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Multisystemic Therapy for Adolescents With Poorly Controlled Type 1 Diabetes: Reduced diabetic ketoacidosis admissions and related costs over 24 months

OBJECTIVE—The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS—A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care. RESULTS—Youth who received MST had significantly fewer hospital admissions than control subjects (χ2 = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions. CONCLUSIONS—The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

Multisystemic therapy for adolescents with poorly controlled type I diabetes : Stability of treatment effects in a randomized controlled trial

The primary purpose of the present study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, improved regimen adherence, metabolic control, and rates of hospitalization for diabetic ketoacidosis (DKA) among adolescents with chronically poorly controlled Type 1 diabetes 6 months after the completion of treatment. A randomized controlled trial was conducted with 127 adolescents and their families. Mean participant age was 13.2 years. Sixty-three percent of participants were African American, and 51% were female. Data were collected at baseline, treatment termination, and 6-month follow-up. Changes in glycated hemoglobin (HbA1c), frequency of blood glucose testing (BGT), and rate of DKA admissions were assessed. In intent-to-treat analyses, a main effect of MST on DKA admissions was found at both treatment termination and follow-up. Improvements in BGT were moderated by family composition; only 2-parent MST families maintained improvements at follow-up. Improvements in HbA1c for the MST group at treatment termination were lost at follow-up. Results show that intensive, home-based psychotherapy created stable reductions in serious lapses in adherence, as indexed by episodes of DKA, among youth with poorly controlled diabetes.

MST for Adolescents with Poorly Controlled Type I Diabetes: Reduced DKA Admissions and Related Costs over 24 Months

OBJECTIVE—The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated. RESEARCH DESIGN AND METHODS—A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care. RESULTS—Youth who received MST had significantly fewer hospital admissions than control subjects (χ2 = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions. CONCLUSIONS—The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

The Effects of Multisystemic Therapy on Diabetes Stress Among Adolescents With Chronically Poorly Controlled Type 1 Diabetes: Findings From a Randomized, Controlled Trial

Objective. The goal of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Stress was also evaluated as a mediator of the effect of MST on adherence and metabolic control. Methods. A randomized, controlled trial was conducted with 127 adolescents with type 1 diabetes mellitus and chronically poor metabolic control (hemoglobin A1c levels of ≥8% at study enrollment and for the past 1 year) who received their diabetes care in a childrens hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for ∼6 months. Data were collected at baseline and at a 7-month posttest (ie, treatment termination). Changes in diabetes-related stress, as measured with a self-report questionnaire, were assessed. Structural equation models were used to test the degree to which changes in stress levels mediated the ability of the MST intervention to improve adherence and metabolic control. Results. In intent-to-treat analyses, participation in MST was associated with significant reductions in diabetes-related stress. Tests for moderation found no significant effects of age, gender, or ethnicity, which suggests that the intervention was equally effective in reducing diabetes stress for all participants. However, structural equation modeling did not provide support for diabetes stress as the mechanism through which MST improved health outcomes. Rather, the final model suggested that MST improved metabolic control through increased regimen adherence. Conclusions. Intensive, home-based psychotherapy reduces diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Such stress reductions are important for the psychological wellbeing of a subset of youths with diabetes who are at high risk for future health complications.

Gynecomastia: Evaluation and Treatment Recommendations for Primary Care Providers

Gynecomastia is defined as excessive development of the breast in boys. It is common in neonates and adolescents. Although in most cases this is a transient phenomenon, it might lead to significant social impediments such as decreased participation in physical education because of embarrassment. A primary care provider should be able to diagnose a false gynecomastia, a physiologic gynecomastia, and a gynecomastia with underlying pathology by taking good history, performing a thorough physical examination, and checking few screening laboratory tests. In most cases with physiologic gynecomastia, just reassurance and close follow-up is sufficient; however, psychologic counseling and surgical intervention may be required in few selected cases of physiologic gynecomastia. Suspected cases with underlying pathologic causes should be referred to a pediatric endocrinologist for further evaluation and management. Treatment of underlying causes should resolve the gynecomastia in those patients.

The effects of weight status on treatment outcomes in a randomized clinical trial of multisystemic therapy for adolescents with type 1 diabetes and chronically poor metabolic control.

Objective:  The purpose of the study was to determine if being overweight attenuated the effect of multisystemic therapy (MST), an intensive, home‐based psychotherapy, on metabolic outcomes among adolescents with type 1 diabetes and chronically poor metabolic control. As overweight is a marker of insulin resistance, it was hypothesized that weight status would limit the impact of behavioral changes in traditional aspects of adherence to the type 1 diabetes regimen on metabolic control.

Dietary Vitamin D Intake Among High-Risk Adolescents With Insulin Dependent Diabetes

Purpose The purpose of the present study was to describe the dietary intake of vitamin D in an urban, low income, predominantly African American sample of adolescents with insulin dependent diabetes. Methods Participants were 99 adolescents diagnosed with insulin dependent diabetes. Vitamin D intake was estimated from dietary recall data. Blood glucose levels were also assessed. Results The average daily vitamin D intake estimated from dietary recall data was 102 IUs (SD = 64.4) with 70% of adolescents consuming less than 50 IUs of vitamin D in their day. Level of vitamin D intake was a significant predictor of HbA1c levels in the current sample. Conclusions Results indicate a need for the assessment of vitamin D levels in this at-risk population, as supplementation may be indicated.

Short stature in children: a practical approach for primary care providers.

Data gathered from population is used to define what is normal for age and gender. Terms such as “height below the 5th percentile” or “height 2 standard deviations below the mean (−2SDs)” are often used to define short stature. A more precise and medically correct definition is the “expected adult height,” which is calculated from parents’ heights. The height of a child should be evaluated in the light of his or her genetic potential. Most children achieve an adult stature within 10 cm of their genetic potential calculated from their parents’ heights. A child who is growing at a much lower percentile than for his or her genetic potential should have a thorough evaluation to exclude any underlying pathology that might explain this slow gain in height.

A Practical Approach to Precocious Puberty

her height is 123.5 cm. Breast development is now at Tanner Stage 3, pubic hair at Stage 2, and vaginal mucosa shows definite estrogen effect. At this followup visit, her growth velocity was determined to be 7 cm per year with a BA of 10 years. A pelvic ultrasound revealed normal ovaries with early pubertal size of the uterus, and results of other studies were as follows: LH, 8 IU/L (normal, 0.8-26 IU/L); FSH, 4.2 IU/L (normal, 1.4-9.6 IU/L); and estradiol, 48 pmol/mL (normal, 70-220 pmol/mL). A diagnosis of rapidly progressing precocious puberty was made and a GnRH stimulation test was done by the pediatric endocrinologist. LH and FSH levels increased to 24 IU/L and 22 IU/L, respectively, showing a pubertal response. A magnetic resonance imaging (MRI) of the brain was done, results of which were normal. She was diagnosed with idiopathic precocious puberty and started on leuprolide, a gonadotropin releasing hormone (GnRH) analog. At 6and 12-month follow-up, the FSH and LH response to GnRH stimulation is suppressed and growth rate has decreased appropriately.

Changing Spectrum of Diabetes Mellitus in Children Challenges With Initial Classification

Objective. To determine the frequency of initial misclassification of diabetes mellitus (DM) in children and to compare the presenting features of DM1, DM2, and the misclassified cases. Results. A total of 206 patients fulfilled the inclusion criteria. Of them, 74.75% had DM1 and 25.25% had DM2. Ten percent of studied patients had a subsequent change in classification. The mean HbA1c of the DM2 patients, who were initially misclassified, was 13.35% (SD = 1.96). The mean HbA1c of DM2 patients with correct initial classification was 8.83% (SD = 3.01). Diabetes ketoacidosis (DKA) was seen in 59.44% of DM1 and 23.91% of DM2 patients. Of the DM2 patients who were initially misclassified, 58.82% had presented in DKA as opposed to only 6.45% of patients who were correctly classified. Conclusion. The initial classification of DM frequently requires revision (10% in this study). The misclassification is highest among DM2 patients who initially present with higher HbA1c and DKA.