Madhu Rajaraman

Taking steps to manage cardiovascular risk can help improve long-term outcomes for type 2 diabetes mellitus, according to two new studies published Aug. 16 in the New England Journal of Medicine.

The first study, which examined weight gain after smoking cessation, found that despite a temporary increase in T2DM risk, post-cessation weight gain did not diminish the long-term benefits of reduced cardiovascular and all-cause mortality.

The analysis included three cohort studies: the Nurses’ Health Study (NHS), Nurses’ Health Study II (NHS II), and the Health Professionals Follow-Up Study (HPFS), with follow-up questionnaires every 2 years. After exclusions, a total of 162,807 patients were included in the diabetes analysis and 170,723 in the mortality analysis, reported Yang Hu of the department of nutrition at Harvard T.H. Chan School of Public Health, Boston, and his coauthors (N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1803626).

In each follow-up cycle, participants who reported being smokers in the previous cycle but “past” smokers in the current cycle were identified. Quitters were defined as either transient quitters (past smokers in the current cycle but current smokers in previous and next cycles), recent quitters (2-6 consecutive years since smoking cessation), and long-term quitters (6 or more consecutive years since cessation). Weight change was observed for the first 6 years after quitting.

Overall, 12,384 cases of T2DM were confirmed. Diabetes risk was higher for recent quitters than for current smokers (hazard ratio, 1.22; 95% confidence interval, 1.12-1.32); this risk peaked 5-7 years after quitting and then gradually decreased. In analysis of patients with the longest follow-up time, diabetes risk dropped after 30 years of cessation to that of participants who had never smoked, the authors reported.

Compared with current smokers, hazard ratios for T2DM in recent quitters were 1.08 (95% CI, 0.93-1.26) for those without weight gain, 1.15 (95% CI, 0.99-1.33) for those with weight gain of 0.1-5.0 kg, 1.36 (95% CI, 1.16-1.58) for those with weight gain of 5.1-10 kg, and 1.59 (95% CI, 1.36-1.85) in those with weight gain of more than 10 kg.

In the mortality analysis, 23,867 deaths occurred, of which 5,492 were due to cardiovascular disease. Compared with current smokers, hazard ratios for death from cardiovascular disease in recent quitters were 0.69 (95% CI, 0.54-0.88) in those without weight gain; 0.47 (95% CI, 0.35-0.63) in those with weight gain of 0.1-5 kg; 0.25 (95% CI, 0.15-0.42) in those with weight gain of 5.1-10 kg; 0.33 (95% CI, 0.18-0.60) in those with weight gain of more than 10 kg; and 0.50 (95% CI, 0.46-0.55) for longer term quitters. The corresponding hazard ratios for all-cause deaths in the same weight gain groups were 0.81 (95% CI, 0.73-0.90); 0.52 (95% CI, 0.46-0.59); 0.46 (95% CI, 0.38-0.55); 0.50 (95% CI, 0.40-0.63); and 0.57 (95% CI, 0.54-0.59).

The findings suggest that weight gain after quitting smoking “did not attenuate the apparent benefits of smoking cessation on reducing cardiovascular mortality or extending longevity,” the authors said. “However, preventing excessive weight gain may maximize the health benefits of smoking cessation through reducing the short-term risk of diabetes and further lowering the long-term risk of death.”

The second study, which included 271,174 patients with T2DM from the Swedish National Diabetes Register and 1,355,870 controls, examined five risk factors: elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure.

All-cause mortality, myocardial infarction, stroke, and hospitalization for heart failure were evaluated. The risk of each outcome among patients with T2DM was estimated according to the number of risk-factor variables within guideline-recommended target ranges, compared with matched controls, wrote Aidin Rawshani, MD, of the department of molecular and clinical medicine at the University of Gothenburg (Sweden), and his coauthors (N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1800256).

Among the T2DM patients, the excess risk of outcomes was reduced with each risk factor variable within the recommended target range. A total of 37,825 patients with T2DM (13.9%) and 137,520 controls (10.1%) died during the study period.

Among T2DM patients with all variables within target range, the hazard ratio was 1.06 for all-cause death (95% CI, 1.00-1.12); 0.84 for acute myocardial infarction (95% CI, 0.75-0.93); and 0.95 for stroke (95% CI, 0.84-1.07). Smoking was the strongest predictor of death, followed by physical activity, marital status, glycated hemoglobin level, and use of statins.

The study results “indicate that having all five risk-factor variables within the target ranges could theoretically eliminate the excess risk of acute myocardial infarction,” Dr. Rawshani and his colleagues wrote. “Patients with type 2 diabetes who had five risk-factor variables within target ranges appeared to have little or no excess risks of death, myocardial infarction, and stroke as compared with the general population.”

Dr. Hu and his coauthors did not report any disclosures. Dr. Rawshani’s coauthors disclosed relationships with numerous companies including Amgen, Astra Zeneca, and Boehringer Ingelheim.

SOURCE: Hu Y et al. N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1803626. Rawshani A et al. N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1800256.

Taking steps to manage cardiovascular risk can help improve long-term outcomes for type 2 diabetes mellitus, according to two new studies published Aug. 16 in the New England Journal of Medicine.

The first study, which examined weight gain after smoking cessation, found that despite a temporary increase in T2DM risk, post-cessation weight gain did not diminish the long-term benefits of reduced cardiovascular and all-cause mortality.

The analysis included three cohort studies: the Nurses’ Health Study (NHS), Nurses’ Health Study II (NHS II), and the Health Professionals Follow-Up Study (HPFS), with follow-up questionnaires every 2 years. After exclusions, a total of 162,807 patients were included in the diabetes analysis and 170,723 in the mortality analysis, reported Yang Hu of the department of nutrition at Harvard T.H. Chan School of Public Health, Boston, and his coauthors (N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1803626).

In each follow-up cycle, participants who reported being smokers in the previous cycle but “past” smokers in the current cycle were identified. Quitters were defined as either transient quitters (past smokers in the current cycle but current smokers in previous and next cycles), recent quitters (2-6 consecutive years since smoking cessation), and long-term quitters (6 or more consecutive years since cessation). Weight change was observed for the first 6 years after quitting.

Overall, 12,384 cases of T2DM were confirmed. Diabetes risk was higher for recent quitters than for current smokers (hazard ratio, 1.22; 95% confidence interval, 1.12-1.32); this risk peaked 5-7 years after quitting and then gradually decreased. In analysis of patients with the longest follow-up time, diabetes risk dropped after 30 years of cessation to that of participants who had never smoked, the authors reported.

Compared with current smokers, hazard ratios for T2DM in recent quitters were 1.08 (95% CI, 0.93-1.26) for those without weight gain, 1.15 (95% CI, 0.99-1.33) for those with weight gain of 0.1-5.0 kg, 1.36 (95% CI, 1.16-1.58) for those with weight gain of 5.1-10 kg, and 1.59 (95% CI, 1.36-1.85) in those with weight gain of more than 10 kg.

In the mortality analysis, 23,867 deaths occurred, of which 5,492 were due to cardiovascular disease. Compared with current smokers, hazard ratios for death from cardiovascular disease in recent quitters were 0.69 (95% CI, 0.54-0.88) in those without weight gain; 0.47 (95% CI, 0.35-0.63) in those with weight gain of 0.1-5 kg; 0.25 (95% CI, 0.15-0.42) in those with weight gain of 5.1-10 kg; 0.33 (95% CI, 0.18-0.60) in those with weight gain of more than 10 kg; and 0.50 (95% CI, 0.46-0.55) for longer term quitters. The corresponding hazard ratios for all-cause deaths in the same weight gain groups were 0.81 (95% CI, 0.73-0.90); 0.52 (95% CI, 0.46-0.59); 0.46 (95% CI, 0.38-0.55); 0.50 (95% CI, 0.40-0.63); and 0.57 (95% CI, 0.54-0.59).

The findings suggest that weight gain after quitting smoking “did not attenuate the apparent benefits of smoking cessation on reducing cardiovascular mortality or extending longevity,” the authors said. “However, preventing excessive weight gain may maximize the health benefits of smoking cessation through reducing the short-term risk of diabetes and further lowering the long-term risk of death.”

The second study, which included 271,174 patients with T2DM from the Swedish National Diabetes Register and 1,355,870 controls, examined five risk factors: elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure.

All-cause mortality, myocardial infarction, stroke, and hospitalization for heart failure were evaluated. The risk of each outcome among patients with T2DM was estimated according to the number of risk-factor variables within guideline-recommended target ranges, compared with matched controls, wrote Aidin Rawshani, MD, of the department of molecular and clinical medicine at the University of Gothenburg (Sweden), and his coauthors (N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1800256).

Among the T2DM patients, the excess risk of outcomes was reduced with each risk factor variable within the recommended target range. A total of 37,825 patients with T2DM (13.9%) and 137,520 controls (10.1%) died during the study period.

Among T2DM patients with all variables within target range, the hazard ratio was 1.06 for all-cause death (95% CI, 1.00-1.12); 0.84 for acute myocardial infarction (95% CI, 0.75-0.93); and 0.95 for stroke (95% CI, 0.84-1.07). Smoking was the strongest predictor of death, followed by physical activity, marital status, glycated hemoglobin level, and use of statins.

The study results “indicate that having all five risk-factor variables within the target ranges could theoretically eliminate the excess risk of acute myocardial infarction,” Dr. Rawshani and his colleagues wrote. “Patients with type 2 diabetes who had five risk-factor variables within target ranges appeared to have little or no excess risks of death, myocardial infarction, and stroke as compared with the general population.”

Dr. Hu and his coauthors did not report any disclosures. Dr. Rawshani’s coauthors disclosed relationships with numerous companies including Amgen, Astra Zeneca, and Boehringer Ingelheim.

SOURCE: Hu Y et al. N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1803626. Rawshani A et al. N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1800256.

Taking steps to manage cardiovascular risk can help improve long-term outcomes for type 2 diabetes mellitus, according to two new studies published Aug. 16 in the New England Journal of Medicine.

The first study, which examined weight gain after smoking cessation, found that despite a temporary increase in T2DM risk, post-cessation weight gain did not diminish the long-term benefits of reduced cardiovascular and all-cause mortality.

The analysis included three cohort studies: the Nurses’ Health Study (NHS), Nurses’ Health Study II (NHS II), and the Health Professionals Follow-Up Study (HPFS), with follow-up questionnaires every 2 years. After exclusions, a total of 162,807 patients were included in the diabetes analysis and 170,723 in the mortality analysis, reported Yang Hu of the department of nutrition at Harvard T.H. Chan School of Public Health, Boston, and his coauthors (N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1803626).

In each follow-up cycle, participants who reported being smokers in the previous cycle but “past” smokers in the current cycle were identified. Quitters were defined as either transient quitters (past smokers in the current cycle but current smokers in previous and next cycles), recent quitters (2-6 consecutive years since smoking cessation), and long-term quitters (6 or more consecutive years since cessation). Weight change was observed for the first 6 years after quitting.

Overall, 12,384 cases of T2DM were confirmed. Diabetes risk was higher for recent quitters than for current smokers (hazard ratio, 1.22; 95% confidence interval, 1.12-1.32); this risk peaked 5-7 years after quitting and then gradually decreased. In analysis of patients with the longest follow-up time, diabetes risk dropped after 30 years of cessation to that of participants who had never smoked, the authors reported.

Compared with current smokers, hazard ratios for T2DM in recent quitters were 1.08 (95% CI, 0.93-1.26) for those without weight gain, 1.15 (95% CI, 0.99-1.33) for those with weight gain of 0.1-5.0 kg, 1.36 (95% CI, 1.16-1.58) for those with weight gain of 5.1-10 kg, and 1.59 (95% CI, 1.36-1.85) in those with weight gain of more than 10 kg.

In the mortality analysis, 23,867 deaths occurred, of which 5,492 were due to cardiovascular disease. Compared with current smokers, hazard ratios for death from cardiovascular disease in recent quitters were 0.69 (95% CI, 0.54-0.88) in those without weight gain; 0.47 (95% CI, 0.35-0.63) in those with weight gain of 0.1-5 kg; 0.25 (95% CI, 0.15-0.42) in those with weight gain of 5.1-10 kg; 0.33 (95% CI, 0.18-0.60) in those with weight gain of more than 10 kg; and 0.50 (95% CI, 0.46-0.55) for longer term quitters. The corresponding hazard ratios for all-cause deaths in the same weight gain groups were 0.81 (95% CI, 0.73-0.90); 0.52 (95% CI, 0.46-0.59); 0.46 (95% CI, 0.38-0.55); 0.50 (95% CI, 0.40-0.63); and 0.57 (95% CI, 0.54-0.59).

The findings suggest that weight gain after quitting smoking “did not attenuate the apparent benefits of smoking cessation on reducing cardiovascular mortality or extending longevity,” the authors said. “However, preventing excessive weight gain may maximize the health benefits of smoking cessation through reducing the short-term risk of diabetes and further lowering the long-term risk of death.”

The second study, which included 271,174 patients with T2DM from the Swedish National Diabetes Register and 1,355,870 controls, examined five risk factors: elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure.

All-cause mortality, myocardial infarction, stroke, and hospitalization for heart failure were evaluated. The risk of each outcome among patients with T2DM was estimated according to the number of risk-factor variables within guideline-recommended target ranges, compared with matched controls, wrote Aidin Rawshani, MD, of the department of molecular and clinical medicine at the University of Gothenburg (Sweden), and his coauthors (N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1800256).

Among the T2DM patients, the excess risk of outcomes was reduced with each risk factor variable within the recommended target range. A total of 37,825 patients with T2DM (13.9%) and 137,520 controls (10.1%) died during the study period.

Among T2DM patients with all variables within target range, the hazard ratio was 1.06 for all-cause death (95% CI, 1.00-1.12); 0.84 for acute myocardial infarction (95% CI, 0.75-0.93); and 0.95 for stroke (95% CI, 0.84-1.07). Smoking was the strongest predictor of death, followed by physical activity, marital status, glycated hemoglobin level, and use of statins.

The study results “indicate that having all five risk-factor variables within the target ranges could theoretically eliminate the excess risk of acute myocardial infarction,” Dr. Rawshani and his colleagues wrote. “Patients with type 2 diabetes who had five risk-factor variables within target ranges appeared to have little or no excess risks of death, myocardial infarction, and stroke as compared with the general population.”

Dr. Hu and his coauthors did not report any disclosures. Dr. Rawshani’s coauthors disclosed relationships with numerous companies including Amgen, Astra Zeneca, and Boehringer Ingelheim.

SOURCE: Hu Y et al. N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1803626. Rawshani A et al. N Engl J Med. 2018 Aug 16. doi: 10.1056/NEJMoa1800256.

Management of type 1 diabetes mellitus in children should include careful consideration of the unique features and challenges that differentiate it from T1DM in adults, according to a new position statement released by the American Diabetes Association.

The statement, published Aug. 10 in Diabetes Care, includes guidance on diagnosis, staging, screening, monitoring, treatment, nutrition, physical activity, and transition from pediatric to adult care.

With regard to diagnosis and staging, the recommendations emphasize the importance of distinguishing between T1DM, type 2 diabetes mellitus, and monogenic diabetes. It also asserts that a pediatric endocrinologist should be consulted before making a diagnosis when “isolated glycosuria or hyperglycemia is discovered in the setting of acute illness and in the absence of classic symptoms,” wrote Jane L. Chiang, MD, of McKinsey & Company and chief medical officer at Diasome Pharmaceuticals in Palo Alto, Calif., and coauthors.

The guidance also describes the three stages of type 1 diabetes development. Stage 1 is presymptomatic and features the presence of beta-cell autoimmunity. Stage 2, also presymptomatic, includes the presence of beta-cell autoimmunity with dysglycemia. Symptomatic disease from insulin deficiency begins in stage 3, and may include hyperglycemia, polyuria, polydipsia, weight loss, polyphagia, fatigue, and blurred vision. Perineal candidiasis is common in girls, and about one-third of cases present with diabetic ketoacidosis (DKA).

In patients with hyperglycemia symptoms, blood glucose, not hemoglobin A_1c, should be used to diagnose acute onset of disease. Delays in diagnosis and insulin replacement therapy should be avoided and a definitive diagnosis made quickly, the authors added.

Because the current method of using HbA_1c to diagnose diabetes was based on studies limited to adults, there is still debate over whether to use HbA_1c to diagnose T1DM in children and adolescents, Dr. Chiang and colleagues noted. Additionally, physicians must take care to distinguish between diabetes types because of increased numbers of overweight children with T1DM, as well as frequent misdiagnosis of monogenic diabetes as T1DM.

The position statement emphasizes the importance of insulin therapy as treatment for children with T1DM and recommends that most patients should be treated with either multiple injections of prandial and basal insulin, or with continuous subcutaneous insulin infusion. HbA_1c should be measured at 3-month intervals to assess glycemic control, with a target HbA_1c of less than 7.5%, the authors said. Also covered are recommendations for blood glucose monitoring, blood and urine ketone monitoring, and continuous glucose monitoring.

The importance of integrating an exercise and nutrition plan is also highlighted in the guidance. In addition to monitoring carbohydrate and caloric intake with the help of a dietitian, 60 minutes of moderate to vigorous activity daily are recommended as an exercise goal. Steps should also be taken to prevent hypoglycemia during and after exercise, the authors added.

Measures must also be taken to anticipate and address the unique behavioral and social challenges that accompany diabetes management in developing adolescents, the authors said. Social and family issues, peer relationships, and disordered eating should all be considered, and, starting at age 12 years, patients should be allowed time to speak in confidentiality with their health care provider, Dr. Chiang and colleagues said.

Additionally, as adolescents assert increased independence and autonomy, independent disease management should be facilitated, and issues such as depression and risky behaviors discussed.

The guidelines also discuss the importance of following the Centers for Disease Control and Prevention immunization schedule, and monitoring growth and weight gain. Patients with T1DM and their caregivers should also be sufficiently educated on comorbidities such as diabetic ketoacidosis, hypoglycemia, retinopathy, dyslipidemia, autoimmune diseases, and other complications.

Supportive environments such as diabetes camps, as well as technological advances, may be effective tools in encouraging diabetes self-management. Though there is no “optimal transition age” for the shift from pediatric to adult care, ADA recommends that providers begin transition preparation in the early adolescent years, and provide counseling on diabetes self-management.

“An ineffective transition from pediatric to adult diabetes care may contribute to fragmentation of health care and increased risk for adverse outcomes,” the authors said. “An individualized approach to transition timing is recommended, prioritizing the developmental needs and preferences of the patient.”

The authors reported relationships with Diasome Pharmaceuticals and numerous other companies.

SOURCE: Chiang J et al. Diabetes Care. 2018 Jul. doi: 10.2337/dci18-0023.

Management of type 1 diabetes mellitus in children should include careful consideration of the unique features and challenges that differentiate it from T1DM in adults, according to a new position statement released by the American Diabetes Association.

The statement, published Aug. 10 in Diabetes Care, includes guidance on diagnosis, staging, screening, monitoring, treatment, nutrition, physical activity, and transition from pediatric to adult care.

With regard to diagnosis and staging, the recommendations emphasize the importance of distinguishing between T1DM, type 2 diabetes mellitus, and monogenic diabetes. It also asserts that a pediatric endocrinologist should be consulted before making a diagnosis when “isolated glycosuria or hyperglycemia is discovered in the setting of acute illness and in the absence of classic symptoms,” wrote Jane L. Chiang, MD, of McKinsey & Company and chief medical officer at Diasome Pharmaceuticals in Palo Alto, Calif., and coauthors.

The guidance also describes the three stages of type 1 diabetes development. Stage 1 is presymptomatic and features the presence of beta-cell autoimmunity. Stage 2, also presymptomatic, includes the presence of beta-cell autoimmunity with dysglycemia. Symptomatic disease from insulin deficiency begins in stage 3, and may include hyperglycemia, polyuria, polydipsia, weight loss, polyphagia, fatigue, and blurred vision. Perineal candidiasis is common in girls, and about one-third of cases present with diabetic ketoacidosis (DKA).

In patients with hyperglycemia symptoms, blood glucose, not hemoglobin A_1c, should be used to diagnose acute onset of disease. Delays in diagnosis and insulin replacement therapy should be avoided and a definitive diagnosis made quickly, the authors added.

Because the current method of using HbA_1c to diagnose diabetes was based on studies limited to adults, there is still debate over whether to use HbA_1c to diagnose T1DM in children and adolescents, Dr. Chiang and colleagues noted. Additionally, physicians must take care to distinguish between diabetes types because of increased numbers of overweight children with T1DM, as well as frequent misdiagnosis of monogenic diabetes as T1DM.

The position statement emphasizes the importance of insulin therapy as treatment for children with T1DM and recommends that most patients should be treated with either multiple injections of prandial and basal insulin, or with continuous subcutaneous insulin infusion. HbA_1c should be measured at 3-month intervals to assess glycemic control, with a target HbA_1c of less than 7.5%, the authors said. Also covered are recommendations for blood glucose monitoring, blood and urine ketone monitoring, and continuous glucose monitoring.

The importance of integrating an exercise and nutrition plan is also highlighted in the guidance. In addition to monitoring carbohydrate and caloric intake with the help of a dietitian, 60 minutes of moderate to vigorous activity daily are recommended as an exercise goal. Steps should also be taken to prevent hypoglycemia during and after exercise, the authors added.

Measures must also be taken to anticipate and address the unique behavioral and social challenges that accompany diabetes management in developing adolescents, the authors said. Social and family issues, peer relationships, and disordered eating should all be considered, and, starting at age 12 years, patients should be allowed time to speak in confidentiality with their health care provider, Dr. Chiang and colleagues said.

Additionally, as adolescents assert increased independence and autonomy, independent disease management should be facilitated, and issues such as depression and risky behaviors discussed.

The guidelines also discuss the importance of following the Centers for Disease Control and Prevention immunization schedule, and monitoring growth and weight gain. Patients with T1DM and their caregivers should also be sufficiently educated on comorbidities such as diabetic ketoacidosis, hypoglycemia, retinopathy, dyslipidemia, autoimmune diseases, and other complications.

Supportive environments such as diabetes camps, as well as technological advances, may be effective tools in encouraging diabetes self-management. Though there is no “optimal transition age” for the shift from pediatric to adult care, ADA recommends that providers begin transition preparation in the early adolescent years, and provide counseling on diabetes self-management.

“An ineffective transition from pediatric to adult diabetes care may contribute to fragmentation of health care and increased risk for adverse outcomes,” the authors said. “An individualized approach to transition timing is recommended, prioritizing the developmental needs and preferences of the patient.”

The authors reported relationships with Diasome Pharmaceuticals and numerous other companies.

SOURCE: Chiang J et al. Diabetes Care. 2018 Jul. doi: 10.2337/dci18-0023.

Management of type 1 diabetes mellitus in children should include careful consideration of the unique features and challenges that differentiate it from T1DM in adults, according to a new position statement released by the American Diabetes Association.

The statement, published Aug. 10 in Diabetes Care, includes guidance on diagnosis, staging, screening, monitoring, treatment, nutrition, physical activity, and transition from pediatric to adult care.

With regard to diagnosis and staging, the recommendations emphasize the importance of distinguishing between T1DM, type 2 diabetes mellitus, and monogenic diabetes. It also asserts that a pediatric endocrinologist should be consulted before making a diagnosis when “isolated glycosuria or hyperglycemia is discovered in the setting of acute illness and in the absence of classic symptoms,” wrote Jane L. Chiang, MD, of McKinsey & Company and chief medical officer at Diasome Pharmaceuticals in Palo Alto, Calif., and coauthors.

The guidance also describes the three stages of type 1 diabetes development. Stage 1 is presymptomatic and features the presence of beta-cell autoimmunity. Stage 2, also presymptomatic, includes the presence of beta-cell autoimmunity with dysglycemia. Symptomatic disease from insulin deficiency begins in stage 3, and may include hyperglycemia, polyuria, polydipsia, weight loss, polyphagia, fatigue, and blurred vision. Perineal candidiasis is common in girls, and about one-third of cases present with diabetic ketoacidosis (DKA).

In patients with hyperglycemia symptoms, blood glucose, not hemoglobin A_1c, should be used to diagnose acute onset of disease. Delays in diagnosis and insulin replacement therapy should be avoided and a definitive diagnosis made quickly, the authors added.

Because the current method of using HbA_1c to diagnose diabetes was based on studies limited to adults, there is still debate over whether to use HbA_1c to diagnose T1DM in children and adolescents, Dr. Chiang and colleagues noted. Additionally, physicians must take care to distinguish between diabetes types because of increased numbers of overweight children with T1DM, as well as frequent misdiagnosis of monogenic diabetes as T1DM.

The position statement emphasizes the importance of insulin therapy as treatment for children with T1DM and recommends that most patients should be treated with either multiple injections of prandial and basal insulin, or with continuous subcutaneous insulin infusion. HbA_1c should be measured at 3-month intervals to assess glycemic control, with a target HbA_1c of less than 7.5%, the authors said. Also covered are recommendations for blood glucose monitoring, blood and urine ketone monitoring, and continuous glucose monitoring.

The importance of integrating an exercise and nutrition plan is also highlighted in the guidance. In addition to monitoring carbohydrate and caloric intake with the help of a dietitian, 60 minutes of moderate to vigorous activity daily are recommended as an exercise goal. Steps should also be taken to prevent hypoglycemia during and after exercise, the authors added.

Measures must also be taken to anticipate and address the unique behavioral and social challenges that accompany diabetes management in developing adolescents, the authors said. Social and family issues, peer relationships, and disordered eating should all be considered, and, starting at age 12 years, patients should be allowed time to speak in confidentiality with their health care provider, Dr. Chiang and colleagues said.

Additionally, as adolescents assert increased independence and autonomy, independent disease management should be facilitated, and issues such as depression and risky behaviors discussed.

The guidelines also discuss the importance of following the Centers for Disease Control and Prevention immunization schedule, and monitoring growth and weight gain. Patients with T1DM and their caregivers should also be sufficiently educated on comorbidities such as diabetic ketoacidosis, hypoglycemia, retinopathy, dyslipidemia, autoimmune diseases, and other complications.

Supportive environments such as diabetes camps, as well as technological advances, may be effective tools in encouraging diabetes self-management. Though there is no “optimal transition age” for the shift from pediatric to adult care, ADA recommends that providers begin transition preparation in the early adolescent years, and provide counseling on diabetes self-management.

“An ineffective transition from pediatric to adult diabetes care may contribute to fragmentation of health care and increased risk for adverse outcomes,” the authors said. “An individualized approach to transition timing is recommended, prioritizing the developmental needs and preferences of the patient.”

The authors reported relationships with Diasome Pharmaceuticals and numerous other companies.

SOURCE: Chiang J et al. Diabetes Care. 2018 Jul. doi: 10.2337/dci18-0023.

Traumatic brain injury might be associated with an increased risk of suicide, according to results published Aug. 14 in JAMA.

In a retrospective cohort study of 7,418,391 Danish individuals, including 34,529 who died by suicide, patients with medical contact for traumatic brain injury (TBI) had increased suicide risk, compared with the general population (adjusted incidence rate ratio [IRR] = 1.90; 95% confidence interval, 1.83-1.97).

Patients were aged 10 years or older, and follow-up was conducted from Jan. 1, 1980, until date of death, emigration from Denmark, or Dec. 31, 2014, whichever came first. Data were obtained from national registries, including the Danish Civil Registration System, the Database for Integrated Labour Market Research, the National Hospital Register, the Psychiatric Central Research Register, and the Cause of Death Register. Associations between the separate registries were possible because of unique identification numbers assigned to every resident of Denmark, wrote Trine Madsen, PhD, of the Danish Research Institute of Suicide Prevention at the Mental Health Centre Copenhagen, Capital Region of Denmark, and her coauthors.

TBI was recorded in the National Patient Register and was categorized into three types of injury: mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injury with evidence of structural brain injury). The number of medical contacts for distinct TBI events, accumulated number of days in hospital treatment, age at first TBI, and time since last medical contact for TBI also were assessed.

Data on psychiatric illness and nonfatal self-harm were obtained from the Psychiatric Central Research Register, because of their association with suicide. Data for deaths by suicide were obtained from the Cause of Death Register. Demographic data collected from other registries included sex, age, marital status, cohabitation status, education, and socioeconomic status. IRRs were calculated using adjusted Poisson regression models.

Of 7,418,391 residents of Denmark included in the follow-up period from 1980 to 2014; 567,823 had a TBI diagnosis. Dr. Madsen and her coauthors also found that 423,502 patients (5.7%) were diagnosed with mild TBI, 24,221 (0.3%) with skull fracture, and 120,100 (1.6%) with severe TBI. A total of 34,529 died by suicide.

Of those who died by suicide, 3,536 (10.2%) had a previous TBI diagnosis (2,701 with mild TBI, 174 with skull fracture, and 661 with severe TBI). The absolute rate of suicide in individuals with hospital contact for TBI was 40.6 per 100,000 person-years (95% CI, 39.2-41.9), compared with 19.9 per 100,000 person-years (95% CI, 19.7-20.1) in those with no hospital contact for TBI.

The fully adjusted analysis showed an IRR of 1.90 (95% CI, 1.83-1.97), as well as an increased risk of suicide by TBI severity. The absolute rate for mild TBI was 38.6 per 100,000 person-years (95% CI, 37.1-40.0) with an IRR of 1.81 (95% CI, 1.74-1.88); 42.4 per 100,000 person-years for skull fracture (95% CI, 36.1-48.7) with an IRR of 2.01 (95% CI, 1.73-2.34, P less than .001), and 50.8 per 100,000 person-years for severe TBI (95% CI, 46.9-54.6) with an IRR of 2.38 (95% CI, 2.20-2.58, P less than .001), compared with individuals with no TBI, the authors wrote.

SOURCE: Madsen T et al. JAMA. 2018 Aug 14;320(6):580-8.

Traumatic brain injury might be associated with an increased risk of suicide, according to results published Aug. 14 in JAMA.

In a retrospective cohort study of 7,418,391 Danish individuals, including 34,529 who died by suicide, patients with medical contact for traumatic brain injury (TBI) had increased suicide risk, compared with the general population (adjusted incidence rate ratio [IRR] = 1.90; 95% confidence interval, 1.83-1.97).

Patients were aged 10 years or older, and follow-up was conducted from Jan. 1, 1980, until date of death, emigration from Denmark, or Dec. 31, 2014, whichever came first. Data were obtained from national registries, including the Danish Civil Registration System, the Database for Integrated Labour Market Research, the National Hospital Register, the Psychiatric Central Research Register, and the Cause of Death Register. Associations between the separate registries were possible because of unique identification numbers assigned to every resident of Denmark, wrote Trine Madsen, PhD, of the Danish Research Institute of Suicide Prevention at the Mental Health Centre Copenhagen, Capital Region of Denmark, and her coauthors.

TBI was recorded in the National Patient Register and was categorized into three types of injury: mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injury with evidence of structural brain injury). The number of medical contacts for distinct TBI events, accumulated number of days in hospital treatment, age at first TBI, and time since last medical contact for TBI also were assessed.

Data on psychiatric illness and nonfatal self-harm were obtained from the Psychiatric Central Research Register, because of their association with suicide. Data for deaths by suicide were obtained from the Cause of Death Register. Demographic data collected from other registries included sex, age, marital status, cohabitation status, education, and socioeconomic status. IRRs were calculated using adjusted Poisson regression models.

Of 7,418,391 residents of Denmark included in the follow-up period from 1980 to 2014; 567,823 had a TBI diagnosis. Dr. Madsen and her coauthors also found that 423,502 patients (5.7%) were diagnosed with mild TBI, 24,221 (0.3%) with skull fracture, and 120,100 (1.6%) with severe TBI. A total of 34,529 died by suicide.

Of those who died by suicide, 3,536 (10.2%) had a previous TBI diagnosis (2,701 with mild TBI, 174 with skull fracture, and 661 with severe TBI). The absolute rate of suicide in individuals with hospital contact for TBI was 40.6 per 100,000 person-years (95% CI, 39.2-41.9), compared with 19.9 per 100,000 person-years (95% CI, 19.7-20.1) in those with no hospital contact for TBI.

The fully adjusted analysis showed an IRR of 1.90 (95% CI, 1.83-1.97), as well as an increased risk of suicide by TBI severity. The absolute rate for mild TBI was 38.6 per 100,000 person-years (95% CI, 37.1-40.0) with an IRR of 1.81 (95% CI, 1.74-1.88); 42.4 per 100,000 person-years for skull fracture (95% CI, 36.1-48.7) with an IRR of 2.01 (95% CI, 1.73-2.34, P less than .001), and 50.8 per 100,000 person-years for severe TBI (95% CI, 46.9-54.6) with an IRR of 2.38 (95% CI, 2.20-2.58, P less than .001), compared with individuals with no TBI, the authors wrote.

SOURCE: Madsen T et al. JAMA. 2018 Aug 14;320(6):580-8.

Traumatic brain injury might be associated with an increased risk of suicide, according to results published Aug. 14 in JAMA.

In a retrospective cohort study of 7,418,391 Danish individuals, including 34,529 who died by suicide, patients with medical contact for traumatic brain injury (TBI) had increased suicide risk, compared with the general population (adjusted incidence rate ratio [IRR] = 1.90; 95% confidence interval, 1.83-1.97).

Patients were aged 10 years or older, and follow-up was conducted from Jan. 1, 1980, until date of death, emigration from Denmark, or Dec. 31, 2014, whichever came first. Data were obtained from national registries, including the Danish Civil Registration System, the Database for Integrated Labour Market Research, the National Hospital Register, the Psychiatric Central Research Register, and the Cause of Death Register. Associations between the separate registries were possible because of unique identification numbers assigned to every resident of Denmark, wrote Trine Madsen, PhD, of the Danish Research Institute of Suicide Prevention at the Mental Health Centre Copenhagen, Capital Region of Denmark, and her coauthors.

TBI was recorded in the National Patient Register and was categorized into three types of injury: mild TBI (concussion), skull fracture without documented TBI, and severe TBI (head injury with evidence of structural brain injury). The number of medical contacts for distinct TBI events, accumulated number of days in hospital treatment, age at first TBI, and time since last medical contact for TBI also were assessed.

Data on psychiatric illness and nonfatal self-harm were obtained from the Psychiatric Central Research Register, because of their association with suicide. Data for deaths by suicide were obtained from the Cause of Death Register. Demographic data collected from other registries included sex, age, marital status, cohabitation status, education, and socioeconomic status. IRRs were calculated using adjusted Poisson regression models.

Of 7,418,391 residents of Denmark included in the follow-up period from 1980 to 2014; 567,823 had a TBI diagnosis. Dr. Madsen and her coauthors also found that 423,502 patients (5.7%) were diagnosed with mild TBI, 24,221 (0.3%) with skull fracture, and 120,100 (1.6%) with severe TBI. A total of 34,529 died by suicide.

Of those who died by suicide, 3,536 (10.2%) had a previous TBI diagnosis (2,701 with mild TBI, 174 with skull fracture, and 661 with severe TBI). The absolute rate of suicide in individuals with hospital contact for TBI was 40.6 per 100,000 person-years (95% CI, 39.2-41.9), compared with 19.9 per 100,000 person-years (95% CI, 19.7-20.1) in those with no hospital contact for TBI.

The fully adjusted analysis showed an IRR of 1.90 (95% CI, 1.83-1.97), as well as an increased risk of suicide by TBI severity. The absolute rate for mild TBI was 38.6 per 100,000 person-years (95% CI, 37.1-40.0) with an IRR of 1.81 (95% CI, 1.74-1.88); 42.4 per 100,000 person-years for skull fracture (95% CI, 36.1-48.7) with an IRR of 2.01 (95% CI, 1.73-2.34, P less than .001), and 50.8 per 100,000 person-years for severe TBI (95% CI, 46.9-54.6) with an IRR of 2.38 (95% CI, 2.20-2.58, P less than .001), compared with individuals with no TBI, the authors wrote.

SOURCE: Madsen T et al. JAMA. 2018 Aug 14;320(6):580-8.

Anemia is known to be a common condition in patients undergoing hiatal hernia repair (HHR), but it turns out to be associated with elevated risk of postoperative complications, according to findings published in Surgical Endoscopy.

In a retrospective study of 263 patients who underwent HHR, 27% were anemic. Anemia in these patients was associated with 2.6-fold greater odds of postoperative complications, reported Guillaume S. Chevrollier, MD, of the department of surgery at Jefferson Medical College, Philadelphia, and his coauthors.

Investigators identified 263 patients for study who underwent HHR between January 2011 and April 2017. Preoperative data included a full physical examination, chest x-ray, esophagogastroduodenoscopy, esophageal manometry, 24-hour pH study, and routine blood work.

Patient data were also assessed for identification of Cameron lesions, defined as either linear erosions or ulcers present at the diaphragmatic hiatus. Baseline data collected for analysis included age, sex, body mass index, Charlson Comorbidity Index, hernia type, hernia size, surgical approach, and urgency of repair.

Preoperative anemia was defined as serum hemoglobin levels less than 13 mg/dL in men and less than 12 mg/dL in women, in accordance with World Health Organization criteria. Outcomes of anemic and nonanemic patients were compared and included measures such as estimated blood loss, operative times, need for blood transfusion, intensive care unit admission, and postoperative complications. Postoperative complications were assessed for severity using the Clavien-Dindo Scale, Dr. Chevrollier and his colleagues wrote.

In total, 70 patients (27%) were anemic before their hernia repair surgery. A majority of patients (54%) were aged 65 years or older, of whom 29% were anemic. Large hernias were most common (60%), followed by moderate size (18%), giant (14%), and small (8%).

Sixty-four patients (24%) developed postoperative complications. Among anemic patients, 41% developed one or more complications, compared with just 18% of nonanemic patients (P less than .01). Anemia was associated with 2.6-fold greater odds of postoperative complications in adjusted multivariable analysis (odds ratio, 2.57; 95% confidence interval, 1.36-4.86; P less than .01), the authors reported.

“Heightened awareness for the presence and the implications of preoperative anemia in patients undergoing HHR is necessary,” the authors wrote. “Consideration for treatment of anemia prior to elective repair is likely warranted.”

No disclosures or conflicts of interest were reported.

SOURCE: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.

Anemia is known to be a common condition in patients undergoing hiatal hernia repair (HHR), but it turns out to be associated with elevated risk of postoperative complications, according to findings published in Surgical Endoscopy.

In a retrospective study of 263 patients who underwent HHR, 27% were anemic. Anemia in these patients was associated with 2.6-fold greater odds of postoperative complications, reported Guillaume S. Chevrollier, MD, of the department of surgery at Jefferson Medical College, Philadelphia, and his coauthors.

Investigators identified 263 patients for study who underwent HHR between January 2011 and April 2017. Preoperative data included a full physical examination, chest x-ray, esophagogastroduodenoscopy, esophageal manometry, 24-hour pH study, and routine blood work.

Patient data were also assessed for identification of Cameron lesions, defined as either linear erosions or ulcers present at the diaphragmatic hiatus. Baseline data collected for analysis included age, sex, body mass index, Charlson Comorbidity Index, hernia type, hernia size, surgical approach, and urgency of repair.

Preoperative anemia was defined as serum hemoglobin levels less than 13 mg/dL in men and less than 12 mg/dL in women, in accordance with World Health Organization criteria. Outcomes of anemic and nonanemic patients were compared and included measures such as estimated blood loss, operative times, need for blood transfusion, intensive care unit admission, and postoperative complications. Postoperative complications were assessed for severity using the Clavien-Dindo Scale, Dr. Chevrollier and his colleagues wrote.

In total, 70 patients (27%) were anemic before their hernia repair surgery. A majority of patients (54%) were aged 65 years or older, of whom 29% were anemic. Large hernias were most common (60%), followed by moderate size (18%), giant (14%), and small (8%).

Sixty-four patients (24%) developed postoperative complications. Among anemic patients, 41% developed one or more complications, compared with just 18% of nonanemic patients (P less than .01). Anemia was associated with 2.6-fold greater odds of postoperative complications in adjusted multivariable analysis (odds ratio, 2.57; 95% confidence interval, 1.36-4.86; P less than .01), the authors reported.

“Heightened awareness for the presence and the implications of preoperative anemia in patients undergoing HHR is necessary,” the authors wrote. “Consideration for treatment of anemia prior to elective repair is likely warranted.”

No disclosures or conflicts of interest were reported.

SOURCE: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.

Anemia is known to be a common condition in patients undergoing hiatal hernia repair (HHR), but it turns out to be associated with elevated risk of postoperative complications, according to findings published in Surgical Endoscopy.

In a retrospective study of 263 patients who underwent HHR, 27% were anemic. Anemia in these patients was associated with 2.6-fold greater odds of postoperative complications, reported Guillaume S. Chevrollier, MD, of the department of surgery at Jefferson Medical College, Philadelphia, and his coauthors.

Investigators identified 263 patients for study who underwent HHR between January 2011 and April 2017. Preoperative data included a full physical examination, chest x-ray, esophagogastroduodenoscopy, esophageal manometry, 24-hour pH study, and routine blood work.

Patient data were also assessed for identification of Cameron lesions, defined as either linear erosions or ulcers present at the diaphragmatic hiatus. Baseline data collected for analysis included age, sex, body mass index, Charlson Comorbidity Index, hernia type, hernia size, surgical approach, and urgency of repair.

Preoperative anemia was defined as serum hemoglobin levels less than 13 mg/dL in men and less than 12 mg/dL in women, in accordance with World Health Organization criteria. Outcomes of anemic and nonanemic patients were compared and included measures such as estimated blood loss, operative times, need for blood transfusion, intensive care unit admission, and postoperative complications. Postoperative complications were assessed for severity using the Clavien-Dindo Scale, Dr. Chevrollier and his colleagues wrote.

In total, 70 patients (27%) were anemic before their hernia repair surgery. A majority of patients (54%) were aged 65 years or older, of whom 29% were anemic. Large hernias were most common (60%), followed by moderate size (18%), giant (14%), and small (8%).

Sixty-four patients (24%) developed postoperative complications. Among anemic patients, 41% developed one or more complications, compared with just 18% of nonanemic patients (P less than .01). Anemia was associated with 2.6-fold greater odds of postoperative complications in adjusted multivariable analysis (odds ratio, 2.57; 95% confidence interval, 1.36-4.86; P less than .01), the authors reported.

“Heightened awareness for the presence and the implications of preoperative anemia in patients undergoing HHR is necessary,” the authors wrote. “Consideration for treatment of anemia prior to elective repair is likely warranted.”

No disclosures or conflicts of interest were reported.

SOURCE: Chevrollier G et al. Surg Endosc. 2018 Jul 11. doi: 10.1007/s00464-018-6328-4.

Prevalence of depression in fathers was similar to that of mothers screened at well-child visits, according to a research letter published in JAMA Pediatrics.

An analysis of data obtained from the Child Health Improvement through Computer Automation (CHICA) pediatric health surveillance system found that 4.4% of fathers who attended the well-child visit and completed a prescreening form scored positive for depression, comparable with the rate in mothers (5%). Overall, fathers composed 11.7% of parents who screened positive for depression, reported Erika R. Cheng, PhD, of Indiana University, Indianapolis, and her colleagues.

Dr. Cheng and her colleagues estimated prevalence of paternal depression using CHICA data from parents of children aged 15 months and younger from five community health centers in Indianapolis between August 1, 2016, and December 31, 2017. CHICA is a 20-question prescreen of pediatric health conditions based on the patient’s existing data.

Maternal postpartum depression was assessed using a modified version of the Edinburgh Postnatal Depression Scale, administered every 90 days during the child’s first 15 months of life, Dr. Cheng and her colleagues wrote.

Fathers were present at 30.8% of well-child visits (2,946 of 9,572) and completed the prescreening at 806 visits (8.4% of total visits). A total of 36 (4.4%) fathers screened positive for depression, compared with 273 (5%) mothers. However, since CHICA assesses depression for only one parent, some cases of paternal depression may have been missed, the investigators added.

“Pediatric clinics are thus promising settings in which to address depression in both parents as part of a family-centered approach to care,” Dr. Cheng and her coauthors concluded. “Addressing these gaps could improve detection and treatment rates of postnatal depression in both mothers and fathers.”

Two of the authors coinvented the CHICA system, and one is a co-owner of Digital Health Solutions, which licensed the system. No other disclosures were reported.

SOURCE: Cheng ER et al. JAMA Pediatr. 2018 Jul 23. doi:10.1001/jamapediatrics.2018.1505.

Prevalence of depression in fathers was similar to that of mothers screened at well-child visits, according to a research letter published in JAMA Pediatrics.

An analysis of data obtained from the Child Health Improvement through Computer Automation (CHICA) pediatric health surveillance system found that 4.4% of fathers who attended the well-child visit and completed a prescreening form scored positive for depression, comparable with the rate in mothers (5%). Overall, fathers composed 11.7% of parents who screened positive for depression, reported Erika R. Cheng, PhD, of Indiana University, Indianapolis, and her colleagues.

Dr. Cheng and her colleagues estimated prevalence of paternal depression using CHICA data from parents of children aged 15 months and younger from five community health centers in Indianapolis between August 1, 2016, and December 31, 2017. CHICA is a 20-question prescreen of pediatric health conditions based on the patient’s existing data.

Maternal postpartum depression was assessed using a modified version of the Edinburgh Postnatal Depression Scale, administered every 90 days during the child’s first 15 months of life, Dr. Cheng and her colleagues wrote.

Fathers were present at 30.8% of well-child visits (2,946 of 9,572) and completed the prescreening at 806 visits (8.4% of total visits). A total of 36 (4.4%) fathers screened positive for depression, compared with 273 (5%) mothers. However, since CHICA assesses depression for only one parent, some cases of paternal depression may have been missed, the investigators added.

“Pediatric clinics are thus promising settings in which to address depression in both parents as part of a family-centered approach to care,” Dr. Cheng and her coauthors concluded. “Addressing these gaps could improve detection and treatment rates of postnatal depression in both mothers and fathers.”

Two of the authors coinvented the CHICA system, and one is a co-owner of Digital Health Solutions, which licensed the system. No other disclosures were reported.

SOURCE: Cheng ER et al. JAMA Pediatr. 2018 Jul 23. doi:10.1001/jamapediatrics.2018.1505.

Prevalence of depression in fathers was similar to that of mothers screened at well-child visits, according to a research letter published in JAMA Pediatrics.

An analysis of data obtained from the Child Health Improvement through Computer Automation (CHICA) pediatric health surveillance system found that 4.4% of fathers who attended the well-child visit and completed a prescreening form scored positive for depression, comparable with the rate in mothers (5%). Overall, fathers composed 11.7% of parents who screened positive for depression, reported Erika R. Cheng, PhD, of Indiana University, Indianapolis, and her colleagues.

Dr. Cheng and her colleagues estimated prevalence of paternal depression using CHICA data from parents of children aged 15 months and younger from five community health centers in Indianapolis between August 1, 2016, and December 31, 2017. CHICA is a 20-question prescreen of pediatric health conditions based on the patient’s existing data.

Maternal postpartum depression was assessed using a modified version of the Edinburgh Postnatal Depression Scale, administered every 90 days during the child’s first 15 months of life, Dr. Cheng and her colleagues wrote.

Fathers were present at 30.8% of well-child visits (2,946 of 9,572) and completed the prescreening at 806 visits (8.4% of total visits). A total of 36 (4.4%) fathers screened positive for depression, compared with 273 (5%) mothers. However, since CHICA assesses depression for only one parent, some cases of paternal depression may have been missed, the investigators added.

“Pediatric clinics are thus promising settings in which to address depression in both parents as part of a family-centered approach to care,” Dr. Cheng and her coauthors concluded. “Addressing these gaps could improve detection and treatment rates of postnatal depression in both mothers and fathers.”

Two of the authors coinvented the CHICA system, and one is a co-owner of Digital Health Solutions, which licensed the system. No other disclosures were reported.

SOURCE: Cheng ER et al. JAMA Pediatr. 2018 Jul 23. doi:10.1001/jamapediatrics.2018.1505.

Respiratory illness was the most common pediatric emergency in ambulatory settings, followed by psychiatric and behavioral illness, seizures, and syncope, according to results published July 20 in Pediatrics.

Investigators conducted a retrospective observational study of data from the Indianapolis emergency medical services (EMS) system between Jan. 1, 2012, and Dec. 31, 2014. All patients younger than 18 years were eligible.

Of 38,841 pediatric EMS transports in the Indianapolis metropolitan area during the 3-year period, fewer than 1% (322) were verified as originating from an ambulatory practice, reported Matthew L. Yuknis, MD, and his coauthors at Indiana University, Indianapolis. Respiratory distress was the most common emergency (58%), followed by psychiatric and behavioral illness (6%), seizure (6%), and syncope (5%).

The most common interventions were use of supplemental oxygen (27%), albuterol (26%), and intravascular access (11%). The most common critical care interventions were administration of fluid bolus (2%), benzodiazepine (2%), or racemic or intramuscular epinephrine (1%). None required use of an artificial airway, cardiopulmonary resuscitation, intraosseous access, or bag mask ventilation, Dr. Yuknis and his colleagues said.

The average time from call to on-scene arrival was 6 minutes (ranging from less than 1 to 15 minutes). The average patient transport time was 13 minutes (ranging from less than 1 to 38 minutes). The average annual frequency of pediatric outpatient emergencies was 42 emergencies per 100,000 people under 18 years of age. Lower socioeconomic status was correlated with increased frequency of emergencies in ambulatory settings, the authors reported.

“These findings update and clarify existing literature with regard to the frequency of pediatric emergencies in the ambulatory setting, the conditions these patients present with, and the use of EMS data to define these events,” the authors wrote. Additionally, the findings can be used to “inform future decisions regarding necessary equipment and procedures.”

No relevant financial disclosures were reported. There was no external funding.

SOURCE: Yuknis M et al. Pediatrics. 2018. doi: 10.1542/peds.2017-3082.

Respiratory illness was the most common pediatric emergency in ambulatory settings, followed by psychiatric and behavioral illness, seizures, and syncope, according to results published July 20 in Pediatrics.

Investigators conducted a retrospective observational study of data from the Indianapolis emergency medical services (EMS) system between Jan. 1, 2012, and Dec. 31, 2014. All patients younger than 18 years were eligible.

Of 38,841 pediatric EMS transports in the Indianapolis metropolitan area during the 3-year period, fewer than 1% (322) were verified as originating from an ambulatory practice, reported Matthew L. Yuknis, MD, and his coauthors at Indiana University, Indianapolis. Respiratory distress was the most common emergency (58%), followed by psychiatric and behavioral illness (6%), seizure (6%), and syncope (5%).

The most common interventions were use of supplemental oxygen (27%), albuterol (26%), and intravascular access (11%). The most common critical care interventions were administration of fluid bolus (2%), benzodiazepine (2%), or racemic or intramuscular epinephrine (1%). None required use of an artificial airway, cardiopulmonary resuscitation, intraosseous access, or bag mask ventilation, Dr. Yuknis and his colleagues said.

The average time from call to on-scene arrival was 6 minutes (ranging from less than 1 to 15 minutes). The average patient transport time was 13 minutes (ranging from less than 1 to 38 minutes). The average annual frequency of pediatric outpatient emergencies was 42 emergencies per 100,000 people under 18 years of age. Lower socioeconomic status was correlated with increased frequency of emergencies in ambulatory settings, the authors reported.

“These findings update and clarify existing literature with regard to the frequency of pediatric emergencies in the ambulatory setting, the conditions these patients present with, and the use of EMS data to define these events,” the authors wrote. Additionally, the findings can be used to “inform future decisions regarding necessary equipment and procedures.”

No relevant financial disclosures were reported. There was no external funding.

SOURCE: Yuknis M et al. Pediatrics. 2018. doi: 10.1542/peds.2017-3082.

Respiratory illness was the most common pediatric emergency in ambulatory settings, followed by psychiatric and behavioral illness, seizures, and syncope, according to results published July 20 in Pediatrics.

Investigators conducted a retrospective observational study of data from the Indianapolis emergency medical services (EMS) system between Jan. 1, 2012, and Dec. 31, 2014. All patients younger than 18 years were eligible.

Of 38,841 pediatric EMS transports in the Indianapolis metropolitan area during the 3-year period, fewer than 1% (322) were verified as originating from an ambulatory practice, reported Matthew L. Yuknis, MD, and his coauthors at Indiana University, Indianapolis. Respiratory distress was the most common emergency (58%), followed by psychiatric and behavioral illness (6%), seizure (6%), and syncope (5%).

The most common interventions were use of supplemental oxygen (27%), albuterol (26%), and intravascular access (11%). The most common critical care interventions were administration of fluid bolus (2%), benzodiazepine (2%), or racemic or intramuscular epinephrine (1%). None required use of an artificial airway, cardiopulmonary resuscitation, intraosseous access, or bag mask ventilation, Dr. Yuknis and his colleagues said.

The average time from call to on-scene arrival was 6 minutes (ranging from less than 1 to 15 minutes). The average patient transport time was 13 minutes (ranging from less than 1 to 38 minutes). The average annual frequency of pediatric outpatient emergencies was 42 emergencies per 100,000 people under 18 years of age. Lower socioeconomic status was correlated with increased frequency of emergencies in ambulatory settings, the authors reported.

“These findings update and clarify existing literature with regard to the frequency of pediatric emergencies in the ambulatory setting, the conditions these patients present with, and the use of EMS data to define these events,” the authors wrote. Additionally, the findings can be used to “inform future decisions regarding necessary equipment and procedures.”

No relevant financial disclosures were reported. There was no external funding.

SOURCE: Yuknis M et al. Pediatrics. 2018. doi: 10.1542/peds.2017-3082.

Digital technology use by parents during family activities may exacerbate internalizing or externalizing behavior in their children, according to results published in Pediatric Research.

In a study of 183 couples with children aged 5 years or younger, mothers perceived an average of 1.65 devices as interfering in their interactions with their child at least once per day, compared with an average of 1.43 devices per day for fathers. In addition, 56% of mothers and 43% of fathers reported that two or more devices interrupted their parent-child activities on a daily basis.

Higher technology interference (“technoference”) was associated with greater externalizing and internalizing behaviors in children and higher parenting stress for both mothers and fathers. Technoference also was associated with lower coparenting quality in fathers only, and greater parent depressive symptoms in mothers only, reported Brandon T. McDaniel, PhD, of Illinois State University, Normal, and Jenny S. Radesky, MD, of the University of Michigan, Ann Arbor.

Zinkevych/iStock/Getty Images

SOURCE: McDaniel B et al. Pediatr Res. 2018. doi: 10.1038/s41390-018-0052-6.

Digital technology use by parents during family activities may exacerbate internalizing or externalizing behavior in their children, according to results published in Pediatric Research.

In a study of 183 couples with children aged 5 years or younger, mothers perceived an average of 1.65 devices as interfering in their interactions with their child at least once per day, compared with an average of 1.43 devices per day for fathers. In addition, 56% of mothers and 43% of fathers reported that two or more devices interrupted their parent-child activities on a daily basis.

Higher technology interference (“technoference”) was associated with greater externalizing and internalizing behaviors in children and higher parenting stress for both mothers and fathers. Technoference also was associated with lower coparenting quality in fathers only, and greater parent depressive symptoms in mothers only, reported Brandon T. McDaniel, PhD, of Illinois State University, Normal, and Jenny S. Radesky, MD, of the University of Michigan, Ann Arbor.

Zinkevych/iStock/Getty Images

SOURCE: McDaniel B et al. Pediatr Res. 2018. doi: 10.1038/s41390-018-0052-6.

Digital technology use by parents during family activities may exacerbate internalizing or externalizing behavior in their children, according to results published in Pediatric Research.

In a study of 183 couples with children aged 5 years or younger, mothers perceived an average of 1.65 devices as interfering in their interactions with their child at least once per day, compared with an average of 1.43 devices per day for fathers. In addition, 56% of mothers and 43% of fathers reported that two or more devices interrupted their parent-child activities on a daily basis.

Higher technology interference (“technoference”) was associated with greater externalizing and internalizing behaviors in children and higher parenting stress for both mothers and fathers. Technoference also was associated with lower coparenting quality in fathers only, and greater parent depressive symptoms in mothers only, reported Brandon T. McDaniel, PhD, of Illinois State University, Normal, and Jenny S. Radesky, MD, of the University of Michigan, Ann Arbor.

Zinkevych/iStock/Getty Images

SOURCE: McDaniel B et al. Pediatr Res. 2018. doi: 10.1038/s41390-018-0052-6.

New clinical guidelines for pediatric hypertension resulted in increased prevalence of hypertension and improved sensitivity in detecting target organ damage among at-risk youth, according to findings published in Pediatrics.

In a clinical practice guideline (CPG) published in 2017, the American Academy of Pediatrics updated its 2004 guideline to include new reference tables for BP values in addition to new definitions of elevated BP and hypertension, including absolute BP cutoff values for adolescents aged 13 years and older (Pediatrics. 2017 Sep;140[6]:e20173035). This was intended to “emulate the recently updated adult hypertension guidelines and to simplify the process of identifying and classifying hypertension in adolescents,” wrote Michael Khoury, MD, of the Heart Institute at Cincinnati Children’s Hospital Medical Center, and his coauthors.

To evaluate the impact of the new guidelines on the prevalence of hypertension and associations with target organ damage, the investigators used data from a study on obesity and type 2 diabetes in 364 patients aged 10-17 years; 59% were obese, and 30% had type 2 diabetes. Three groups were identified: patients with obesity and type 2 diabetes, patients with obesity but no type 2 diabetes, and healthy (“lean”) controls.

Patients fasted overnight for a minimum of 10 hours, after which body mass index was calculated, blood pressure was taken, and anthropometric, laboratory, echocardiography, and carotid assessments were performed. Average BP measurements were categorized according to the 2004 guideline and to the new CPG.

In carotid ultrasonography assessments, a composite of carotid intima-media thickness was formed from the average of three sites, and a composite carotid intima-media thickness greater than or equal to the 90th percentile of that measured in the lean patients, who were the controls, was considered abnormal. In echocardiography assessments, left ventricular mass (LVM) and LVM index were calculated. Elevated LVM was defined by the pediatric cutoff of LVM index greater than or equal to 38.6 g/m.

For diastolic function, tissue Doppler velocities under the 10th percentile and an average early left ventricular filling/peak early myocardial velocity ratio greater than or equal to the 90th percentile in controls were considered abnormal. Lastly, pulse wave velocity (PWV) was measured to determine arterial stiffness, and a PWV greater than or equal to the 90th percentile for the controls was considered abnormal.

BP classification under the new guideline resulted in an increased prevalence of hypertension at 13% (10% stage 1, 3% stage 2), compared with the 2004 guideline at 8% (6% stage 1, 2% stage 2), with a P value of .007.

Of the 75 patients classified as having elevated BP in the 2004 guideline, 19 (25%) were reclassified as having stage 1 hypertension under the CPG. These 19 patients were older, compared with patients who remained in the elevated blood pressure category (16.5 ± 0.9 vs. 15.5 ± 1.7 years; P = .02). The patients who were reclassified also had higher body mass indexes (38.8 ± 8.2 vs. 33.6 ± 7.4; P = .01) and diastolic blood pressures (76.5 mm Hg ± 8.7 vs. 62.1 ± 12.2 mm Hg; P less than .001), Dr. Khoury and his colleagues reported.

Reclassification to a higher BP category was associated with increased odds of an abnormal target organ damage (TOD) values, and both guidelines produced similar odds, “suggesting that the two guidelines produce similar associations with TOD,” the authors wrote. Reclassification based on the CPG definition accounted for 31% of patients with increased LVM, compared with 20% as defined in the 2004 guideline (P less than .001), and for 33% of patients with abnormal PWV, compared with 23% in the 2004 guideline, suggesting improved sensitivity of hypertension categorization in detecting LVM. A similar effect was seen in other measures of TOD, the authors noted.

The findings suggest that, combined with the increased prevalence of hypertension under the new guidelines, “the CPG may contribute to an increased detection of abnormal LVM and other measures of TOD,” the authors wrote. “This, in turn, may contribute to risk stratification in clinical decision making for youth presenting with BP concerns,” they concluded.

The study was supported by a National Institutes of Health grant. The authors had no relevant disclosures.

SOURCE: Khoury M et al. Pediatrics. 2018 Jul 5. doi: 10.1542/peds.2018-0245.

New clinical guidelines for pediatric hypertension resulted in increased prevalence of hypertension and improved sensitivity in detecting target organ damage among at-risk youth, according to findings published in Pediatrics.

In a clinical practice guideline (CPG) published in 2017, the American Academy of Pediatrics updated its 2004 guideline to include new reference tables for BP values in addition to new definitions of elevated BP and hypertension, including absolute BP cutoff values for adolescents aged 13 years and older (Pediatrics. 2017 Sep;140[6]:e20173035). This was intended to “emulate the recently updated adult hypertension guidelines and to simplify the process of identifying and classifying hypertension in adolescents,” wrote Michael Khoury, MD, of the Heart Institute at Cincinnati Children’s Hospital Medical Center, and his coauthors.

To evaluate the impact of the new guidelines on the prevalence of hypertension and associations with target organ damage, the investigators used data from a study on obesity and type 2 diabetes in 364 patients aged 10-17 years; 59% were obese, and 30% had type 2 diabetes. Three groups were identified: patients with obesity and type 2 diabetes, patients with obesity but no type 2 diabetes, and healthy (“lean”) controls.

Patients fasted overnight for a minimum of 10 hours, after which body mass index was calculated, blood pressure was taken, and anthropometric, laboratory, echocardiography, and carotid assessments were performed. Average BP measurements were categorized according to the 2004 guideline and to the new CPG.

In carotid ultrasonography assessments, a composite of carotid intima-media thickness was formed from the average of three sites, and a composite carotid intima-media thickness greater than or equal to the 90th percentile of that measured in the lean patients, who were the controls, was considered abnormal. In echocardiography assessments, left ventricular mass (LVM) and LVM index were calculated. Elevated LVM was defined by the pediatric cutoff of LVM index greater than or equal to 38.6 g/m.

For diastolic function, tissue Doppler velocities under the 10th percentile and an average early left ventricular filling/peak early myocardial velocity ratio greater than or equal to the 90th percentile in controls were considered abnormal. Lastly, pulse wave velocity (PWV) was measured to determine arterial stiffness, and a PWV greater than or equal to the 90th percentile for the controls was considered abnormal.

BP classification under the new guideline resulted in an increased prevalence of hypertension at 13% (10% stage 1, 3% stage 2), compared with the 2004 guideline at 8% (6% stage 1, 2% stage 2), with a P value of .007.

Of the 75 patients classified as having elevated BP in the 2004 guideline, 19 (25%) were reclassified as having stage 1 hypertension under the CPG. These 19 patients were older, compared with patients who remained in the elevated blood pressure category (16.5 ± 0.9 vs. 15.5 ± 1.7 years; P = .02). The patients who were reclassified also had higher body mass indexes (38.8 ± 8.2 vs. 33.6 ± 7.4; P = .01) and diastolic blood pressures (76.5 mm Hg ± 8.7 vs. 62.1 ± 12.2 mm Hg; P less than .001), Dr. Khoury and his colleagues reported.

Reclassification to a higher BP category was associated with increased odds of an abnormal target organ damage (TOD) values, and both guidelines produced similar odds, “suggesting that the two guidelines produce similar associations with TOD,” the authors wrote. Reclassification based on the CPG definition accounted for 31% of patients with increased LVM, compared with 20% as defined in the 2004 guideline (P less than .001), and for 33% of patients with abnormal PWV, compared with 23% in the 2004 guideline, suggesting improved sensitivity of hypertension categorization in detecting LVM. A similar effect was seen in other measures of TOD, the authors noted.

The findings suggest that, combined with the increased prevalence of hypertension under the new guidelines, “the CPG may contribute to an increased detection of abnormal LVM and other measures of TOD,” the authors wrote. “This, in turn, may contribute to risk stratification in clinical decision making for youth presenting with BP concerns,” they concluded.

The study was supported by a National Institutes of Health grant. The authors had no relevant disclosures.

SOURCE: Khoury M et al. Pediatrics. 2018 Jul 5. doi: 10.1542/peds.2018-0245.

New clinical guidelines for pediatric hypertension resulted in increased prevalence of hypertension and improved sensitivity in detecting target organ damage among at-risk youth, according to findings published in Pediatrics.

In a clinical practice guideline (CPG) published in 2017, the American Academy of Pediatrics updated its 2004 guideline to include new reference tables for BP values in addition to new definitions of elevated BP and hypertension, including absolute BP cutoff values for adolescents aged 13 years and older (Pediatrics. 2017 Sep;140[6]:e20173035). This was intended to “emulate the recently updated adult hypertension guidelines and to simplify the process of identifying and classifying hypertension in adolescents,” wrote Michael Khoury, MD, of the Heart Institute at Cincinnati Children’s Hospital Medical Center, and his coauthors.

To evaluate the impact of the new guidelines on the prevalence of hypertension and associations with target organ damage, the investigators used data from a study on obesity and type 2 diabetes in 364 patients aged 10-17 years; 59% were obese, and 30% had type 2 diabetes. Three groups were identified: patients with obesity and type 2 diabetes, patients with obesity but no type 2 diabetes, and healthy (“lean”) controls.

Patients fasted overnight for a minimum of 10 hours, after which body mass index was calculated, blood pressure was taken, and anthropometric, laboratory, echocardiography, and carotid assessments were performed. Average BP measurements were categorized according to the 2004 guideline and to the new CPG.

In carotid ultrasonography assessments, a composite of carotid intima-media thickness was formed from the average of three sites, and a composite carotid intima-media thickness greater than or equal to the 90th percentile of that measured in the lean patients, who were the controls, was considered abnormal. In echocardiography assessments, left ventricular mass (LVM) and LVM index were calculated. Elevated LVM was defined by the pediatric cutoff of LVM index greater than or equal to 38.6 g/m.

For diastolic function, tissue Doppler velocities under the 10th percentile and an average early left ventricular filling/peak early myocardial velocity ratio greater than or equal to the 90th percentile in controls were considered abnormal. Lastly, pulse wave velocity (PWV) was measured to determine arterial stiffness, and a PWV greater than or equal to the 90th percentile for the controls was considered abnormal.

BP classification under the new guideline resulted in an increased prevalence of hypertension at 13% (10% stage 1, 3% stage 2), compared with the 2004 guideline at 8% (6% stage 1, 2% stage 2), with a P value of .007.

Of the 75 patients classified as having elevated BP in the 2004 guideline, 19 (25%) were reclassified as having stage 1 hypertension under the CPG. These 19 patients were older, compared with patients who remained in the elevated blood pressure category (16.5 ± 0.9 vs. 15.5 ± 1.7 years; P = .02). The patients who were reclassified also had higher body mass indexes (38.8 ± 8.2 vs. 33.6 ± 7.4; P = .01) and diastolic blood pressures (76.5 mm Hg ± 8.7 vs. 62.1 ± 12.2 mm Hg; P less than .001), Dr. Khoury and his colleagues reported.

Reclassification to a higher BP category was associated with increased odds of an abnormal target organ damage (TOD) values, and both guidelines produced similar odds, “suggesting that the two guidelines produce similar associations with TOD,” the authors wrote. Reclassification based on the CPG definition accounted for 31% of patients with increased LVM, compared with 20% as defined in the 2004 guideline (P less than .001), and for 33% of patients with abnormal PWV, compared with 23% in the 2004 guideline, suggesting improved sensitivity of hypertension categorization in detecting LVM. A similar effect was seen in other measures of TOD, the authors noted.

The findings suggest that, combined with the increased prevalence of hypertension under the new guidelines, “the CPG may contribute to an increased detection of abnormal LVM and other measures of TOD,” the authors wrote. “This, in turn, may contribute to risk stratification in clinical decision making for youth presenting with BP concerns,” they concluded.

The study was supported by a National Institutes of Health grant. The authors had no relevant disclosures.

SOURCE: Khoury M et al. Pediatrics. 2018 Jul 5. doi: 10.1542/peds.2018-0245.

Gestational exposure to grain products fortified with folic acid resulted in delayed thinning of the cerebral cortex, and thus may protect against later psychosis, according to results published in JAMA Psychiatry.

In a retrospective, observational cohort study of 292 patients aged 8-18 years, increases in cortical thickness were associated with folic acid exposure in the bilateral frontal and temporal regions of the brain (9.9%-11.6%; corrected P less than .001 to P = .03). Delayed, age-associated thinning in temporal and parietal regions was also observed (beta = –11.1 to –13.9; corrected P = .002), reported Hamdi Eryilmaz, PhD, of the department of psychiatry at Massachusetts General Hospital, Boston, and his coauthors.

The study authors first observed MRI scans in the Massachusetts General Hospital (MGH) cohort, which included the 292 patients aged 8-18 years, and then conducted subsequent analyses on two additional cohorts – the Philadelphia Neurodevelopmental Cohort (PNC) and the National Institutes of Health MRI Study of Normal Brain Development (NIH) cohort – to test the reliability and specificity of cortical development associations and the relevance of MRI changes to psychopathological characteristics, the authors wrote.

Using the U.S. implementation of folic acid fortification in grain foods in 1996 and 1997 to define exposure status, the investigators identified MRI scans of 97 prerollout (not exposed), 96 rollout (partly exposed), and 99 postrollout (fully exposed) unique individuals in the MGH group between January 2005 and March 2015, for patients born between January 1993 and December 2001. They also collected information on demographics; reason for MRI scan; and prior use of psychotropic medications, folic acid, or multivitamins.

The PNC cohort consisted of 861 patients, also aged 8-18 years, from community health settings in Philadelphia who had an MRI assessment and a clinical assessment of psychiatric symptoms. The NIH comparison cohort included 217 patients recruited from six health sites across the United States and born before the fortification rollout.

The MGH analysis contrasted mean cortical thickness and linear and quadratic models of age-associated change in cortical thickness within the fully exposed and nonexposed groups. PNC and NIH analyses evaluated quadratic associations of age with cortical thickness.

In the MGH cohort, increases in cortical thickness were associated with folic acid exposure in the bilateral frontal and temporal regions of the brain (9.9%-11.6%; corrected P less than .001 to P = .03), and delayed, age-associated thinning in the temporal and parietal regions was observed (corrected P = .002). Thickness was higher in the fully exposed group, compared with those in the nonexposed group. The effect was intermediate in the partly exposed group, Dr. Eryilmaz and his coauthors wrote.

In the PNC cohort, delayed, age-related thinning was observed in four clusters overlapping with the MGH analysis: left frontal, right inferior temporal, left inferior parietal, and right inferior parietal. In addition, onset of cortical thinning was found to be between 13.0 and 14.3 years of age in least-square regression analysis. In the comparison NIH cohort, though, only the left frontal cortex demonstrated significant quadratic thinning; the break point occurred at a significantly younger age, compared with those in the PNC group (P less than .001).

SOURCE: Eryilmaz H et al. JAMA Psychiatry. 2018 Jul 3. doi: 10.1001/jamapsychiatry.2018.1381.

Gestational exposure to grain products fortified with folic acid resulted in delayed thinning of the cerebral cortex, and thus may protect against later psychosis, according to results published in JAMA Psychiatry.

In a retrospective, observational cohort study of 292 patients aged 8-18 years, increases in cortical thickness were associated with folic acid exposure in the bilateral frontal and temporal regions of the brain (9.9%-11.6%; corrected P less than .001 to P = .03). Delayed, age-associated thinning in temporal and parietal regions was also observed (beta = –11.1 to –13.9; corrected P = .002), reported Hamdi Eryilmaz, PhD, of the department of psychiatry at Massachusetts General Hospital, Boston, and his coauthors.

The study authors first observed MRI scans in the Massachusetts General Hospital (MGH) cohort, which included the 292 patients aged 8-18 years, and then conducted subsequent analyses on two additional cohorts – the Philadelphia Neurodevelopmental Cohort (PNC) and the National Institutes of Health MRI Study of Normal Brain Development (NIH) cohort – to test the reliability and specificity of cortical development associations and the relevance of MRI changes to psychopathological characteristics, the authors wrote.

Using the U.S. implementation of folic acid fortification in grain foods in 1996 and 1997 to define exposure status, the investigators identified MRI scans of 97 prerollout (not exposed), 96 rollout (partly exposed), and 99 postrollout (fully exposed) unique individuals in the MGH group between January 2005 and March 2015, for patients born between January 1993 and December 2001. They also collected information on demographics; reason for MRI scan; and prior use of psychotropic medications, folic acid, or multivitamins.

The PNC cohort consisted of 861 patients, also aged 8-18 years, from community health settings in Philadelphia who had an MRI assessment and a clinical assessment of psychiatric symptoms. The NIH comparison cohort included 217 patients recruited from six health sites across the United States and born before the fortification rollout.

The MGH analysis contrasted mean cortical thickness and linear and quadratic models of age-associated change in cortical thickness within the fully exposed and nonexposed groups. PNC and NIH analyses evaluated quadratic associations of age with cortical thickness.

In the MGH cohort, increases in cortical thickness were associated with folic acid exposure in the bilateral frontal and temporal regions of the brain (9.9%-11.6%; corrected P less than .001 to P = .03), and delayed, age-associated thinning in the temporal and parietal regions was observed (corrected P = .002). Thickness was higher in the fully exposed group, compared with those in the nonexposed group. The effect was intermediate in the partly exposed group, Dr. Eryilmaz and his coauthors wrote.

In the PNC cohort, delayed, age-related thinning was observed in four clusters overlapping with the MGH analysis: left frontal, right inferior temporal, left inferior parietal, and right inferior parietal. In addition, onset of cortical thinning was found to be between 13.0 and 14.3 years of age in least-square regression analysis. In the comparison NIH cohort, though, only the left frontal cortex demonstrated significant quadratic thinning; the break point occurred at a significantly younger age, compared with those in the PNC group (P less than .001).

SOURCE: Eryilmaz H et al. JAMA Psychiatry. 2018 Jul 3. doi: 10.1001/jamapsychiatry.2018.1381.

Gestational exposure to grain products fortified with folic acid resulted in delayed thinning of the cerebral cortex, and thus may protect against later psychosis, according to results published in JAMA Psychiatry.

In a retrospective, observational cohort study of 292 patients aged 8-18 years, increases in cortical thickness were associated with folic acid exposure in the bilateral frontal and temporal regions of the brain (9.9%-11.6%; corrected P less than .001 to P = .03). Delayed, age-associated thinning in temporal and parietal regions was also observed (beta = –11.1 to –13.9; corrected P = .002), reported Hamdi Eryilmaz, PhD, of the department of psychiatry at Massachusetts General Hospital, Boston, and his coauthors.

The study authors first observed MRI scans in the Massachusetts General Hospital (MGH) cohort, which included the 292 patients aged 8-18 years, and then conducted subsequent analyses on two additional cohorts – the Philadelphia Neurodevelopmental Cohort (PNC) and the National Institutes of Health MRI Study of Normal Brain Development (NIH) cohort – to test the reliability and specificity of cortical development associations and the relevance of MRI changes to psychopathological characteristics, the authors wrote.

Using the U.S. implementation of folic acid fortification in grain foods in 1996 and 1997 to define exposure status, the investigators identified MRI scans of 97 prerollout (not exposed), 96 rollout (partly exposed), and 99 postrollout (fully exposed) unique individuals in the MGH group between January 2005 and March 2015, for patients born between January 1993 and December 2001. They also collected information on demographics; reason for MRI scan; and prior use of psychotropic medications, folic acid, or multivitamins.

The PNC cohort consisted of 861 patients, also aged 8-18 years, from community health settings in Philadelphia who had an MRI assessment and a clinical assessment of psychiatric symptoms. The NIH comparison cohort included 217 patients recruited from six health sites across the United States and born before the fortification rollout.

The MGH analysis contrasted mean cortical thickness and linear and quadratic models of age-associated change in cortical thickness within the fully exposed and nonexposed groups. PNC and NIH analyses evaluated quadratic associations of age with cortical thickness.

In the MGH cohort, increases in cortical thickness were associated with folic acid exposure in the bilateral frontal and temporal regions of the brain (9.9%-11.6%; corrected P less than .001 to P = .03), and delayed, age-associated thinning in the temporal and parietal regions was observed (corrected P = .002). Thickness was higher in the fully exposed group, compared with those in the nonexposed group. The effect was intermediate in the partly exposed group, Dr. Eryilmaz and his coauthors wrote.

In the PNC cohort, delayed, age-related thinning was observed in four clusters overlapping with the MGH analysis: left frontal, right inferior temporal, left inferior parietal, and right inferior parietal. In addition, onset of cortical thinning was found to be between 13.0 and 14.3 years of age in least-square regression analysis. In the comparison NIH cohort, though, only the left frontal cortex demonstrated significant quadratic thinning; the break point occurred at a significantly younger age, compared with those in the PNC group (P less than .001).

SOURCE: Eryilmaz H et al. JAMA Psychiatry. 2018 Jul 3. doi: 10.1001/jamapsychiatry.2018.1381.

Patients who experienced adverse changes in employment status after acute myocardial infarction (AMI) reported increased depression and lower quality of life, according to results published June 12 in Circulation: Cardiovascular Quality and Outcomes.

At 1-year follow-up, 27.4% of patients with adverse employment change scored high on measures of depression, compared with 16.7% of patients who did not experience a change in status. These patients also reported lower health status and difficulty affording medications, wrote Haider J. Warraich, MD, a cardiologist at Duke University in Durham, N.C., and coauthors.

The number of readmissions within the first year was the factor most strongly associated with adverse change in employment. Baseline smoking status, hypertension, and postdischarge bleeding were also significantly associated with adverse change in employment, the authors said.

At 1 year follow-up, patients with an adverse change in employment were more likely than those with no change to report depression (27.4% with PHQ score greater than 3, compared with 16.7% in the no-change group). These patients also reported lower health status (mean EuroQoL score of 73 compared with 78) and moderate to extreme financial hardship with medication costs (41.0% compared with 28.4%), though there was no difference in medication adherence, the authors reported.

The results indicate that, although job loss in acute MI patients has dropped in comparison with previous studies, patients who experience an adverse change in employment are still “at increased risk of depression, lower quality of life, and increased financial hardship with medication costs compared with those who continue working,” the authors wrote.

“These results underscore the need for interventions to address this patient-centered outcome and its health impact,” they concluded.

Daiichi Sankyo and Lilly USA funded TRANSLATE-ACS. This analysis was funded in part by a grant from the National Heart, Lung, and Blood Institute.

SOURCE: Warraich H et al. Circ Cardiovasc Qual Outcomes. 2018 Jun 12. doi: 10.1161/circoutcomes.117.004528.

Patients who experienced adverse changes in employment status after acute myocardial infarction (AMI) reported increased depression and lower quality of life, according to results published June 12 in Circulation: Cardiovascular Quality and Outcomes.

At 1-year follow-up, 27.4% of patients with adverse employment change scored high on measures of depression, compared with 16.7% of patients who did not experience a change in status. These patients also reported lower health status and difficulty affording medications, wrote Haider J. Warraich, MD, a cardiologist at Duke University in Durham, N.C., and coauthors.

The number of readmissions within the first year was the factor most strongly associated with adverse change in employment. Baseline smoking status, hypertension, and postdischarge bleeding were also significantly associated with adverse change in employment, the authors said.

At 1 year follow-up, patients with an adverse change in employment were more likely than those with no change to report depression (27.4% with PHQ score greater than 3, compared with 16.7% in the no-change group). These patients also reported lower health status (mean EuroQoL score of 73 compared with 78) and moderate to extreme financial hardship with medication costs (41.0% compared with 28.4%), though there was no difference in medication adherence, the authors reported.

The results indicate that, although job loss in acute MI patients has dropped in comparison with previous studies, patients who experience an adverse change in employment are still “at increased risk of depression, lower quality of life, and increased financial hardship with medication costs compared with those who continue working,” the authors wrote.

“These results underscore the need for interventions to address this patient-centered outcome and its health impact,” they concluded.

Daiichi Sankyo and Lilly USA funded TRANSLATE-ACS. This analysis was funded in part by a grant from the National Heart, Lung, and Blood Institute.

SOURCE: Warraich H et al. Circ Cardiovasc Qual Outcomes. 2018 Jun 12. doi: 10.1161/circoutcomes.117.004528.

Patients who experienced adverse changes in employment status after acute myocardial infarction (AMI) reported increased depression and lower quality of life, according to results published June 12 in Circulation: Cardiovascular Quality and Outcomes.

At 1-year follow-up, 27.4% of patients with adverse employment change scored high on measures of depression, compared with 16.7% of patients who did not experience a change in status. These patients also reported lower health status and difficulty affording medications, wrote Haider J. Warraich, MD, a cardiologist at Duke University in Durham, N.C., and coauthors.

The number of readmissions within the first year was the factor most strongly associated with adverse change in employment. Baseline smoking status, hypertension, and postdischarge bleeding were also significantly associated with adverse change in employment, the authors said.

At 1 year follow-up, patients with an adverse change in employment were more likely than those with no change to report depression (27.4% with PHQ score greater than 3, compared with 16.7% in the no-change group). These patients also reported lower health status (mean EuroQoL score of 73 compared with 78) and moderate to extreme financial hardship with medication costs (41.0% compared with 28.4%), though there was no difference in medication adherence, the authors reported.

The results indicate that, although job loss in acute MI patients has dropped in comparison with previous studies, patients who experience an adverse change in employment are still “at increased risk of depression, lower quality of life, and increased financial hardship with medication costs compared with those who continue working,” the authors wrote.

“These results underscore the need for interventions to address this patient-centered outcome and its health impact,” they concluded.

Daiichi Sankyo and Lilly USA funded TRANSLATE-ACS. This analysis was funded in part by a grant from the National Heart, Lung, and Blood Institute.

SOURCE: Warraich H et al. Circ Cardiovasc Qual Outcomes. 2018 Jun 12. doi: 10.1161/circoutcomes.117.004528.