), parent co-participation (time spent in the parent app), and app satisfaction on use (time spent in Aim2Be). Models were stratified by age and satisfaction was explored as a moderator. Results: Preteens (n = 83) engagement with the social poll (β = 0.26, p < 0.001), virtual health coach (β = 0.24, p = 0.01), app satisfaction (β = 0.31, p = 0.01), and parent co-participation (β = 0.24, p = 0.01) predicted use. In teens (n = 90), engagement with the virtual coach (β = 0.31, p < 0.001) and full utilization of social wall features (β = 0.41, p < 0.001) predicted use. Furthermore, satisfaction moderated the effects of partial utilization of the social wall among teens (β = 0.32 p = 0.02). Conclusion: Social support in mHealth apps may impact users differently depending on age. Features that include health professionals or peers may be more advantageous across ages. App developers should consider age when designing interventions. Clinical Trial Registration NCT03651284.

Recruiting families using social media versus pediatric obesity clinics: A secondary analysis of the Aim2Be RCT

BACKGROUND

Recruitment of participants continues to be a challenge that researchers must overcome to yield successful study results. Over the past decade, there has been a dramatic increase in the use of social media platforms to recruit research participants. We conducted a secondary analysis of the Aim2Be randomized controlled trial (RCT) to examine if there was variability between participants recruited via social media versus pediatric obesity clinics.

METHODS

Parents and their children living with overweight or obesity were recruited through social media (i.e., Facebook advertisements) (n = 119) or pediatric obesity management clinics (n = 95) to participate in the Aim2Be RCT. We compared recruitment costs, recruitment rate, participant retention, intervention engagement, obesity-related risk factors, and behavioral habits.

RESULTS

Facebook recruitment resulted in more participant contacts, but higher attrition during 'high effort' stages of the recruitment process. Group differences emerged regarding costs (Facebook: $407 versus clinics: $699). There were no group differences in participant retention or intervention engagement. Families recruited from Facebook were younger parents (42.6 versus 46.0 years; p < 0.001) and children (12.2 versus 13.9 years; p < 0.001), a higher percentage male children, and fewer had previously participated in a pediatric weight management program. Parents recruited from Facebook self-reported greater screen time for themselves, and their children reported lower physical activity levels and higher caloric and sugar intake.

CONCLUSIONS

Social media and clinical site recruitment are complementary strategies that appear to draw in families with different profiles, but regardless of how they were recruited, all families had the potential to benefit from pediatric obesity management.

Adolescent and Caregiver Perspectives on Family Navigation to Improve Healthcare Access and Use for Managing Pediatric Obesity

We interviewed families to explore their views on the role of family navigation (FN) to improve access to and use of health services for managing pediatric obesity. From March to December, 2020, we conducted individual, structured telephone interviews with adolescents with obesity (13-17 years old) and their caregivers from Edmonton and Calgary, Canada. Among our 37 participants (14 adolescents, 23 caregivers), most (n = 27; 73.0%) reported FN could improve their access to obesity management. Participants recommended several activities to support healthcare access and use, including appointment reminders, evening/weekend appointments, parking/transportation support, and in-clinic childcare, all of which help families to attend appointments over an extended period to support obesity management. Most participants preferred FN be offered by healthcare professional 'navigators' who were approachable, empathic, and compassionate since issues regarding health and obesity can be sensitive, emotional topics to discuss. Overall, families supported integrating FN into multidisciplinary pediatric obesity management to improve healthcare access and use by navigators who apply a range of practical strategies and relational skills to enhance long-term access and adherence to care.

Reductions in Bone Mineral Density Are Apparent Early in Children With Prevalent Osteonecrosis Lesions Following Leukemia Therapy

Osteonecrosis (ON) is a serious complication of childhood acute lymphoblastic leukemia. We determined the prevalence of osteonecrotic lesions in our patient population by a one-time multisite magnetic resonance imaging (MRI) more than 1 year following leukemia therapy. MRI findings were evaluated in relationship to clinical factors (including longitudinal changes in bone mineral density [BMD]). Eighty-six children enrolled in the Steroid Associated Osteoporosis in the Pediatric Population (STOPP) study were evaluated for ON at 3.1 ± 1.3 years following therapy. Thirty children had a total of 150 confirmed ON lesions (35%). Lumbar spine (LS) BMD Z-scores (mean ± SD) were low at diagnosis and similar between patients with and without ON (-1.09 ± 1.53 versus -1.27 ± 1.25, p = 0.549). LS BMD Z-scores declined from baseline to 12 months in children with ON (-0.31 ± 1.02) but not in those without (0.13 ± 0.82, p = 0.035); the hip BMD Z-scores from baseline to 24 months declined in both groups, but to a greater extent in those with ON (-1.77 ± 1.22) compared to those without (-1.03 ± 1.07, p = 0.045). At the time of the MRI, mean total hip and total body (TB) BMD Z-scores were lower in children with ON (hip -0.98 ± 0.95 versus -0.28 ± 1.06, p = 0.010; TB -1.36 ± 1.10 versus -0.48 ± 1.50, p = 0.018). Pain occurred in 11/30 (37%) with ON versus 20/56 (36%) without, p = 0.841. In multivariable models, older age at diagnosis (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.15-2.13; p = 0.004), and hip BMD Z-score at MRI (OR 2.23; 95% CI, 1.02-4.87; p = 0.046) were independently associated with ON. Overall, one-third of children demonstrated ON after leukemia therapy. Those with ON had greater reductions in spine and hip BMD Z-scores in the first 1 and 2 years of therapy, respectively. Older age and lower hip BMD Z-scores at MRI were significantly associated with prevalent, off-therapy ON. These data assist in identifying children at risk of ON. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Severe obesity and global developmental delay in preschool children: Findings from a Canadian Paediatric Surveillance Program study

Background

The co-presentation of severe obesity (SO) and global developmental delay (GDD) in Canadian preschool children has not been examined. However, SO and GDD may require syndromic diagnoses and unique management considerations.

Objectives

To determine (1) minimum incidence; (2) age of onset and risk factors; and (3) health care utilization for co-presenting SO and GDD.

Methods

Through the Canadian Paediatric Surveillance Program (CPSP), a monthly form was distributed to participants from February 2018 to January 2020 asking for reports of new cases of SO and GDD among children ≤5 years of age. We performed descriptive statistics for quantitative questions and qualitative content analysis for open-ended questions.

Results

Forty-seven cases (64% male; 51% white; mean age: 3.5 ± 1.2 years) were included. Age of first weight concern was 2.5 ± 1.3 years and age of GDD diagnosis was 2.7 ± 1.4 years. Minimum incidence of SO and GDD was 3.3 cases per 100,000 for ≤5 years of age per year. Identified problems included school and/or behavioural problems (n = 17; 36%), snoring (n = 14; 30%), and asthma/recurrent wheeze (n = 10; 21%). Mothers of 32% of cases (n = 15) had obesity and 21% of cases (n = 10) received neonatal intensive care. Microarray was ordered for 57% (n = 27) of children. A variety of clinicians and services were accessed. As reported by CPSP participants, challenges faced by families and health service access were barriers to care.

Conclusion

Children with SO and GDD have multiple comorbidities, and require early identification and referral to appropriate services. These cases may also benefit from additional testing to rule out known genetic obesity syndromes.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

A multi-centre retrospective study of Nocardia speciation and antimicrobial susceptibility in Queensland, Australia

The study aims to characterise the species identification and antimicrobial susceptibility testing (AST) results of Nocardial isolates from adult patients across major public hospitals in Queensland, Australia, over a 15-year period. A multi-centre retrospective observational study of Nocardia sp. isolates was conducted from 7 major public hospitals in Queensland, Australia, over a 15-year period. Clinical samples from patients aged ≥ 18 years that isolated Nocardia sp. were included. Demographic and clinical data were collected, along with species identification and AST results. Overall, 484 Nocardia sp. were isolated. Most patients were male (297, 61%) with a mean (IQR) age of 60 (51-75) and a median (IQR) Charlson Comorbidity Index of 4 (2-6). Of these, 239 (49%) patients were immunosuppressed. Organisms were most frequently isolated from sputum (174, 36%), and superficial swabs (102, 21%). Patients presented with pulmonary infections (165, 35%) and superficial skin and soft tissue infections (87, 18%) most commonly. One hundred (21%) isolates were deemed pulmonary colonisation and were not treated. Of the speciated organisms, N. nova complex was the most common (93, 19%), followed by N. farcinica complex (79, 16%). Organisms were reliably susceptible to linezolid (240/245, 98%), amikacin (455/470, 97%), and trimethoprim/sulfamethoxazole (459/476, 96%), but less so to imipenem (243/472, 51%) and ceftriaxone (261/448, 58%). This is the largest Australian description of Nocardia sp. to date. Given antimicrobials are often commenced prior to AST results and sometimes even speciation, characterisation of local species and antibiogram data is important to guide empiric choices and local guidelines.

Sodium nitrite poisoning: A series of 20 fatalities in which post-mortem blood nitrite and nitrate concentrations are reported

Sodium nitrite has several industrial applications however its accidental or intentional ingestion has been associated with severe toxicity and death. We present a series of 20 cases over 2 years in which evidence of sodium nitrite ingestion was found at the scene and supported by biochemical analysis of post-mortem blood nitrite and nitrate levels. Routine toxicological screening was performed on post-mortem blood samples received at University Hospitals of Leicester (UHL) NHS Trust, including ethanol analysis by headspace gas chromatography-flame ionisation detection (HS GC-FID), drug screening by high resolution accurate mass-mass spectrometry (HRAM-MS) and confirmatory drug quantitation by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cases in which the history indicated the possibility of nitrite salts present at the scene, purchase of a suicide kit or a dusky-ash appearance of skin on post-mortem were referred to a specialist laboratory for nitrite and nitrate analysis. Analysis was based upon the gas-phase chemiluminescent reaction between nitric oxide (NO) and ozone; NO levels were determined using an NOA 280A, Sievers NO analyser. Twenty post-mortem cases in which sodium nitrite ingestion was the most probable cause of death were reported between January 2020 and February 2022; mean age was 31 years (range 14-49) with 9/20 (45%) female. 16/20 (80%) of cases had a history of depression and / or mental health issues. In half of the cases, anti-depressant / anti-psychotic drugs were prescribed; these drugs were detected in 8/20 (40%) cases. Ethanol was detected in 4/20 (20%) cases and anti-emetic drugs in 7/20 (35%) cases; anti-emetic drugs may be used to aid retention of sodium nitrite. Illicit drugs (amphetamine, cannabis and cocaine) were present in 3/20 cases (15%). Nitrite was found to be elevated in all but one case (95%), and nitrate was elevated in 17/20 (85%) cases. This paper highlights a surge in numbers of deaths across England and Wales due to sodium nitrite toxicity. Although, nitrite poisoning remains a rare cause of death, it is worthwhile considering its use in individuals with suicidal ideation given its unregulated availability online. The detection and quantitation of nitrite and nitrate requires specialised, highly reliable methodology currently only available in research laboratories. Implication of sodium nitrite ingestion also relies heavily upon circumstantial evidence combined with quantification. The provision of a quantitative nitrite / nitrate analytical service greatly assists in determining the cause of death in these cases.

A multi-center, randomized, 12-month, parallel-group, feasibility study to assess the acceptability and preliminary impact of family navigation plus usual care versus usual care on attrition in managing pediatric obesity: a study protocol

BACKGROUND

Pediatric obesity management can be successful, but some families discontinue care prematurely (i.e., attrition), limiting treatment impact. Attrition is often a consequence of barriers and constraints that limit families' access to obesity management. Family Navigation (FN) can improve access, satisfaction with care, and treatment outcomes in diverse areas of healthcare. To help our team prepare for a future effectiveness trial, the objectives of our randomized feasibility study are to (i) explore children's and caregivers' acceptability of FN and (ii) examine attrition, measures of study rigor and conduct, and responses to FN + Usual Care vs Usual Care by collecting clinical, health services, and health economic data.

METHODS

In our 2.5-year study, 108 6-17-year-olds with obesity and their caregivers will be randomized (1:1) to FN + Usual Care or Usual Care after they enroll in obesity management clinics in Calgary and Mississauga, Canada. Our Stakeholder Steering Committee and research team will use Experience-Based Co-Design to design and refine our FN intervention to reduce families' barriers to care, maximizing the intervention dose families receive. FN will be delivered by a navigator at each site who will use logistical and relational strategies to enhance access to care, supplementing obesity management. Usual Care will be offered similarly at both clinics, adhering to expert guidelines. At enrollment, families will complete a multidisciplinary assessment, then meet regularly with a multidisciplinary team of clinicians for obesity management. Over 12 months, both FN and Usual Care will be delivered virtually and/or in-person, pandemic permitting. Data will be collected at 0, 3, 6, and 12 months post-baseline. We will explore child and caregiver perceptions of FN acceptability as well as evaluate attrition, recruitment, enrolment, randomization, and protocol integrity against pre-set success thresholds. Data on clinical, health services, and health economic outcomes will be collected using established protocols. Qualitative data analysis will apply thematic analysis; quantitative data analysis will be descriptive.

DISCUSSION

Our trial will assess the feasibility of FN to address attrition in managing pediatric obesity. Study data will inform a future effectiveness trial, which will be designed to test whether FN reduces attrition.

TRIAL REGISTRATION

This trial was registered prospectively at ClinicalTrials.gov (# NCT05403658 ; first posted: June 3, 2022).

Risk factors associated with prevalent vertebral fractures in Duchenne muscular dystrophy

Patients with Duchenne muscular dystrophy (DMD) have a high fracture burden due to progressive myopathy and steroid-induced osteoporosis. This study in males with DMD showed that markers of systemic glucocorticoid exposure including shorter stature, greater bone age delay, and lower lumbar spine bone mineral density were associated with spine fragility.

INTRODUCTION

Fragility  fractures are frequent in DMD. The purpose of this study was to identify clinical factors associated with prevalent vertebral fractures (VF) in boys, teens/young adults with Duchenne muscular dystrophy (DMD).

METHODS

This was a cross-sectional study of males aged 4-25 years with DMD. VF were evaluated using the modified Genant semi-quantitative method on T4-L4 lateral spine radiographs. Areal bone mineral density (aBMD) was measured at the lumbar spine (LS) and used to estimate volumetric BMD (vBMD). Clinical factors were analyzed for their association with the Spinal Deformity Index (SDI, the sum of the Genant grades).

RESULTS

Sixty participants were enrolled (mean age 11.5 years, range 5.4-19.5). Nineteen participants (32%) had a total of 67 VF; 23/67 VF (34%) were moderate or severe. Participants with VF were shorter (mean height Z-score ± standard deviation: - 3.1 ± 1.4 vs. - 1.8 ± 1.4, p = 0.001), had longer glucocorticoid exposure (mean duration 6.0 ± 3.3 vs. 3.9 ± 3.3 years, p = 0.027), greater bone age (BA) delay (mean BA to chronological age difference - 3.2 ± 3.4 vs. - 1.3 ± 1.2 years, p = 0.035), and lower LSaBMD Z-scores (mean - 3.0 ± 1.0 vs. - 2.2 ± 1.2, p = 0.023). There was no difference in LSvBMD Z-scores. Multivariable Poisson regression showed that every 0.1 mg/kg/day increment in average glucocorticoid daily dose was associated with a 1.4-fold SDI increase (95% confidence interval: 1.1-1.7, p = 0.013). Greater BA delay (p < 0.001), higher weight Z-score (p = 0.004), decreased height Z-score (p = 0.025), and lower LSvBMD Z-score (p = 0.025) were also associated with SDI increase.

CONCLUSION

Readily measurable clinical variables were associated with prevalent VF in males with glucocorticoid-treated DMD. These variables may be useful to identify candidates for primary osteoporosis prevention after glucocorticoid initiation.

The effect of building-level socioeconomic status on bystander cardiopulmonary resuscitation: a retrospective cohort study

Background/Introduction

In out-of-hospital cardiac arrest (OHCA), bystander cardiopulmonary resuscitation (BCPR) increases survival [1]. Understanding the social determinants of BCPR receipt can inform the design of public health interventions to increase BCPR. The association of socioeconomic status (SES) with BCPR is generally poorly understood.

Purpose

We aimed to evaluate the effect of SES on BCPR in OHCA using a building-level SES marker.

Methods

This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry, an ongoing long-term prospective registry for OHCA in the Asia-Pacific region, between 2010 to 2018. We categorized patients into low, medium and high Singapore Housing Index (SHI) levels. The SHI, which appraises a residential property value on an ordinal scale of 1 to 7 (low to high), is a building-level marker that has a robust association with income and residence value [2]. The primary outcome was receipt of BCPR. The secondary outcomes were pre-hospital return of spontaneous circulation (ROSC) and survival – defined as survival to 30 days or hospital discharge, whichever occurred first.

Results

A total of 12,730 OHCA cases were included (Figure 1), the median age was 71 years and 58.9% were male. BCPR rate was 56.7%. OHCA patients in the low SHI tier were the youngest, most likely male, and least likely to have any medical co-morbidities (Table 1). Compared the low SHI category, those in the medium and high SHI categories were more likely to receive BCPR (medium SHI: adjusted odds ratio [aOR] 1.483, 95% CI 1.301–1.691, p&lt;0.01; high SHI: aOR 1.933, 95% CI 1.669–2.240, p&lt;0.01). As a continuous variable, every unit increase in SHI was associated with increased BCPR (aOR 1.142, 95% CI 1.110–1.174, p&lt;0.001). High SHI patients had higher survival compared to low SHI patients on unadjusted analysis (OR 1.789, 95% CI 1.080–2.964) but not adjusted analysis (adjusted for age, sex, race, witness status, arrest time, past medical history of cancer, and first arrest rhythm). There were no significant differences in the proportion of ROSC across three categories of SHI (p=0.426). When comparing high with low SHI, females had larger increases in BCPR rates compared to males (ratio of OR 1.370, 95% CI 1.012–1.853). There were no significant associations between SHI and BCPR in the subgroups age ≥65 years, witnessed arrest, daytime arrest, and arrests after 2014, and no interaction effects were observed.

Conclusions

Lower building-level SES was independently associated with lower rate of BCPR. Higher SES was associated with higher 30-day survival on unadjusted analysis but not adjusted analysis, and this study may be under-powered for this outcome. Females were more susceptible to the effect of low SES on lower rate of BCPR, and community CPR training should focus on recognizing OHCA and performing BCPR in women in low SES communities.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council, Clinician Scientist Awards, Singapore (NMRC/CSA/024/2010, NMRC/CSA/0049/2013 and NMRC/CSA-SI/0014/2017) and Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012).

QTc interval in anorexia nervosa: a systematic review and meta-analysis

Background

Patients with anorexia nervosa (AN) are at higher risk of sudden cardiac death. Although the underlying aetiology for this association remains unclear. It may be related to prolongation of the QT interval, which can degenerate into fatal ventricular arrhythmias. However, the presence of prolonged heart rate-corrected QT interval (QTc) in AN remains controversial, and two previous meta-analyses on AN and QTc showed contradictory findings [1,2].

Purpose

In this systematic review and meta-analysis, we aimed to evaluate if AN was associated with changes in the QTc interval and dispersion.

Methods

MEDLINE, EMBASE and COCHRANE databases were systematically searched from inception to January 2021. Random-effects meta-analysis and meta-regression were used. The inclusion criteria were (i) confirmed diagnosis of AN, (ii) measurement of QTc on electrocardiogram and (iii) peer-reviewed articles. The primary endpoint of the study was the duration of the QTc interval calculated using the Bazett (QTcB), Hodges (QTcH), Fridericia (QTcF) and Framingham (QTcFr) formulae. The secondary endpoints were QT dispersion (QTd) and QTc dispersion (QTcd).

Results

The 25 eligible studies included 5687 patients (1862 AN, 3825 control) (Figure 1: PRISMA diagram). The majority of patients were female (96.3%) with a mean age between 14.3 to 31.0 years and mean duration of disease ranging from 9.1 to 129.6 months. The mean BMI ranged from 13.7 to 18.5 kg/m2. Pooled analysis did not show significant prolongation between AN versus control in QTcB (mean difference (MD) MD 4.9ms, 95% CI −3.2, 13.1ms, p=0.23; I2=95%; n=24/25 studies; Figure 2A), QTcH (MD 1.3ms, 95% CI −8.5, 11.2ms, p=0.79; I2=71%; n=3/25 studies), and QTcF (MD 3.1ms, 95% CI −21.6, 27.7ms, p=0.81; I2=97%; n=3/25 studies). Only two studies reporting QTcFr showed a significant prolongation between AN and control (MD 15.9ms, 95% CI 0.0, 31.8ms, p=0.05, I2=65%; n=2/25 studies; Figure 2B). However, QTd and QTcd were significantly greater in AN than control (MD 21.3ms, 95% CI 10.4, 32.3ms, p=0.0001, I2=94%; Figure 2C and MD 16.9ms, 95% CI 4.5, 29.3ms, p=0.007 I2=93%; Figure 2D, respectively).

Conclusion

To the best of our knowledge, this is the largest meta-analysis of QTc in AN and the first meta-analysis exploring the significance of QTd and QTcd in AN. AN was not found to be associated with prolongation of QTc calculated using the Bazett, Fridericia and Hodges formulae. However, an association of AN with prolonged QTc was observed in the studies using the Framingham formula. More pronounced dispersion (QTd and QTcd) was also observed in patients with AN.

Funding Acknowledgement

Type of funding sources: None.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

P-696 Serum androgen levels and risk of endometrial hyperplasia and malignancy in patients with polycystic ovarian syndrome: a cross-sectional analysis

Study question

In patients with polycystic ovarian syndrome (PCOS), are serum androgen levels (total and free testosterone) associated with the risk of endometrial hyperplasia or cancer?

Summary answer

Patients with PCOS diagnosed with endometrial hyperplasia or cancer had statistically significantly lower serum levels of androgens compared to PCOS patients with a normal endometrium.

What is known already

PCOS affects as many as 12% of women of reproductive age. Women with PCOS are almost three times as likely to develop endometrial cancer as women without PCOS, and endometrial hyperplasia precedes cancer in 36% of cases. Known risk factors of endometrial hyperplasia include anovulation, obesity, and resultant unopposed estrogen stimulation of the endometrium. A hallmark of PCOS is hyperandrogenism, however the effect of androgens on the endometrium is unclear.

Study design, size, duration

This was a cross-sectional, retrospective study of patients aged 18-40, being evaluated for oligomenorrhea and/or PCOS in the Reproductive Endocrinology Clinic at Los Angeles County Hospital, California, USA. All patients underwent an endometrial biopsy and serum measurement of free and total testosterone, estradiol, and hemoglobin A1c. Patients diagnosed with PCOS and with an endometrial biopsy diagnosis were included in the study. Patients on any hormonal therapy were excluded.

Participants/materials, setting, methods

In all patients included in the study, serum androgen levels (free and total testosterone) were measured by mass spectrometry. All endometrial biopsies were analyzed by an experienced histopathology, and all diagnoses of endometrial hyperplasia or cancer were confirmed by histologic studies.

Main results and the role of chance

Using the Rotterdam criteria, a total of 232 patients were diagnosed with PCOS during the study period. Of these patients, 161 patients (70%) had a normal endometrium, 19 (8%) were diagnosed with endometrial hyperplasia (EH) without atypia, 38 (16%) were diagnosed with EH with atypia, and 14 (6%) were diagnosed with endometrial cancer. Patients with a normal endometrium had a mean total testosterone of 60.9 ng/dL and mean free testosterone of 9.3 ng/dL. Relatively, patients with EH without atypia, EH with atypia, and endometrial cancer had lower mean total testosterone levels of 50.1 ng/dL, 45.5 ng/dL, and 30.1 ng/dL, respectively (p-values 0.04, 0.02, 0.001, respectively), as well as lower mean free testosterone levels of 8.2 pg/mL, 6.7 pg/mL, and 5.5 pg/mL, respectively (p-values 0.04, 0.03, and 0.01, respectively). There was no significant difference in age, parity, BMI, estradiol levels, or hemoglobin A1c between the four groups.

Limitations, reasons for caution

Limitations of our study include its retrospective nature. Furthermore, hormone levels were only measured in the serum, and not in the endometrial tissue directly, which would give the most insight into their actions on the endometrium.

Wider implications of the findings

Our findings suggest that androgens have a protective effect on the endometrium against endometrial hyperplasia and cancer. Further studies are needed to evaluate the therapeutic potential role of androgens in the prevention or treatment of these conditions.

Trial registration number

not applicable

The Aim2Be mHealth Intervention for Children With Overweight or Obesity and Their Parents: Person-Centered Analyses to Uncover Digital Phenotypes

Background

Despite the growing number of mobile health (mHealth) interventions targeting childhood obesity, few studies have characterized user typologies derived from individuals’ patterns of interactions with specific app features (digital phenotypes).

Objective

This study aims to identify digital phenotypes among 214 parent-child dyads who used the Aim2Be mHealth app as part of a randomized controlled trial conducted between 2019 and 2020, and explores whether participants’ characteristics and health outcomes differed across phenotypes.

Methods

Latent class analysis was used to identify distinct parent and child phenotypes based on their use of the app’s behavioral, gamified, and social features over 3 months. Multinomial logistic regression models were used to assess whether the phenotypes differed by demographic characteristics. Covariate-adjusted mixed-effect models evaluated changes in BMI z scores (zBMI), diet, physical activity, and screen time across phenotypes.

Results

Among parents, 5 digital phenotypes were identified: socially engaged (35/214, 16.3%), independently engaged (18/214, 8.4%) (socially and independently engaged parents are those who used mainly the social or the behavioral features of the app, respectively), fully engaged (26/214, 12.1%), partially engaged (32/214, 15%), and unengaged (103/214, 48.1%) users. Married parents were more likely to be fully engaged than independently engaged (P=.02) or unengaged (P=.01) users. Socially engaged parents were older than fully engaged (P=.02) and unengaged (P=.01) parents. The latent class analysis revealed 4 phenotypes among children: fully engaged (32/214, 15%), partially engaged (61/214, 28.5%), dabblers (42/214, 19.6%), and unengaged (79/214, 36.9%) users. Fully engaged children were younger than dabblers (P=.04) and unengaged (P=.003) children. Dabblers lived in higher-income households than fully and partially engaged children (P=.03 and P=.047, respectively). Fully engaged children were more likely to have fully engaged (P<.001) and partially engaged (P<.001) parents than unengaged children. Compared with unengaged children, fully and partially engaged children had decreased total sugar (P=.006 and P=.004, respectively) and energy intake (P=.03 and P=.04, respectively) after 3 months of app use. Partially engaged children also had decreased sugary beverage intake compared with unengaged children (P=.03). Similarly, children with fully engaged parents had decreased zBMI, whereas children with unengaged parents had increased zBMI over time (P=.005). Finally, children with independently engaged parents had decreased caloric intake, whereas children with unengaged parents had increased caloric intake over time (P=.02).

Conclusions

Full parent-child engagement is critical for the success of mHealth interventions. Further research is needed to understand program design elements that can affect participants’ engagement in supporting behavior change.

Trial Registration

ClinicalTrials.gov NCT03651284; https://clinicaltrials.gov/ct2/show/NCT03651284

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-4080-2

Re-referring Children for Multidisciplinary Obesity Management

OBJECTIVES

To examine characteristics of children referred for obesity management based on referral frequency, child- and referrer-related variables associated with re-referral, and determine whether re-referral increased treatment initiation.

STUDY DESIGN

This population-level, retrospective analysis included all 2- to 17-year-olds referred for obesity management to 1 of 3 multidisciplinary clinics in Alberta, Canada between April 2013 and December 2017. Children were dichotomized based on referral frequency, specifically once only or more than once (re-referred). Data were retrieved from standardized referral forms and patient registries. Analyses included logistic regression and generalized estimating equations models.

RESULT

We analyzed data from 2745 children (47.2% female; mean age: 11.4 years; mean body mass index z score: 3.03) and 2705 physicians (60.2% female; 65.6% pediatricians). Overall, 300 (10.2%) children were re-referred with most (n = 276; 92.0%) being referred twice. Children were less likely to be re-referred if they were referred by a family physician (vs pediatrician) (aOR 0.62; 95% CI 0.46-0.84; P = .0018) or scheduled a clinic appointment following their index referral (aOR: 0.29; 95% CI 0.21-0.4; P < .001). Treatment initiation was higher in children who were referred once only (42.1%) vs their re-referred peers (18.0%; P < .0001); however, for children who were re-referred, they were more likely to initiate treatment following their second referral (aOR 2.3; 95% CI 1.22-4.31; P = .01). This improvement was not sustained on subsequent referrals (aOR 0.44; 95% CI 0.17-1.12; P = .08).

CONCLUSIONS

Few children were re-referred for pediatric obesity management; however, for those children who were re-referred, being re-referred once only increased the likelihood of treatment initiation.

Efficacy of the Aim2Be intervention in changing lifestyle behaviours among adolescents with overweight and obesity: A Randomized Controlled Trial (Preprint)

BACKGROUND

Aim2Be is a gamified lifestyle app designed to promote lifestyle behavior changes among Canadian adolescents and their families.

OBJECTIVE

The primary aim was to test the efficacy of the Aim2Be app with support from a live coach to reduce weight outcomes (BMI Z score [zBMI]) and improve lifestyle behaviors among adolescents with overweight and obesity and their parents versus a waitlist control group over 3 months. The secondary aim was to compare health trajectories among waitlist control participants over 6 months (before and after receiving access to the app), assess whether support from a live coach enhanced intervention impact, and evaluate whether the app use influenced changes among intervention participants.

METHODS

A 2-arm parallel randomized controlled trial was conducted from November 2018 to June 2020. Adolescents aged 10 to 17 years with overweight or obesity and their parents were randomized into an intervention group (Aim2Be with a live coach for 6 months) or a waitlist control group (Aim2Be with no live coach; accessed after 3 months). Adolescents' assessments at baseline and at 3 and 6 months included measured height and weight, 24-hour dietary recalls, and daily step counts measured with a Fitbit. Data on self-reported physical activity, screen time, fruit and vegetable intake, and sugary beverage intake of adolescents and parents were also collected.

RESULTS

A total of 214 parent-child participants were randomized. In our primary analyses, there were no significant differences in zBMI or any of the health behaviors between the intervention and control groups at 3 months. In our secondary analyses, among waitlist control participants, zBMI (P=.02), discretionary calories (P=.03), and physical activity outside of school (P=.001) declined, whereas daily screen time increased (P<.001) after receiving access to the app compared with before receiving app access. Adolescents randomized to Aim2Be with live coaching reported more time being active outside of school compared with adolescents who used Aim2Be with no coaching over 3 months (P=.001). App use did not modify any changes in outcomes among adolescents in the intervention group.

CONCLUSIONS

The Aim2Be intervention did not improve zBMI and lifestyle behaviors in adolescents with overweight and obesity compared with the waitlist control group over 3 months. Future studies should explore the potential mediators of changes in zBMI and lifestyle behaviors as well as predictors of engagement.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03651284; https://clinicaltrials.gov/ct2/show/study/NCT03651284.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-4080-2.

162 A Closed Loop Audit Assessing and Improving the Quality of Electronic Discharge Documents in a Neurosurgical Ward for Patient Safety and Continuity of Care

Aim

To assess the quality of neurosurgical electronic discharge documents (EDDs) as per the Scottish Intercollegiate Guidelines Network's (SIGN) discharge document guidelines, and to implement interventions to ensure patient safety and continuity of care.

Method

We performed a closed loop audit on the quality of EDDs at the neurosurgical unit at Ninewells Hospital. We collected six sets of two-weeks’ worth of EDDs from the Tayside EDD system coinciding with foundation trainee changeover times for a representative sample of pre- and intra-COVID-19 EDDs. We analysed our findings and developed interventions in collaboration with the MDT. These included a copy-paste template, educational poster, and presentation, and more. We implemented the interventions and reassessed EDDs after three months.

Results

A total of 207 EDDs were included. Pre-interventions, 88% of the EDDs were inadequate in quality when compared to SIGN’s guidelines. This had 33% reduction post-interventions. The percentage of EDDs adequate in quality doubled post-interventions, from 22% to 43%. The most commonly mistaken or missed criterion pre- and post-intervention was the neurological status on admission and discharge. Others were mistaking presenting complaint for diagnosis and vice versa, and not mentioning follow-up or new medications.

Conclusions

Accurate records of care, including discharge documents, are central to the principles of good medical practice outlined by the GMC. This study showed that EDD quality is compromised due to time pressures, lack of information and constant changeover due to COVID-19. We alleviated this by creating accessible interventions that assure safe patient care despite the challenges of changeover and COVID-19.

Metabolically healthy obesity in children enrolled in the CANadian Pediatric Weight management Registry (CANPWR): An exploratory secondary analysis of baseline data

Our study purpose was to determine the prevalence of metabolically healthy obesity (MHO) and examine factors associated with MHO in children with obesity. This cross-sectional study was a secondary, exploratory analysis of data that included 2-17 years old with a body mass index (BMI) ≥85th percentile from the CANadian Pediatric Weight management Registry. Children were classified as having MHO or metabolically unhealthy obesity (MUO) using consensus-based criteria. Those with MHO had normal triglycerides, high-density lipoprotein cholesterol, blood pressure, and fasting glucose. Logistic regression was used to examine factors associated with MHO, which included calculating odds ratios (ORs) and 95% confidence intervals (CIs). In total, 945 children were included (mean age: 12.3 years; 51% female). The prevalence of MHO was 31% (n = 297), with lower levels across increasing age categories (2-5 years [n = 18; 43%], 6-11 years [n = 127; 35%], 12-17 years [n = 152; 28%]). Children with MHO were younger, weighed less, and had lower BMI z-scores than their peers with MUO (all p < 0.01). MHO status was positively associated with physical activity (OR: 1.18; 95% CI: 1.01-1.38), skim milk intake (OR: 1.10; 95% CI: 1.01-1.19), and fruit intake (OR: 1.12; 95% CI: 1.01-1.24) and negatively associated with BMI z-score (OR: 0.69; 95% CI: 0.60-0.79), total screen time in hours (OR: 0.79; 96% CI: 0.68-0.92), and intake of fruit flavoured drinks (OR: 0.91; 95% CI: 0.84-0.99). These findings may help guide clinical decision-making regarding obesity management by focusing on children with MUO who are at relatively high cardiometabolic risk.

The impact of the COVID-19 pandemic on adolescents and young adults living with type 2 diabetes

Objectives

The aim of this study was to assess the impacts of the COVID-19 pandemic on adolescents and young adults living with type 2 diabetes (T2D) involved in the national Improving Renal Complications in Adolescents with T2D through REsearch (iCARE) study.

Methods

The Environmental influences on Child Health Outcomes (ECHO) COVID-19 Questionnaire developed by the National Institutes of Health ECHO COVID-19 Task Force was administered to participants (n=85) from the iCARE study between June 2020 and October 2020. Children 12 years old (via parent report) and adolescents and young adults ≥13 years old (via self-report) participated. The questionnaire assessed the impact of the pandemic on health-care appointments, lifestyle, internet use, social connections and mental health.

Results

Participants were 17.0±3.1 (range, 12 to 27) years of age and predominantly female (61.3%). During the pandemic, 69.4% were able to attend their health-care appointments by telephone or virtual platforms, 31.7% ate more, 45.1% slept more and 29.3% spent less time on physical activities. There was an increase in internet use for both educational (42.0%) and noneducational purposes (54.9%). Participants felt less socially connected (64.6%). Participants also felt sometimes (59.2%), often (19.7%) and very often (6.7%) satisfied with their lives.

Discussion

Our study revealed that the COVID-19 pandemic has had various impacts on the daily lives of adolescents and young adults living with T2D. Future research should include longitudinal studies of the health burden of the COVID-19 pandemic on this population, with a more in-depth evaluation of mental health outcomes and clinical outcomes.

Delgocitinib in atopic dermatitis

Delgocitinib ointment is a newly approved topical medication for the treatment of atopic dermatitis (AD). AD usually has onset in early childhood and is a common, often chronic relapsing inflammatory skin condition that affects all age groups. AD has a large impact on patients' quality of life including physical health and emotional impacts. Conventional management of AD consists of phototherapy and treatments that comprise corticosteroids (both topically and systemically), topical calcineurin inhibitors (tacrolimus and pimecrolimus) or systemic immunosuppressants like ciclosporin. New targeted therapies for AD, including interleukin (IL)-4/13 inhibitors, Janus kinase (JAK) inhibitors and IL-13 inhibitors have been introduced for both topical and systemic use. In this review, we give an overview of the use of delgocitinib, the first topical JAK inhibitor to be approved for AD, including its preclinical pharmacology, pharmacokinetics and metabolism, safety, existing clinical trials and future directions.

A Validated Risk Prediction Model for Bone Fragility in Children With Acute Lymphoblastic Leukemia

Although bone fragility may already be present at diagnosis of pediatric acute lymphoblastic leukemia (ALL), routine performance of dual-energy X-ray absorptiometry (DXA) in every child is not universally feasible. The aim of this study was to develop and validate a risk prediction model for low lumbar spine bone mineral density (LS BMD Z-score ≤ -2.0) at diagnosis, as an important indicator for fracture risk and further treatment-related BMD aggravation. Children with ALL (4-18 years), treated according to the Dutch Childhood Oncology Group protocol (DCOG-ALL9; model development; n = 249) and children from the Canadian Steroid-Associated Osteoporosis in the Pediatric Population cohort (STOPP; validation; n = 99) were included in this study. Multivariable logistic regression analyses were used to develop the prediction model and to confirm the association of low LS BMD at diagnosis with symptomatic fractures during and shortly after cessation of ALL treatment. The area under the receiver operating characteristic curve (AUC) was used to assess model performance. The prediction model for low LS BMD at diagnosis using weight (β = -0.70) and age (β = -0.10) at diagnosis revealed an AUC of 0.71 (95% CI, 0.63-0.78) in DCOG-ALL9 and 0.74 (95% CI, 0.63-0.84) in STOPP, and resulted in correct identification of 71% of the patients with low LS BMD. We confirmed that low LS BMD at diagnosis is associated with LS BMD at treatment cessation (OR 5.9; 95% CI, 3.2-10.9) and with symptomatic fractures (OR 1.7; 95% CI, 1.3-2.4) that occurred between diagnosis and 12 months following treatment cessation. In meta-analysis, LS BMD at diagnosis (OR 1.6; 95% CI, 1.1-2.4) and the 6-month cumulative glucocorticoid dose (OR 1.9; 95% CI, 1.1-3.2) were associated with fractures that occurred in the first year of treatment. In summary, a prediction model for identifying pediatric ALL patients with low LS BMD at diagnosis, as an important indicator for bone fragility, was successfully developed and validated. This can facilitate identification of future bone fragility in individual pediatric ALL patients. © 2021 American Society for Bone and Mineral Research (ASBMR).

Osteoporotic Fractures and Vertebral Body Reshaping in Children With Glucocorticoid-treated Rheumatic Disorders

CONTEXT

Osteoporotic fractures are an important cause of morbidity in children with glucocorticoid-treated rheumatic disorders.

OBJECTIVE

This work aims to evaluate the incidence and predictors of osteoporotic fractures and potential for recovery over six years following glucocorticoid (GC) initiation in children with rheumatic disorders.

METHODS

Children with GC-treated rheumatic disorders were evaluated through a prospective inception cohort study led by the Canadian STeroid-induced Osteoporosis in the Pediatric Population (STOPP) Consortium. Clinical outcomes included lumbar spine bone mineral density (LS BMD), vertebral fractures (VF), non-VF, and vertebral body reshaping.

RESULTS

A total of 136 children with GC-treated rheumatic disorders were enrolled (mean age 9.9 years, SD 4.4). The 6-year cumulative fracture incidence was 16.3% for VF, and 10.1% for non-VF. GC exposure was highest in the first 6 months, and 24 of 38 VF (63%) occurred in the first 2 years. Following VF, 16 of 19 children (84%) had complete vertebral body reshaping. Increases in disease activity and body mass index z scores in the first year and declines in LS BMD z scores in the first 6 months predicted incident VF over the 6 years, while higher average daily GC doses predicted both incident VF and non-VF. LS BMD z scores were lowest at 6 months (mean -0.9, SD 1.2) and remained low by 6 years even when adjusted for height z scores (-0.6, SD 0.9).

CONCLUSION

VF occurred early and were more common than non-VF in children with GC-treated rheumatic disorders. Eighty-four percent of children with VF underwent complete vertebral body reshaping, whereas vertebral deformity persisted in the remainder of children. On average, LS BMD z scores remained low at 6 years, consistent with incomplete recovery.

Physician-related predictors of referral for multidisciplinary paediatric obesity management: a population-based study

BACKGROUND

It is recommended that primary care-based physicians refer children with overweight and obesity to multidisciplinary paediatric obesity management, which can help to improve weight and health.

OBJECTIVE

To determine predictors of referral to multidisciplinary paediatric obesity management.

METHODS

This retrospective, population-level study included physicians who could refer 2-17 years old with a body mass index ≥85th percentile to one of three multidisciplinary paediatric obesity management clinics in Alberta, Canada. Physician demographic and procedural data were obtained from Practitioner Claims and Provider Registry maintained by Alberta Health from January 2014 to December 2017. Physician characteristics were compared based on whether they did or did not refer children for obesity management. Univariable and multivariable logistic regression models analysed associations between physician characteristics and referral making.

RESULTS

Of the 3863 physicians (3468 family physicians, 395 paediatricians; 56% male; 49.3 ± 12.2 years old; 22.3 ± 12.6 years since graduation) practicing during the study period, 1358 (35.2%) referred at least one child for multidisciplinary paediatric obesity management. Multivariable regression revealed that female physicians (versus males) [odds ratio (OR): 1.68, 95% confidence interval (CI): 1.46-1.93; P < 0.0001], paediatricians (versus family physicians) (OR: 4.89, 95% CI: 3.85-6.21; P < 0.0001) and urban-based physicians (versus non-urban-based physicians) (OR: 2.17, 95% CI: 1.79-2.65; P < 0.0001) were more likely to refer children for multidisciplinary paediatric obesity management.

CONCLUSIONS

Approximately one-third of family physicians and paediatricians referred children for multidisciplinary paediatric obesity management. Strategies are needed to improve referral practices for managing paediatric obesity, especially among male physicians, family physicians and non-urban-based physicians as they were less likely to refer children.

Variability in How Canadian Pediatric Weight Management Clinics Deliver Care: Evidence from the CANadian Pediatric Weight Management Registry

Background: Clinical practice guidelines for pediatric weight management highlight the importance of family-based behavioral strategies to enhance health behaviors. Little is known, however, of how clinics implement these programs. The study objectives were to (1) describe how Canadian pediatric weight management clinics deliver care and (2) evaluate change in services over time. Methods: The CANadian Pediatric Weight management Registry (CANPWR) is a multisite prospective cohort study of participants enrolled in a Canadian pediatric weight management clinic. Clinical program characteristics (e.g., referral process, inclusion criteria, funding, program characteristics, patient interaction methods, and follow-up) were collected at the start and end of the CANPWR recruitment period (2015-2019). Results: Entrance into the nine clinics varied with limiting criteria based on geographic proximity, age, weight status, and presence of health conditions. The clinics varied in size (50-220 new patients/year). The planned length of intervention varied widely, from 10 weeks to open-ended (median 2 years). Behavior modification strategies were delivered with a mix of individual and group-based sessions and most were delivered in person, complemented by use of virtual care. Over time, more clinics saw patients under the age of 5 years and all clinics defined a program length. Conclusion: Although all clinics offered family-based behavioral weight management services, these varied considerably, especially in program entrance criteria, size of clinic, and the length of intervention. The influence of the variability in delivery of services on health outcomes will be addressed in future studies.

The Accuracy of Incident Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score <-1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8-15) with 46% of IVF (95% CI 30-61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57-85) but would require radiographs in 37% of children (95% CI 32-42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83-91), the greatest overall accuracy at 82% (95% CI 78-86), and the lowest radiography rate at 17% (95% CI 14-22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67-92), but required radiographs in 65% (95% CI 60-70). These results provide guidance for targeting spine radiography in children at risk for IVF. © 2021 American Society for Bone and Mineral Research (ASBMR).

Diabetic ketoacidosis at type 1 diabetes diagnosis in children during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic has led to significant public health measures that have resulted in decreased acute pediatric care utilization. We evaluated whether the rate of severe presentations of new onset type 1 diabetes (DM1), such as, diabetic ketoacidosis (DKA) has changed since the COVID-19 public health measures were enacted.

RESEARCH DESIGN AND METHODS

A retrospective chart review of children less than 18 years of age presenting with new onset DM1 during the pandemic period of March 17, 2020 to August 31, 2020 was conducted at two tertiary care pediatric hospitals in Alberta, Canada. Rates of DKA and severe DKA were compared to the same time period in the year 2019 (pre-pandemic control).

RESULTS

The number of children presenting with newly diagnosed DM1 was similar during the pandemic year of 2020 compared with 2019 (107 children in 2020 vs. 114 in 2019). The frequency of DKA at DM1 onset was significantly higher in the pandemic period (68.2% vs 45.6%; p < 0.001) and incidence of severe DKA was also higher (27.1% in 2020 vs 13.2% in 2019; p = 0.01).

CONCLUSIONS

There was a significant increase in DKA and severe DKA in children presenting with new onset DM1 during the COVID-19 pandemic period. This emphasizes the need for educating health care professionals and families to be aware of the symptoms of hyperglycemia and the importance of early diagnosis and treatment even during public health measures for COVID-19.

Strategies to reduce attrition in managing paediatric obesity: A systematic review

OBJECTIVE

To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity.

METHODS

We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality.

RESULTS

Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]).

CONCLUSION

Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

Systemic medication requirement in post-surgical patients with eosinophilic chronic rhinosinusitis

BACKGROUND

Eosinophilic chronic rhinosinusitis (eCRS) is contemporarily managed by surgical creation of a 'neo-sinus' cavity and corticosteroid irrigations. While most patients gain control of their disease with this approach, similar to preventive inhaler therapy in asthma, some patients need systemic therapies. This study aimed to define those patients needing ongoing systemic therapy for eCRS.

METHODS

Consecutive adult patients (&gt;18 years) who were seen at a tertiary referral clinic, diagnosed as eCRS and underwent endoscopic sinus surgery were included. Patients were followed up for a minimum of 12 months. All patients had a simple neo- sinus cavity surgically created and used initially a once daily topical corticosteroid irrigation maintenance therapy. Patients who re- quired long term systemic oral corticosteroids and/or biologic therapy were compared to those who remained on topical control.

RESULTS

222 patients with eCRS were assessed (follow-up 2.76 years). Long term systemic therapy was required in 5.4% of pa- tients. Receiver operating curve analysis predicted local treatment failure at an eosinophil count cut-off level 0.455x109/L. Asthma, atopy and aspirin sensitivity also predicted long term systemic therapy. There were no associations with nasal polyposis or revi- sion surgery. Multivariate logistic regression showed elevated blood eosinophil count &gt;0.455 x109/L was 9.27 times more likely to require for systemic medication.

CONCLUSION

Pre-operative blood eosinophil count &gt;0.45 x109/L was associated with failure of local therapy following contem- porary management of eCRS. The quantitative value of serum eosinophilia may be a useful predictor of disease progression and those patients in need of systemic therapies, such as biologic agents.

Adverse cardiovascular ageing among older women and cardiometabolic ageing

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): National Medical Research Council (NMRC)

Background

Despite longer life expectancies, women may experience reduced ‘health-span’ (period of life spent in good health) due to accumulation of risks over their longer life spans. Metabolic factors present in diet and lifestyle may provide modifiable solutions to tackle burdens of cardiovascular (CV) ageing in women.

Objective

We aim to study gender differences in CV structure and function among community older adults without clinical CV disease, as well as metabolic perturbations in their study samples.

Methods

We examined a prospective cohort study of older adults, obtaining their medical history, serum sampling, echocardiography and cardiac magnetic resonance (CMR) imaging on a single day visit. Echo E/A ratio was computed as a ratio of peak velocity flow in early diastole E (m/s) to peak velocity flow in late diastole by atrial contraction A (m/s) mitral inflow velocities. Longitudinal strain (ε) at any time point (t) in the cardiac cycle from end-diastole (time 0) was calculated as: ε(t)=(L(t)-L0)/L0, obtaining left atrial (LA) reservoir strain (εs), conduit strain (εe) and booster strain (εa) by CMR. Metabolomics profiling was performed by standard mass spectrometry techniques.

Results

Among n = 492 (49.6%, n = 244 women, mean age 73 ± 4 years) participants, women had lower prevalence of hypertension (52% vs 58%, p &lt; 0.0001), smoking (4% vs 35%, p &lt; 0.0001), but higher prevalence of dyslipidemia (52% vs 50%, p = 0.001) compared to men. Women had lower left ventricular mass index (69 vs 71 g/m2, p &lt; 0.0001) compared to men. However, women had more adverse CV function, such as lower E/A ratio (0.78 vs 0.85, p &lt; 0.0001), lower LA booster (εa) (16.5 vs 17.8, p = 0.027) and lower LA reservoir (εs) strain rate (1.5 vs 1.6, p = 0.012), compared to men. Amino acids such as alanine, arginine, aspartate, citrulline, glycine, phenylalanine and valine were similar between gender. However, women had higher levels of tyrosine (76 vs 68 μM, p = 0.015). On multivariate adjustment, apart from age, tyrosine was independently associated with E/A ratio (β=0.002, 95%CI 0.00-0.004, p = 0.044) and εs (β=0.004, 95%CI 0.00-0.009, p = 0.048) among women. 

Conclusion

Utilizing conventional and sensitive CV imaging, women appeared to have more adverse CV functions with ageing. As a branched chain amino acid linked to future risk of CV disease, tyrosine may be linked to adverse CV function. Factors that contribute to these cardiometabolic profiles, such as menopause, diet or lifestyle warrant further research.

Comparison of Clinical and Social Characteristics of Canadian Youth Living With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to describe the clinical and social characteristics of 2 Canadian cohorts of adolescents with diabetes.

METHODS

Participants from the Improving renal Complications in Adolescents with type 2 diabetes through REsearch (iCARE) study (n=322) and the Early Determinants of Cardio-Renal Disease in Youth With Type 1 Diabetes (n=199) study were compared.

RESULTS

Adolescents were 10 to 18 years of age (mean ± standard deviation: 14.8±2.4 years). The T2DM cohort had a shorter duration of diabetes. Both groups had glycated hemoglobin levels above target. The type 2 diabetes (T2D) cohort was comprised of predominantly Indigenous youth. The type 1 diabetes (T1D) cohort was 58.3% European/Caucasian, with a high proportion (41.7%) of visible minority groups (Afro-Caribbean, Asian/Pacific Islander, Hispanic). The prevalence of obesity, hypertension, left ventricular hypertrophy, albuminuria and hyperfiltration was higher in the T2D cohort. The T1D cohort was more socially and economically advantaged in all 4 dimensions of health inequality.

CONCLUSIONS

There are significant differences in clinical and social characteristics of adolescents with T2D and T1D in Canada. Both have inadequate glycemic control with evidence of onset and progression of diabetes-related complications.