Hispanic Caregivers' experience of pediatric type 1 diabetes: A qualitative study

OBJECTIVE

It is widely recognized that Type 1 Diabetes (T1D) outcomes are worse among Hispanic children; however, little is published about the perspectives of these patients and their caregivers. Our intent was to characterize the lived experience of Hispanic caregivers of children with T1D, focusing on the role of language and culture and their perspectives on current medical care and alternative care models. We studied Hispanic caregivers of patients (age 2-17 years) with T1D of greater than 6 months' duration.

RESEARCH DESIGN AND METHODS

We completed semi-structured interviews and focus-groups of a purposive sample of 20 members of our population of interest. We developed a codebook and completed multidisciplinary consensus coding, then conducted iterative thematic analysis using qualitative software and discussion to generate themes.

RESULTS

We gathered data from 20 Hispanic caregivers of T1D patients (11.37 ± 3.00 years old, 4.80 ± 2.84 years since diagnosis). 85% of caregivers were female, 80% preferred Spanish, and 15% were college-educated. Our analysis yielded 4 themes across the participants: (1) Culturally-based nutrition challenges, (2) Social isolation and lack of support for T1D care, (3) Hesitancy to fully embrace diabetes technology, and (4) Deferential views of care experience and providers. Overarching all of these themes was support for Hispanic group-based models of care tailored to address these concerns.

CONCLUSIONS

The unique concerns among Hispanic caregivers of children with T1D suggest the importance of culturally tailored interventions to improve care. With successful implementation, such interventions could diminish widening disparities in healthcare outcomes.

Safety Protocols for Adolescent Substance Use Research in Clinical Settings

PURPOSE

Research involving adolescent risk behaviors must balance data confidentiality with participant safety when risky behaviors are revealed. This report details a safety protocol and reports the experience of two contemporaneous studies that used it with variant safety thresholds.

METHODS

We developed a safety protocol for research with adolescent patients and used it in two concurrent studies of adolescent patients, aged 14-18 years. Study "PC" recruited participants from a primary care adolescent medical clinic (N = 490), and Study "SP" recruited participants from subspecialty pediatric clinics (N = 434); both studies involved a similar self-administered assessment of health behaviors. The protocol sets thresholds for clinical intervention (positive safety flags) for past 3-month heavy alcohol consumption (Study PC: 10 or more drinks and Study SP: "binge-"level drinking), illicit drug use other than marijuana and alcohol in combination with a substance other than marijuana, and sets a positive screen for depression. We examined the rates of positive safety flags in both protocol settings, used significance testing to describe demographic differences between participants with and without positive flags in both studies, and described clinician experiences with protocol implementation.

RESULTS

In studies PC/SP, .6%/8.8% of participants were flagged for heavy alcohol consumption, respectively; .2%/0% for illicit drug use, 2.2%/.7% for combination substance use, and 14.9%/4.8% for depression. Some clinicians found managing positive flags challenging, although both studies completed recruitment on time and without serious adverse events.

CONCLUSIONS

The protocol was feasible in clinical settings. The findings and experiences documented in this report could be useful for future protocols.

Health Care Transition in Youth With Type 1 Diabetes and an A1C >9%: Qualitative Analysis of Pre-Transition Perspectives

OBJECTIVE | To explore expectations for transition to adult care and experiences with transition planning among adolescents and young adults with type 1 diabetes and an A1C >9% at a tertiary care U.S. pediatric center. METHODS | We conducted semi-structured interviews in a purposive sample of patients 14-23 years of age who had had type 1 diabetes for at least 1 year and had an A1C >9%. A multidisciplinary team conducted iterative thematic analysis with deductive and inductive coding aided by NVivo software. RESULTS | Fourteen subjects participated (nine adolescents and five young adults, mean age 17.1 ± 3.2 years, 57% male, 79% Caucasian, 14% Hispanic, diabetes duration 8.2 ± 4.6 years, mean A1C 10.0 ± 0.8% for adolescents and 10.1 ± 0.7% for young adults). Qualitative analysis yielded four key themes. The first was lack of formal preparation; participants of all ages demonstrated a lack of preparation for transition and ignorance about the process, describing it as coming "out of the blue." The second was a desire for delayed and gradual transition; participants wanted to defer being "serious" about transition to a later/uncertain date, with a preference to "wait until I'm older" among all ages. Participants described ideal transition as a gradual process, taking place "a little at a time." The third was attachment to pediatric providers; participants demonstrated a nearly universal attachment to and "familiarity" with their pediatric diabetes care providers and expressed worries about an "uncomfortable" transition to adult providers. The fourth was concern about an impersonal adult care setting: participants perceived adult care as "formal," "scarier," and "tougher," with increased criticism about poor control; participants expressed fear that adult providers would not "know me" or appreciate "my diabetes journey." CONCLUSION | We demonstrated a lack of transition preparation and anxiety about transition and adult care among youth with type 1 diabetes and elevated A1C. Our results may help guide early, iterative pediatric transition counseling, with a special focus on addressing attachment and fears about adult diabetes care.

Transitions in Care from Pediatric to Adult Health Care Providers: Ongoing Challenges and Opportunities for Young Persons with Diabetes

Adolescence and young adulthood are times of multiple developmental changes, including physiological, social, emotional, cognitive, and behavioral transformations. The adolescent or young adult living with type 1 or type 2 diabetes must navigate the vicissitudes of these developmental stages while managing the rigors and self-care demands of these conditions. Diabetes in children is managed by adults, mainly by parents. As the child matures, diabetes management tasks transition from parents to the developing teen. This transition in care is a process that generally begins in early adolescence and culminates when the older teen successfully accepts and manages diabetes self-care tasks. Along with the transitions in diabetes management tasks, older teens and young adults must be prepared for transfer from the pediatric diabetes care team to an adult-focused health care team. Numerous publications have described the challenges associated with both the process of transition and the act of transfer. Lack of preparation during transition followed by unsuccessful transfer often results in gaps in diabetes care exceeding 6 months, deterioration in glycemic control, increase in emergency room use and hospitalization, and emergence of diabetes complications among older teens and young adults. There is need for ongoing research internationally to address these deficiencies in order to improve the short- and long-term health of young persons with diabetes.

The Impact of Technology on Current Diabetes Management

Technological innovations have revolutionized the treatment of type 1 diabetes. Although technological advances can potentially improve diabetes outcomes, maintenance of target glycemic control, at the present time, remains largely dependent on patient and family motivation, competence, and adherence to daily diabetes care requirements. Trials of closed loop or "artificial pancreas" technology show great promise to automate insulin delivery and achieve near normal glucose control and reduced hypoglycemia with minimal patient intervention.

Humanism and professionalism education for pediatric hematology-oncology fellows: A model for pediatric subspecialty training

BACKGROUND

Humanism and professionalism are virtues intrinsic to the practice of medicine, for which we lack a standard, evidence-based approach for teaching and evaluation. Pediatric hematology-oncology (PHO) fellowship training brings new and significant stressors, making it an attractive setting for innovation in humanism and professionalism training.

PROCEDURE

We electronically surveyed a national sample of PHO fellows to identify fellows' educational needs in humanism and professionalism. Next, we developed a case-based, faculty-facilitated discussion curriculum to teach this content within pilot fellowship programs. We assessed whether fellowships would decide to offer the curriculum, feasibility of administering the curriculum, and satisfaction of fellow and faculty participants.

RESULTS

Surveys were completed by 187 fellows (35%). A minority (29%) reported that their training program offers a formal curriculum in humanism and/or professionalism. A majority desires more formal teaching on balancing clinical practice and research (85%), coping with death/dying (85%), bereavement (78%), balancing work and personal life (75%), navigating challenging relationships with patients (74%), and depression/burn out (71%). These six topics were condensed into four case-based modules, which proved feasible to deliver at all pilot sites. Ten fellowship programs agreed to administer the novel curriculum. The majority (90%) of responding fellows and faculty reported the sessions touched on issues important for training, stimulated reflective communication, and were valuable.

CONCLUSIONS

Pediatric hematology-oncology fellows identify numerous gaps in their training related to humanism and professionalism. This curriculum offers an opportunity to systematically address these educational needs and can serve as a model for wider implementation. Pediatr Blood Cancer 2015;62:335-340. © 2014 Wiley Periodicals, Inc.

Selecting blood glucose monitoring systems

A wide range of blood glucose monitoring systems is available for use in different applications. The systems have varying characteristics which should be taken into consideration during selection. Operator technique can influence the quality of the results.

Blood lancing systems for skin puncture

Blood tests increasingly require only a few microlitres of blood. Lancing systems used for the collection of blood have the potential to transmit infection if used improperly. These systems vary in the amount of blood and pain produced.

Blood glucose measuring systems

Glucose monitoring and lancing systems have proved useful in a range of patient testing applications in hospitals, general practice and for use by patients at home. Products are becoming easier to use and less technique dependent. It is important to be aware of their specific characteristics and to adhere to manufacturers' and local hospital laboratory guidelines.

Cloning of the gene encoding rat JAK2, a protein tyrosine kinase

A complete cDNA clone encoding the rat JAK2 protein tyrosine kinase was isolated from an Nb2-SP (rat pre-T lymphoma cell line) cDNA library. The nucleotide (nt) and deduced amino acid (aa) sequences for this clone were determined and an open reading frame of 3399 bp, encoding a protein of a deduced mass of 130 kDa, was found. The coding regions of the rat and murine Jak2 clones share 93.4% nt identity and 97.1% aa identity. Northern analysis demonstrated that the 5-kb mRNA is highly abundant in brain and spleen, less abundant in skeletal muscle and testis, and detectable in kidney, heart, lung and liver. Translation of the rat Jak2 mRNA in rabbit reticulocytes results in a protein which is specifically immunoprecipitated by antibodies (Ab) recognizing JAK2, but not by Ab recognizing JAK1.

Significance of the hydrogen ion concentration in synovial fluid in rheumatoid arthritis

The hydrogen ion (H+) concentration and pCO2 were measured in the synovial fluid (SF) from the knee joints of 130 patients with arthritis by an acid-base analyser (ABL2 Acid-Base Laboratory), using a simple technique which prevented contact with air. H+ concentration was significantly higher in SF from 60 RA patients (mean 64.4 n mol/l; range 38-142 n mol/l) compared with patients with OA (mean 44 n mol/l; range 29-56 n mol/l), and 40 with other arthritides (mean 52 n mol/l). The H+ concentration in the SF showed a significant association with other variables of local inflammation-platelet, total leucocyte and polymorph counts, 5-nucleotidase, acid phosphatase and IgA levels in the SF and the clinical knee score, but not with the volume of the effusion. A similar relationship between these variables of inflammatory activity and SF pCO2 was also established. A higher SF H+ concentration was also found in systemically active disease, but no difference in SF pH between seropositive and seronegative patients. Whilst the pH of SF approximated to that of the blood in OA, it was significantly lower in the SF in RA. SF pH is a useful marker of local inflammatory activity, and its measurement is simple, reliable and rapid. It is relevant because changes in pH influence many of the processes involved in inflammation and the pH difference between SF and blood influences the transfer of drugs into the joint.

Problems associated with the analysis and interpretation of saliva lithium

The correlation between serum and saliva lithium levels in patients undergoing lithium prophylaxis therapy is discussed. Although a high correlation can be obtained, there is an unacceptably high individual variation of paired results. Two strategies were used in an attempt to improve the reliability of saliva as a predictor of serum levels. A naturally occurring marker in saliva and serum was used. This showed high correlation but still did not prevent large sporadic differences. Serially paired results in individual patients also showed occasional excessive variation. Although saliva lithium has been used for monitoring when serum assessment is impracticable, it is considered that it is, as yet, an unreliable technique.