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OBJECTIVE Disparities in type 1 diabetes related to use of technologies like continuous glucose monitors (CGMs) and utilization of diabetes care are pronounced based on socioeconomic status (SES), race, and ethnicity. However, systematic reports of perspectives from patients in vulnerable communities regarding barriers are limited. RESEARCH DESIGN AND METHODS To better understand barriers, focus groups were conducted in Florida and California with adults ≥18 years old with type 1 diabetes with selection criteria including hospitalization for diabetic ketoacidosis, HbA1c >9%, and/or receiving care at a Federally Qualified Health Center. Sixteen focus groups were conducted in English or Spanish with 86 adults (mean age 42 ± 16.2 years). Transcript themes and pre–focus group demographic survey data were analyzed. In order of frequency, barriers to diabetes technology and endocrinology care included 1) provider level (negative provider encounters), 2) system level (financial coverage), and 3) individual level (preferences). RESULTS Over 50% of participants had not seen an endocrinologist in the past year or were only seen once including during hospital visits. In Florida, there was less technology use overall (38% used CGMs in FL and 63% in CA; 43% used pumps in FL and 69% in CA) and significant differences in pump use by SES (P = 0.02 in FL; P = 0.08 in CA) and race/ethnicity (P = 0.01 in FL; P = 0.80 in CA). In California, there were significant differences in CGM use by race/ethnicity (P = 0.05 in CA; P = 0.56 in FL) and education level (P = 0.02 in CA; P = 0.90 in FL). CONCLUSIONS These findings provide novel insights into the experiences of vulnerable communities and demonstrate the need for multilevel interventions aimed at offsetting disparities in diabetes.

OBJECTIVE To assess the use of a portable retinal camera in diabetic retinopathy (DR) screening in multiple settings and the presence of associated risk factors among children, adolescents, and young adults with type 1 diabetes. DESIGN AND METHODS Five hundred youth with type 1 diabetes of at least 1 year’s duration were recruited from clinics, diabetes camp, and a diabetes conference and underwent retinal imaging using a nonmydriatic fundus camera. Retinal characterization was performed remotely by a licensed ophthalmologist. Risk factors for DR development were evaluated by a patient-reported questionnaire and medical chart review. RESULTS Of the 500 recruited subjects aged 9–26 years (mean 14.9, SD 3.8), 10 cases of DR were identified (nine mild and one moderate nonproliferative DR) with 100% of images of gradable quality. The prevalence of DR was 2.04% (95% CI 0.78–3.29), at an average age of 20.2 years, with the youngest affected subject being 17.1 years of age. The rate of DR was higher, at 6.5%, with diabetes duration >10 years (95% CI 0.86–12.12, P = 0.0002). In subjects with DR, the average duration of diabetes was 12.1 years (SD 4.6, range 6.2–20.0), and in a subgroup of clinic-only subjects (n = 114), elevated blood pressure in the year before screening was associated with DR (P = 0.0068). CONCLUSION This study in a large cohort of subjects with type 1 diabetes demonstrates that older adolescents and young adults (>17 years) with longer disease duration (>6 years) are at risk for DR development, and screening using a portable retinal camera is feasible in clinics and other locations. Recent elevated blood pressure was a risk factor in an analyzed subgroup.

OBJECTIVE Daily self-monitoring of blood glucose (SMBG) is essential for type 1 diabetes management yet is challenging during adolescence. Ecological momentary assessment (EMA) is the repeated sampling of behaviors and experiences in real time in the natural environment. The purpose of this study was to evaluate 1) the validity of self-reported SMBG values via text message–delivered EMA surveys compared with objective SMBG values via glucose meters and 2) in-the-moment motivators and barriers to performing SMBG in a pediatric type 1 diabetes population. Methods Youth (n = 62, aged 11–21 years) with type 1 diabetes received three text messages daily for 10 days containing surveys inquiring about SMBG engagement. Objective SMBG values were downloaded from glucose meters. Results On average, participants reported performing SMBG 4 times/day. Of the self-reported SMBG values, 39.6% were accurate. Inaccurate values included additions (i.e., self-reported value with no objective value), omissions (i.e., objective value with no self-reported value), and alterations (difference between self-report and objective SMBG values ≥10 mg/dL). Of the matched pairs of self-reported and objective SMBG values, 41.3% were altered. Bland–Altman plots determined that the mean difference between self-reported and objective glucose data were −5.43 mg/dL. Participants reported being motivated to check their blood glucose because it was important for their health, and reported barriers included wanting to ignore the task, forgetting, and not having devices. Conclusion Youth’s self-reported SMBG values may not align with objective readings. The results of this study can facilitate future research to determine individual factors related to SMBG and accuracy of self-reporting.

Background and Aims Many traditional assessments of risk for coronary heart disease (CHD) and diabetes require laboratory studies performed after an 8-hour fast. We assessed whether metabolic-syndrome (MetS) severity would remain linked to future CHD and diabetes even when assessed from non-fasting samples. Methods and Results Participants in the Atherosclerosis Risk in Communities study were assessed at 4 visits and followed for 20-years of adjudicated CHD outcomes. We used Cox proportional-hazard models (for 20-year CHD outcomes) and logistic regression (for 9-year diabetes outcomes) to compare incident disease risk associated with a race/ethnicity-specific MetS-severity Z-score (MetS-Z) calculated in participants who were fasting ( > 8 hours) or non-fasting. All analyses were adjusted for sex, race, education, income and smoking. MetS Z-scores were overall similar between participants who were always fasting vs. those non-fasting at Visits 1-3 (all values -0.1 – 0.4), while MetS-Z for participants who were non-fasting at Visit-4 were higher at each visit. Baseline MetS-Z was linked to future CHD when calculated from both fasting and non-fasting measurements, with hazard ratio (HR) for fasting MetS-Z 1.53 (95% confidence interval [CI] 1.42,1.66) and for non-fasting 1.28 (CI 1.08,1.51). MetS-Z at Visit-1 also remained linked to future diabetes when measured from non-fasting samples, with odds ratio for fasting MetS-Z 3.10 (CI 2.88,3.35) and for non-fasting 1.92 (CI 1.05,3.51). Conclusions MetS-Z remained linked to future CHD and diabetes when assessed from non-fasting samples. A score such as this may allow for identification of at-risk individuals and serve as a motivation toward interventions to reduce risk.

Access to human pancreas samples from organ donors has greatly advanced our understanding of type 1 diabetes pathogenesis; however, previous studies have shown that donors have a high rate of substance use, and its impact on pancreatic histopathology in this disease is not well described. One-hundred-thirty-one type 1 diabetes and 111 control organ donor pancreata from persons 12-89 years of age (mean 29.8 ± 15.5 years) within the Network for Pancreatic Organ donors with Diabetes (nPOD) were examined for insulin positivity, insulitis, amyloid staining, acute and chronic pancreatitis, and chronic exocrine changes (acinar atrophy, fibrosis, fatty infiltration, or periductal fibrosis); findings were compared by history of substance use. A secondary analysis compared exocrine pancreatic histopathologic findings in type 1 diabetes versus control organ donors regardless of substance use history. We observed a high but congruent rate of substance use in type 1 diabetes and control organ donors (66.4% and 64% respectively). Among donors with type 1 diabetes (but not controls), islet amyloid (OR 9.96 [1.22, 81.29]) and acute pancreatitis (OR 3.2 [1.06, 9.63]) were more common in alcohol users while chronic exocrine changes (OR 8.86 [1.13, 69.31]) were more common in cocaine users. Substance use impacted the pancreata of donors with type 1 diabetes more than controls. Overall, despite similar rates of substance use, acute pancreatitis (15.3% versus 4.5%, p=0.0061), chronic pancreatitis (29.8% versus 9.9%, p=0.0001), and chronic exocrine changes (73.3% versus 36.9%, p

Background The association of race/ethnicity with childhood-onset systemic lupus erythematosus (cSLE) outcomes has been well described, with non-White individuals experiencing a more severe disease phenotype including increased damage accrual and higher rates of renal involvement. However, there are limited data regarding patient-reported outcomes (PROs) across race and ethnic groups in cSLE. This study assesses the association of race/ethnicity with Patient-Reported Outcomes Measurement Information System (PROMIS®) in cSLE patients at enrollment in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. Methods The CARRA Registry is a convenience cohort of pediatric patients with rheumatic disease including cSLE primarily from North America. This study included cSLE patients enrolled in the CARRA registry within two years from cSLE diagnosis who met ≥ 4/11 ACR classification criteria for lupus. Baseline demographics, laboratory, and disease features as well as PROs were obtained. Analysis of variance (ANOVA) was used to assess the difference in the PROMIS summary T-score means across races/ethnicities. Relationships between SLEDAI and PRO scores were analyzed using Pearson’s correlation coefficients. Multivariable linear regression analysis was used to examine the association of race and ethnicity with PROMIS scores at baseline. P-values Results 588 cSLE patients met inclusion criteria: 84% were female, 24.2% non-Hispanic White, 23% African American, and 19% Hispanic. The mean age at diagnosis was 13.2 years (SD 3.1). Household income and highest parental education varied by race/ethnic group, as did frequency of rash, leukopenia, and positive anti-Sm antibody (table 1). The cohort had low-moderate baseline disease activity, with a mean SLEDAI of 6.14 (SD 6.8). There was no difference in disease activity across races/ethnicities in one-way ANOVA analysis. The overall PROMIS PHG-7 mean T-score was 38.6 (SD 6.4), more than 1 SD below the general population mean of 50. The mean Pain Interference T-score of 54 (SD 10) was slightly above, and the Physical Function Mobility mean T-score of 47.5 (SD 10.13) was slightly below the population mean of 50. There was a negative moderate correlation between PROMIS Pain Interference and Physical Function Mobility (Pearson correlation coefficient: −0.52). There was no association between race/ethnicity and PROMIS scores in multivariable linear regression analysis. Conclusions In this large multiethnic CARRA pediatric lupus cohort, global health (PGH-7), pain interference, and physical function mobility as measured by PROMIS did not vary across races/ethnicities. The relatively low baseline disease activity may explain this lack of association. Long-term follow-up data is needed to assess for associations between PROs and race/ethnicity over time.

There are pervasive disparities in health outcomes for people living with diabetes based on socioeconomic status, race, and ethnicity. These longstanding disparities are magnified by the devastating impact of COVID-19 for underserved communities with diabetes. As part of a Project Extension for Community Healthcare Outcomes (ECHO™) Diabetes outreach program in Florida and California, over 15 participating Federally Qualified Health Centers (FQHC) were provided Diabetes Support Coaches (DSC) to facilitate patient engagement. DSCs hold invaluable expert knowledge as they live with diabetes, themselves, and reside in the geographic catchment areas they serve - combining a traditional Community Health Worker (CHW) role with peer support models. DSCs complete standardized training in health coaching and receive Diabetes Paraprofessional Level 1 certification through the American Association of Diabetes Care and Education Specialists (ADCES). DSCs offer one-on-one peer support for interested patients, create local resource guides for diabetes management, host community events, disseminate information about technologies like continuous glucose monitors (CGM), and assist with appointment reminders and other engagement activities. Patient encounters with DSCs are documented in REDCap® and pre/post-test evaluation for patients includes HbA1c, the Diabetes Distress Scale, use of diabetes technology, and social support density. Preliminary data from n=19 adults with T1D and T2D (9 Hispanic, 10 Non-Hispanic Black) participating with DSCs at two FQHCs in Miami show statistically significant improvement in HbA1c mean ± SD: -1.21 ± 1.49, 95% CI (-1.93, -0.49) p Disclosure A. F. Walker: None. S. L. Filipp: None. N. Cuttriss: Consultant; Self; Cecelia Health. L. G. Baer: None. L. Figg: None. K. K. Hood: Consultant; Self; Cecelia Health, Cercacor, LifeScan Diabetes Institute. R. Lal: Consultant; Self; Abbott Diabetes, Biolinq, Capillary Biomedical, Inc., Morgan Stanley, Tidepool. M. Basina: None. J. J. Wong: None. K. Yabut: None. D. M. Maahs: Advisory Panel; Self; Abbott Diabetes, Dompe, Eli Lilly and Company, Medtronic, Novo Nordisk, Consultant; Self; aditxt. M. J. Haller: Board Member; Self; SAB Biotherapeutics, Inc., Consultant; Self; MannKind Corporation, Other Relationship; Self; Janssen Pharmaceuticals, Inc., Sanofi. E. Sheehan: None. S. C. Westen: None. C. Anez-zabala: None. X. Roque: None. A. Bernier: None. L. Bain: None. M. J. Gurka: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

The Project Extension for Community Healthcare Outcomes (ECHO™) model addresses disparities by empowering primary care provider (PCPs), through tele-education, to meet the needs of underserved communities lacking access to subspecialty care. Given the rapid replication of this model, it is vital to understand the perspectives of participating PCPs to refine program implementation. Project ECHO™ Type 1 Diabetes (T1D) program was piloted in Florida and California with >15 Federally Qualified Health Centers (FQHC). PCPs completed pre/post-test surveys assessing knowledge and confidence in T1D care. Exit surveys and focus groups were conducted to understand their experiences (N=92 providers, 41 from FL and 51 from CA were queried). Qualitative analysis of open-ended survey feedback and thematic analysis of focus group data used the Consolidated Framework for Implementation Research (CFIR). The CFIR identifies five domains that affect intervention implementation - including internal and external factors to the healthcare organization. Pre/post surveys demonstrated significant improvements in providers’ diabetes knowledge; mean ± SD change in score for an 11-item knowledge evaluation from pre/post: (1.0 ± 1.8, [Min: -2, Max: +5], p-value: 0.0003) and increase in overall confidence evaluated on a 4-point likert scale (0.6 ± 0.4 [Min: -0.1, Max: 1.6] p-value Disclosure A. F. Walker: None. S. L. Filipp: None. K. Turner: None. G. L. Zori: None. J. Maizel: None. N. Cuttriss: Consultant; Self; Cecelia Health. L. G. Baer: None. L. Figg: None. K. K. Hood: Consultant; Self; Cecelia Health, Cercacor, LifeScan Diabetes Institute. R. Lal: Consultant; Self; Abbott Diabetes, Biolinq, Capillary Biomedical, Inc., Morgan Stanley, Tidepool. M. Basina: None. M. J. Haller: Board Member; Self; SAB Biotherapeutics, Inc., Consultant; Self; MannKind Corporation, Other Relationship; Self; Janssen Pharmaceuticals, Inc., Sanofi. J. J. Wong: None. K. Yabut: None. D. Naranjo: None. E. Lewit: None. D. M. Maahs: Advisory Panel; Self; Abbott Diabetes, Dompe, Eli Lilly and Company, Medtronic, Novo Nordisk, Consultant; Self; aditxt. E. Sheehan: None. S. C. Westen: None. C. Anez-zabala: None. X. Roque: None. B. C. Fitzgerald: None. A. Bernier: None. M. J. Gurka: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

We characterized the prevalence of obesity among Florida children 2–19 years old using electronic health records (EHRs). The obesity prevalence for 331,641 children was 16.9%. Obesity prevalence at 6–11 years (19.5%) and 12–19 years (18.9%) were approximately double the prevalence of obesity among children 2–5 years (9.9%). The highest prevalence of severe obesity occurred in rural Florida (21.7%) and non-Hispanic children with multiple races had the highest obesity prevalence (21.1%) across all racial/ethnic groups. Our results highlight EHR as a low-cost alternative to estimate the prevalence of obesity and severe obesity in Florida children, both overall and within subpopulations.

OBJECTIVE We assessed whether changes in metabolic syndrome (MetS) severity during the treatment of prediabetes are associated with reduced risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). RESEARCH DESIGN AND METHODS We analyzed data from the Diabetes Prevention Program (DPP) for 2,476 adults in 1996–1999 with prediabetes randomized to receive treatment with lifestyle modification, metformin, or placebo for 2–3 years and followed through 2014 for T2DM and CVD outcomes. We calculated effect sizes from baseline in a MetS severity z score (MetS-Z) and the individual MetS components, and assessed relationships between 1-year effect size and incident T2DM and CVD using hazard ratios (HRs) and mediation analysis. RESULTS Baseline MetS-Z and its components were associated with risk of incident T2DM and CVD. During year 1 of intervention, MetS-Z and its components decreased most with lifestyle modification, followed by treatment with metformin and placebo. Risk of T2DM within 1–5 years was most strongly associated with 1-year changes in MetS-Z and waist circumference (both HRs for a 1 SD increase = 1.80), whereas the risk of CVD was associated with a 1-year change in MetS-Z, glucose, and systolic blood pressure. In mediation analyses, the effect of lifestyle modification on T2DM risk was mediated by 1-year changes in MetS-Z, waist circumference, glucose, and triglycerides, whereas the effect of metformin was mediated by MetS-Z and glucose. CONCLUSIONS Changes in these risk indicators of MetS severity during intervention in the DPP reflect altered disease risk and may help in tracking earlier responses to treatment and in motivating patients.

Increased waiting time in pediatric emergency departments is a well-recognized and complex problem in a resource-limited US health care system. Efforts to reduce emergency department wait times include modeling arrival rates, acuity, process flow, and human resource requirements. The aim of this study was to investigate queue theory and load-leveling principles to model arrival rates and to identify a simple metric for assisting with determination of optimal physical space and human resource requirements. We discovered that pediatric emergency department arrival rates vary based on time of day, day of the week, and month of the year in a predictable pattern and that the hourly change in pediatric emergency department waiting room census may be useful as a simple metric to identify target times for shifting resources to better match supply and demand at no additional cost.

Early detection of diabetic retinopathy (DR) is imperative; however, adherence to screening guidelines is poor. We hypothesized that youth and young adults with type 1 diabetes (T1D) who met American Diabetes Association criteria for recommended DR screening at the time of the study (10 years old or greater with diabetes duration of 5 years or more) would report multiple barriers to screening and that targeted barriers and subpopulations could be identified to improve access to care. 271 youth aged 10 to 26 years with T1D of at least 5 years duration were recruited from clinic, diabetes camp, and a diabetes conference and completed a patient-reported questionnaire. 113 (41.7%) reported at least one barrier to DR screening, with missed school and work being the most common (20.7%). Older participants (P = 0.007) and those with a longer diabetes duration (P = 0.018) were more likely to report barriers to screening. Recruitment location, sex, race and ethnicity, HbA1c, insulin regimen, and clinic visit frequency were not associated with reporting at least one barrier. Slightly less than two-thirds (62.1%) of participants who responded (n = 235 out of 271) adhered to recommended screening guidelines of the time and reported having an eye exam within the past year, 24.7% 12-23 months ago, 9.8% 2 years ago or more, and 3.4% had never had a DR exam. As older patients and those with longer duration of diabetes are more likely to have DR, targeted interventions to address barriers to care, such as, missed school and work should be implemented in these groups.

A progressive, treadmill-based VO2max is the gold standard of cardiorespiratory fitness determination but is rarely used in pediatric clinics due to time requirements and cost. Simpler and shorter fitness tests such as the Squat Test or Step Test may be feasible and clinically useful alternatives. However, performance comparisons of these tests to treadmill VO2max tests are lacking. The primary aim of this cross-sectional study was to assess the correlation between Squat and Step Test scores and VO2max in a pediatric population. As secondary outcomes, we calculated correlations between Rated Perceived Exertion Scale (RPE) scores, NIH PROMIS Physical Activity scores, and BMI z-score with VO2max, and we also evaluated the ability of each fitness test to discriminate low and high-risk patients based on the FITNESSGram. Forty children aged 10-17 completed these simple cardiorespiratory fitness tests. Statistically significant correlations were observed between VO2max and the Step Test (r = -0.549) and Squat Test (r = -0.429) scores, as well as participant BMI z-score (r = -0.458). RPE and PROMIS scores were not observed to be correlated with VO2max. Area Under the Receiver Operator Curve was relatively high for BMI z-scores and the Step Test (AUC = 0.813, 0.713 respectively), and lower for the Squat Test (AUC = 0.610) in discriminating risk according to FITNESSGram Scores. In this sample, the Step Test performed best overall. These tests were safe, feasible, and may add great value in assessing cardiorespiratory fitness in a clinical setting.

Highlights • Postcard reminders increased vaccination rates during preventive care visits. • Postcards may prime parents for provider recommendations. • Reminders may be most effective if combined with provider-targeted interventions., Parent-targeted reminders increase human papillomavirus (HPV) vaccination rates. Our postcard reminders increased HPV vaccine initiation (receipt of at least one dose) by 60% among girls, but not substantially among boys. To select a complementary intervention that would maximize the effect of reminders, we assessed the percentage increase in HPV vaccine initiation from reminders increasing preventive care visits or increasing the likelihood of vaccine receipt during preventive care. We conducted a secondary analysis of the postcard reminders from a quasi-experimental, factorial designed, feasibility trial conducted in 2013–2014 among 2,470 11- to 17-year-old girls enrolled in Florida’s Medicaid or Children’s Health Insurance Programs. We used log-linear models and a 4-way decomposition method to estimate the mediating and interacting effects of preventive visits on the effect of postcards on HPV vaccination. After receiving a preventive visit, 76% (269/356) of girls remained unvaccinated. Nearly half of the effect of postcards on HPV vaccination was mediated by preventive visits (44%; 95% CI = 9.2% to 78.0%). Postcards increased HPV vaccine initiation mainly by increasing the likelihood of HPV vaccine receipt during preventive visits (pure indirect effect = 32.3%; 95% CI = 1.5% to 63.1%), and also by increasing the occurrence of preventive visits (mediated interaction = 11.3%; 95% CI = 1.5 to 21.1). Reminders likely increased vaccination rates during well visits by priming parents for HPV vaccine conversations with their child’s health care provider. Thus, reminder effectiveness may be increased if timed closely to preventive care visits and/or combined with interventions that improve provider recommendations. Trial Registration: ClinicalTrials.gov, NCT04208269, Registered 23, December 2019 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04208269.

Background and Purpose: Ischemic stroke is associated with the metabolic syndrome (MetS) as diagnosed using dichotomous criteria; however, these criteria exhibit racial/ethnic discrepancies. Our goal was to assess whether ischemic stroke risk extended over the spectrum of worsening MetS severity using a sex- and race/ethnicity-specific MetS-severity Z score. Methods: We used Cox-proportional hazards models to assess the relationship between baseline MetS- Z score and incident ischemic stroke among participants of the Atherosclerosis Risk in Communities study and Jackson Heart Study who were free from diabetes, coronary heart disease or stroke at baseline, evaluating 13 141 white and black individuals with mean follow-up of 18.6 years. Results: We found that risk of ischemic stroke increased consistently with MetS severity, with a hazard ratio of 1.75 (95% CI, 1.35–2.27) for those >75th percentile compared to those Conclusions: Ischemic stroke risk increased over the spectrum of MetS severity in the absence of baseline diabetes mellitus, further implicating potential etiologic risks from processes underlying MetS. Individuals with elevated MetS severity should be counselled toward lifestyle modification to lower ischemic stroke risk.

Disparities in the use of CGMs and insulin pumps in T1D based on socioeconomic status (SES) and race/ethnicity are pronounced. However, systematic reports of perspectives from patients in vulnerable communities are limited. To better understand barriers, focus groups were conducted in Florida and California with adults with T1D. Selection criteria included hospitalization for DKA, HbA1C >9%, or receiving care at a Federally Qualified Health Center. A total of 16 focus groups were conducted in English or Spanish with 86 adults (Table 1). Transcript themes and pre-focus group demographic survey data were analyzed. In order of frequency, barriers to diabetes technology included: (1) provider-level (overtly blocked/discouraged by provider) (2) system-level (financial barriers related to coverage) and (3) individual-level (difficulty with use or preference issues). In Florida there was less technology use overall (38% had used CGMs in FL, 63% in CA; 43% had used pumps in FL, 69% in CA) and significant differences in pump use by SES (P=0.02 in FL, P=0.08 in CA) and race/ethnicity (P=0.01 in FL, P=0.80 in CA). In California there were significant differences in CGM use by race/ethnicity (P=0.05 in CA, P=0.56 in FL) and education level (P=0.02 in CA, P=0.90 in FL). These findings provide novel insights and demonstrate the need for multi-level interventions and further research on variations in technology use based on geographic location. Disclosure A.F. Walker: None. N. Cuttriss: None. M.J. Haller: Advisory Panel; Self; SAB Biotherapeutics, Inc. S.L. Filipp: None. K. Yabut: None. C. Anez-Zabala: None. K.K. Hood: Research Support; Self; Dexcom, Inc. Speaker’s Bureau; Self; LifeScan, Inc., MedIQ. X. Roque: None. D. Naranjo: None. G. Aulisio: None. A. Addala: None. S. Look: None. M.J. Gurka: None. D.M. Maahs: Advisory Panel; Self; Eli Lilly and Company, Insulet Corporation, Medtronic, Novo Nordisk A/S. Consultant; Self; Abbott, Sanofi. Research Support; Self; Bigfoot Biomedical, Dexcom, Inc., Roche Diabetes Care, Tandem Diabetes Care. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Project ECHOTM (Extension for Community Healthcare Outcomes) is a hub-spoke telehealth outreach model that democratizes specialty knowledge to reduce disparities and improve health outcomes. Limited access to endocrinologists forces many primary care providers (PCPs) to manage patients with type 1 diabetes (T1D) without specialty support. As such, Stanford and the University of Florida partnered to develop and pilot “ECHO T1D”, a teleECHOTM clinic focused on T1D in California (CA) and Florida (FL), respectively. Our goal was to demonstrate the feasibility of ECHO T1D and improve PCPs’ abilities to manage patients with T1D. Primary care spokes were recruited targeting Federally Qualified Health Centers (FQHCs) where vulnerable T1D patient populations more likely rely on PCPs for care. In CA, 11 spokes enrolled with 37 clinics serving ∼900 patients with T1D who do not receive routine specialty T1D care. In FL, 12 spokes enrolled with 67 clinics serving ∼1,000 patients with T1D. Multidisciplinary hub team specialists were recruited and a 6-month curriculum was developed. Weekly 1-hour teleECHO sessions consisting of didactic presentations and case reviews were offered for 27 sessions. Weekly engagement of the 70 participating PCPs (69% in CA) ranged from 0 to 27 (mean 14) sessions and 65 completed both baseline and exit surveys. Baseline data demonstrated low confidence in providing T1D care, especially related to diabetes technology. Pre/post surveys demonstrated statistically significant improvements in provider confidence in T1D management and knowledge (p=0.02). PCPs who attended ≥ 50% sessions had the largest improvements. Over 90% of PCPs reported changes in medical practice (e.g., insulin and pump adjustments) and 95% would recommend the program to colleagues. The ECHO model can be applied to T1D to improve PCPs’ ability to manage patients with T1D. Future directions include evaluating influence on patient level outcomes and applying the model to insulin-requiring T2D patients. Disclosure N. Cuttriss: None. C. Anez-Zabala: None. L.G. Baer: None. S.L. Filipp: None. M. Basina: None. M.J. Gurka: None. L. Figg: None. M.J. Haller: Advisory Panel; Self; SAB Biotherapeutics, Inc. K.K. Hood: Research Support; Self; Dexcom, Inc. Speaker’s Bureau; Self; LifeScan, Inc., MedIQ. X. Roque: None. R. Lal: Consultant; Self; Abbott, Biolinq. S.C. Westen: None. D.M. Maahs: Advisory Panel; Self; Eli Lilly and Company, Insulet Corporation, Medtronic, Novo Nordisk A/S. Consultant; Self; Abbott, Sanofi. Research Support; Self; Bigfoot Biomedical, Dexcom, Inc., Roche Diabetes Care, Tandem Diabetes Care. M. Town: Other Relationship; Self; Insulet Corporation. C. Wang: None. J.J. Wong: None. K. Yabut: None. A.F. Walker: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Diabetes technology is changing and integral for diabetes care. Our hypothesis is patients who start using continuous glucose monitoring (CGM) technology at diagnosis will have better clinical outcomes and higher levels of satisfaction and lower levels of burden than patients who initiate CGM therapy later in the course of their disease management. Methods: This quality improvement study offered Freestyle Libre CGM to all patients newly diagnosed with T1D. The primary outcome was improvement in self-reported treatment satisfaction as measured by the Diabetes Treatment Satisfaction Questionnaire-Parent (DTSQ-P). Secondary outcomes included adolescent treatment satisfaction, fear of hypoglycemia, diabetes distress, burden, and QOL. Measures were given at baseline and 3 months. Data for participants was compared with retrospective data from age-matched controls who did not receive a Libre at diagnosis. Results: 26 parent-child dyads between the ages of 4-17 years old participated in the study. Preliminary results showed improved DTSQ-parents scores 47.1 ± 8.0 to 50 ± 9.9 over the 3 month study. Please see tables for parent and child version of DTSQ- DDS, PedQL, FOH, PAID results. Conclusions: There were trends towards improved satisfaction and QOL scores. This shows supportive data for improved quality and satisfaction measures in using CGM technology starting at diagnosis. Disclosure P. Hiers: None. J. Adams: None. S.L. Filipp: None. M.J. Haller: Advisory Panel; Self; SAB Biotherapeutics, Inc. Funding Diabetes Action Research and Education Foundation (468)

Primary care providers (PCPs) manage type 1 diabetes (T1D) and complex diabetes for people who lack access to multispecialty care. Project ECHOTM (Extension for Community Healthcare Outcomes) is a low-dose, high frequency workforce development hub-spoke model that leverages telehealth to connect multidisciplinary specialists (“hub”) with PCPs across regional clinic sites (“spokes”). Applying the ECHO model, we piloted the model for T1D (Project ECHO T1D) in the states of California (CA) and Florida (FL) targeting PCPs managing adult and pediatric patients with T1D. Weekly hour-long teleECHOTM sessions were led by each hub in CA and FL over a 6 month pilot period. Each session included 1 to 2 case presentation. Prior to each teleECHO session, PCPs uploaded de-identified case presentations for discussion via REDCap®. Recommendations were provided by other participants and the multidisciplinary hub teams. Characteristics of case presentations were tracked in CA and FL. During the 6 month intervention, 47 new and follow-up cases were presented in CA and 45 in FL. Middle age adults (33.9±17.4 years-old, 20% pediatric) with poorly controlled diabetes (HbA1c 9.6±2.2% in CA and 10.4±2.8% in FL) were frequent cases. Common thematic questions submitted by PCPs in CA and FL, respectively, included: insulin dose adjustments (49%, 47%), social concerns (37%, 47%), behavioral health (29%, 34%), diabetes devices (44%, 13%), and diabetes education (15%, 38%). Patients commonly had depression (29.3%, 28.1%), recent hospitalizations (27%, 17%) and ER visits (33%, 26%) in the past year. Greatest barriers to care were social support (34%, 28%), financial (29%, 22%), diabetes knowledge (22%, 25%), attitudes and beliefs (27%, 16%) and psychiatric issues (20%, 19%). Findings illustrate the complexity of diabetes being managed by PCPs and the need for healthcare delivery innovation in diabetes education to support PCPs and primary care clinics who manage patients with complex diabetes who lack access to diabetes specialty care. Disclosure N. Cuttriss: None. C. Anez-Zabala: None. L.G. Baer: None. S.L. Filipp: None. M. Basina: None. M.J. Gurka: None. L. Figg: None. M.J. Haller: Advisory Panel; Self; SAB Biotherapeutics, Inc. K.K. Hood: Research Support; Self; Dexcom, Inc. Speaker’s Bureau; Self; LifeScan, Inc., MedIQ. X. Roque: None. R. Lal: Consultant; Self; Abbott, Biolinq. S.C. Westen: None. D.M. Maahs: Advisory Panel; Self; Eli Lilly and Company, Insulet Corporation, Medtronic, Novo Nordisk A/S. Consultant; Self; Abbott, Sanofi. Research Support; Self; Bigfoot Biomedical, Dexcom, Inc., Roche Diabetes Care, Tandem Diabetes Care. M. Town: Other Relationship; Self; Insulet Corporation. C. Wang: None. J.J. Wong: None. K. Yabut: None. A.F. Walker: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

OBJECTIVES: Attention deficit hyperactivity disorder (ADHD) and the medications used to treat it are associated with obesity. Stimulants lead to weight loss, while antipsychotics and antidepressants lead to weight gain. Little is known, however, how alpha-2-agonists impact weight, or the independent effect on BMI of these four classes of medications, which are often prescribed concurrently. We aimed to estimate the proximal change in BMI associated with start of medication and to assess whether medication-specific departures in BMI varied by age and sex. STUDY DESIGN: We analysed longitudinal electronic health records from children (4–19 years) with an ADHD diagnosis seen at one healthcare system (2011–2018). Their BMI z-scores were fit as a cubic function of age via a mixed model, separately by sex and adjusting for race/ethnicity. From this model, we estimated annual changes in BMI-z after medication, allowing changes to vary by age and sex. RESULTS: Among the 22 714 children with ADHD (mean initial age = 10.0), 4335 (19.1%) were never prescribed ADHD medication. The others (80.9%) experienced departures in BMI-z after start of all four medication classes, which varied across age and sex (interaction P-values < .01). All medications had larger impacts at younger ages. As expected, decreased BMI-z was observed with stimulants, while antidepressants and antipsychotics led to BMI-z increases; alpha-agonists also were associated with BMI-z increases. CONCLUSIONS: This longitudinal study revealed that ADHD medications are independently associated with proximal changes in BMI-z after initiation, significantly varying by sex and age. Future research should study further the interactions of these medications on long-term impacts on obesity.

The obesity epidemic has increased risk for nonalcoholic fatty-liver disease (NAFLD), nonalcoholic steatohepatitis (NASH), advanced fibrosis and cirrhosis. We hypothesized that metabolic syndrome (MetS) severity would correlate with markers of NAFLD and NASH fibrosis. We evaluated cross-sectional data from 5463 participants of the National Health and Nutrition Examination Survey 1999-2012, age 20 to 64 years with and without diabetes, excluding those with heavy drinking and infectious liver serologies. We used linear and logistic regression to evaluate links between MetS-severity (using a race/ethnicity-specific MetS-severity-Z-score, MetS-Z) and apparent NALFD sequelae, using elevated alanine aminotransferase (ALT) to determine presence of NAFLD and elevated NAFLD Fibrosis Score to identify advanced fibrosis (NASH Clinical Research Network scoring stage 3-4). The prevalence of unexplained ALT elevations and advanced fibrosis were 11.4% and 1.37%, respectively. MetS-Z-scores were higher among those with elevated ALT (0.7, 95% confidence interval [CI]: 0.6, 0.8) and advanced fibrosis (1.7, CI: 1.5,1.9), compared to those without liver abnormalities (0.2, CI:0.2, 0.3). For every 1-standard-deviation unit increase in MetS-Z, there were higher odds of elevated ALT (OR = 1.58, CI: 1.44, 1.72) and advanced fibrosis (OR = 1.96, CI: 1.77, 2.18), with some attenuation after adjustment for age, sex, race/ethnicity, and diabetes status. Significant differences were noted by race/ethnicity, with stronger links among whites versus blacks. The degree of MetS-severity was associated with progressive increase in apparent NAFLD and advanced fibrosis; as MetS-severity has also been linked to future cardiovascular disease, diabetes, and chronic kidney disease, this provides support for use of a MetS-severity score to screen for general health, with high levels triggering further assessment for liver abnormalities.

ObjectiveWe aim to assess the feasibility of a pragmatic randomized trial of antibiotics vs. no antibiotics in symptomatic premature infants after birth. Most premature infants are exposed to antibiotics after birth without evidence of benefit or harm for this practice. No study to date has attempted to randomize premature infants to antibiotics vs no antibiotics after birth.Study DesignInfants Results186 subjects were enrolled (98 infants and 88 mothers) were enrolled over a 2-year period. 56% of infants (n=55) were randomized; 48% of infants randomized to the no antibiotics arm were switched and received antibiotics within the first 48 hours after birth. Serious adverse events were not significantly different between the randomization arms.ConclusionThis is the first prospective randomized trial of antibiotics vs no antibiotics after birth in symptomatic premature infants. The results of this trial establish a framework of feasibility for a larger multicentered trial that is needed to evaluate the risks and benefits of routine antibiotic exposure in premature infants.

BACKGROUND: Adverse childhood experiences (ACEs) have life-long health consequences, yet screening remains challenging. Particularly in clinical settings, brief screeners that could lead to comprehensive assessments may be more feasible. We explore how two ACEs (economic hardship; parental/caregiver divorce/separation) are associated with other ACEs, asthma, and emotional, developmental, or behavioral (EDB) problems. METHODS: Using the 2016 National Survey of Children’s Health, we assessed the associations between ACEs and asthma and EDB problems and calculated sensitivities, specificities and predictive values. RESULTS: Parents frequently reported 1+ ACEs for their child (50.3%). Individual ACE frequency ranged from 4.2%-29.6%; all were significantly associated with EDB problems (adjusted odds ratios [aORs]: 2.2-5.1) and more ACEs confirmed higher odds. Two ACES (economic hardship; parental/caregiver divorce/separation) co-occurred frequently with other ACEs; having either predicted EDB problems similarly to other ACEs (aORs 1.8; 95% CI 1.4, 2.3) and having both greatly increased odds (aOR 3.8; 95% CI 2.8, 5.2). The negative predictive value of EDB problems associated with citing neither ACE was high (95.7%). Similar trends with asthma were observed. CONCLUSIONS: Economic hardship and caregiver separation are strongly associated with other ACEs, EDB problems and asthma. A brief screener including these ACEs may reduce clinical barriers to broader ACEs screening.

Esophagogastroduodenoscopy (EGD) is commonly performed for abdominal pain in children, and in the presence of alarm symptoms, the diagnostic yield of this procedure is high. The aim of this study was to investigate the utility of EGD when performed for uncomplicated abdominal pain in children in the absence of alarm symptoms. Charts of all children less than 18 years of age who underwent EGD at the University of Florida between January 2016 and October 2018 were reviewed. Of 1478 children who underwent EGD for any indication, 287 patients (male-to-female = 123:164) were discovered to have undergone EGD, in the absence of colonoscopy, for uncomplicated acute or chronic abdominal pain, nausea, vomiting, gastroesophageal reflux, and/or dyspepsia, with no alarm symptoms. A significant change in clinical management was noted in 20 (7.0%) children. The findings of this procedure changed clinical management in a minority of our study participants.

Introduction Influenza vaccine hesitancy is a global barrier to controlling seasonal influenza. Influenza vaccination rates in university students lag behind current goals and pose a significant threat to the health of students on campuses. A broader understanding of the knowledge, attitudes and beliefs of university students are needed to develop targeted interventions to increase vaccination. Methods An anonymous cross-sectional survey was developed and distributed via REDCap to graduate and undergraduate students via individual college listservs at a large public university. Survey questions included demographic information and questions about vaccination history, preference for vaccine type (inactivated vaccine (IIV) or live attenuated vaccine (LAIV), knowledge of influenza vaccines, reasons for accepting or refusing vaccine and preference for receiving vaccine information and education. Results Students in 14 colleges received the survey and 1039 respondents were included in analysis. Sixty two percent reported having been vaccinated for influenza and of those vaccinated most were in health-related fields that require vaccination. Graduate and vaccinated students were more knowledgeable about influenza; undergraduates had lower vaccination rates. Students preferred IIV over LAIV and were more knowledgeable about IIV. Those with history of vaccination during childhood had higher rates of vaccination. Twenty six percent overall and 41.6% of the unvaccinated still believed you could get the flu from the flu vaccine. Fear of needles and inconvenience were cited as major reasons for not getting vaccinated. Incentives were cited as important motivators by only 20%. Students preferred to receive vaccine information from medical providers followed by online information and campus events. Conclusions A multipronged approach to increasing influenza vaccination of university students will be needed. Myths about influenza vaccine persist even in a relatively educated population. Programs will need to target undergraduate and students in non health-related fields, offer vaccine choices - IIV and LAIV and promote vaccination through medical providers and online information., Public health; Infectious disease; Vaccines; Influenza; Vaccine hesitancy; University students

Introduction With obesity rates and obesity-related healthcare costs increasing, policy makers must understand the scope of obesity across populations. Objective This study sought to characterize adult obesity using electronic health records (EHRs) available from a statewide clinical data research network, the OneFlorida Clinical Research Consortium, which contains claims and EHR data from over 12 million patients in Florida. The primary aim was to compare EHR-based Florida obesity rates with those rates obtained from the Behavioural Risk Factor Surveillance System (BRFSS). Methods Body mass index from OneFlorida patient data (2012-2016) was used to characterize obesity among adults 20-79 years old. Obesity rates from both OneFlorida and BRFSS (2013) were reported by demographics and by county. Results Among the 1,344,015 adults in OneFlorida with EHR data and who met inclusion criteria, the obesity rate was 37.1%. Women had higher obesity rates compared with men. Obesity rates varied within racial/ethnic groups, with the highest rate among African-Americans (45.7%). Obesity rates from OneFlorida were consistently higher than those found in BRFSS (overall 27.8%). Conclusions Utilizing clinical big data available through hospital system and health partner collaborations provides an important view of the extent of obesity. Although these data are available only from healthcare users, they are large in scope, directly measured and are available sooner than commonly used national data sources.

Childhood metabolic syndrome (MetS) is associated with insulin resistance and increased risk for later development of type 2 diabetes (T2DM) and cardiovascular disease (CVD). In using MetS severity z-scores, our objective was to assess longitudinal associations in MetS severity, fasting insulin levels as a sign of insulin resistance and risk for T2DM, and uric acid levels as a biomarker of oxidative stress leading to CVD.We used linear regression to analyze longitudinal data from 285 white and black participants from the Bogalusa Heart Study evaluated at baseline at ages 5-19 and as young adults after a mean of 12.0 years follow-up. We assessed correlations between childhood MetS severity and young-adult MetS severity, fasting insulin, and uric acid levels, both overall and by sex- and racial subgroups.Overall, childhood MetS z-scores were positively associated with young-adult MetS z-scores (r = 0.52), insulin (r = 0.34), and uric acid (r = 0.28) (all P 0.001). These associations were consistent across all sex- and racial subgroups, except for young adult uric acid in white males in which childhood MetS-z was not associated (r = 0.15, P = 0.243). There was a strong cross-sectional association of young-adult MetS z-scores with insulin (r = 0.70) and uric acid (r = 0.57) (both P 0.001), which was consistent for all sex- and racial subgroups.These positive longitudinal correlations between childhood MetS z-scores and markers of later insulin resistance and oxidative stress suggest long-term durability of risk for CVD and T2DM. This suggests potential for MetS severity to serve as an indicator to monitor for future risk of T2DM and CVD.

BACKGROUND: Estimates of adiposity in evaluating the metabolic syndrome (MetS) have traditionally utilized measures of waist circumference (WC), whereas body mass index (BMI) is more commonly used clinically. Our objective was to determine if a MetS severity Z-score employing BMI as its measure of adiposity (MetS-Z-BMI) would perform similarly to a WC-based score (MetS-Z-WC) in predicting future disease. METHODS: To formulate the MetS-Z-BMI, we performed confirmatory factor analysis on a sex- and race/ethnicity-specific basis on MetS-related data for 6,870 adult participants of the National Health and Nutrition Survey 1999–2010. We then validated this score and compared it to MetS-Z-WC in assessing correlations with future coronary heart disease (CHD) and Type 2 diabetes mellitus (T2DM) using Cox proportional hazard analysis of 13,094 participants of the Atherosclerosis Risk in Communities study and Jackson Heart Study. RESULTS: Loading factors, which represent the relative contribution of each component to the latent MetS factor, were lower for BMI than for WC in formulating the two respective scores (MetS-Z-BMI and MetS-Z-WC). Nevertheless, MetS-Z-BMI and MetS-Z-WC exhibited similar hazard ratios (HR) toward future disease. For each one standard-deviation-unit increase in MetS-Z-BMI, HR for CHD was 1.76 (95% confidence interval [CI]: 1.65, 1.88) and HR for T2DM was 3.39 (CI 3.16, 3.63) (both p

IntroductionProject ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs’ abilities to manage patients with T1D.Research design and methodsHealth centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences.ResultsIn Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01).ConclusionsThe ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.

We sought to investigate temporal trends in prediabetes prevalence among US adolescents using two definitions and evaluate relationships with obesity and a MetS-severity score. We evaluated data from 5418 non-Hispanic white, non-Hispanic black, and Hispanic adolescents aged 12–19 participating in the National Health and Nutrition Examination Survey 1999–2014 with complete data regarding MetS and hemoglobin A1c (HbA1c). Prediabetes status was defined by American Diabetes Association (ADA) criteria: fasting glucose 100–125 mg/dL or HbA1c 5.7%–6.4%. MetS severity was assessed with a MetS-severity Z-score. Prevalence of prediabetes as defined by HbA1c abnormalities significantly increased from 1999–2014, while prevalence of prediabetes as defined by fasting glucose abnormalities showed no significant temporal trend. There were variations in these trends across different racial/ethnic groups. MetS Z-score was overall more strongly correlated with HbA1c, fasting insulin, and the homeostasis model of insulin resistance than was BMI Z-score. These correlations were true in each racial/ethnic group with the exception that in non-Hispanic white adolescents, in whom the MetS Z-score was not significantly correlated with HbA1c measurements. We found conflicting findings of temporal trends of US adolescent prediabetes prevalence based on the ADA’s prediabetes criteria. The increasing prevalence of prediabetes by HbA1c assessment is concerning and raises the urgency for increased awareness and appropriate measures of prediabetes status among physicians and patients.

Objective: Food insecurity has been linked to adverse health consequences. We sought to determine if food insecurity was related to obesity and prediabetes risk in U.S. adolescents. We also investigated if Supplemental Nutrition Assistance Program (SNAP) utilization mitigated any observed risks. Materials and Methods: We used linear and logistic regression analysis of cross-sectional data from a nationally representative sample of U.S. adolescents aged 12–19 years participating in the National Health And Nutrition Examination Survey 2003–2014 who had an income:poverty ratio of

T1D care for many patients in both the pediatric and adult populations in the U.S. falls on primary care providers (PCPs). Persistently suboptimal outcomes for people with T1D and a lack of access to subspecialty care mandates the development of innovative healthcare delivery models. Using the Project ECHO (Extension for Community Healthcare Outcomes) model, Stanford University and the University of Florida partnered to develop and pilot a “ECHO T1D” teleECHOTM clinic. The goal of the pilot was to demonstrate the feasibility of an ECHO model for T1D and improve the ability of PCPs to manage patients with T1D. Utilizing a “Hub-and-Spoke” model, we recruited and partnered with PCPs at non-specialty diabetes practices across Florida and California and held weekly hour teleECHO sessions consisting of didactic presentations and case reviews. Precision recruitment methods to target clinics in remote and medically underserved regions included: (1) geocoding to identify high-need areas, (2) claims data to identify PCPs treating T1D, (3) survey data from PCPs. The 18-month pilot program is ongoing and enrollment demonstrated extremely high interest amongst PCPs as the pilot program filled beyond capacity. In California, 11 Spoke sites enrolled with 37 clinics serving roughly 900 adult and pediatric patients with T1D who do not receive specialty T1D care. In Florida, 12 Spoke sites enrolled with 67 clinics who serve roughly 1,300 patients with T1D. PCPs and their clinic staff have become local experts in T1D, providing a more informed level of care for the many patients who lack access to endocrinologists. Project ECHO T1D is an innovative healthcare delivery model which appears capable of building capacity for diabetes management education in the medically underserved. Having demonstrated proof-of-concept for ECHO T1D, future efforts will focus on replicating the model and on designing studies to demonstrate improvements in patient level outcomes. Disclosure N. Cuttriss: None. C. Anez-Zabala: None. L.G. Baer: None. A. Bernier: None. M. Basina: None. S.L. Filipp: None. K.K. Hood: Consultant; Self; Lilly Diabetes. Research Support; Self; Dexcom, Inc. Speaker's Bureau; Self; Johnson & Johnson Diabetes Institute. M.J. Gurka: None. R. Lal: Consultant; Self; Abbott. M.J. Haller: Advisory Panel; Self; Pancreum, SAB Biotherapeutics. D.M. Maahs: Advisory Panel; Self; Novo Nordisk Inc. Consultant; Self; Abbott, Sanofi. Research Support; Self; Dexcom, Inc., Tandem Diabetes Care. H. Hu: None. M. Town: None. E. Sheehan: None. C. Wang: None. K. Yabut: None. A.F. Walker: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Adults and children with type 1 diabetes (T1D) in the U.S. do not meet targets for HbA1c. These deficits are even more pronounced based on race/ethnicity and socioeconomic status (SES). Most studies on T1D health outcomes focus on data from endocrinology clinics, yet, primary care clinics play a central role in the management of patients, especially those affected by health disparities. To better understand barriers for individuals with T1D in primary care settings, survey research was conducted with 110 Primary Care Providers (PCPs) in Florida (n=52) and California (n=58) using publicly available state-wide provider directories. Surveys were completed by PCPs in a range of settings including solo (20%), multi-specialty group (35%), single-specialty group (21%), hospital/hospital-owned systems (12%) and ‘other’ (12%). For pediatric T1D populations, 58% of PCPs reported referring children to endocrinologists for diabetes care and only 45% checked HbA1c for children with T1D during clinic visits. For adult T1D populations, 30% of PCPs referred patients to endocrinologists and 65% checked for HbA1c. Overall, providers expressed a lack of confidence in caring for T1D patients, especially when it came to technologies like CGMs (only 28% said they were “moderately” or “extremely” confident herein) and insulin pumps (only 17% said they were “moderately” or “extremely” confident). The lack of confidence surrounding diabetes-technologies was especially evident for PCPs in practice 1-10 years or 31+ years (p Disclosure A.F. Walker: None. N. Cuttriss: None. M.J. Haller: Advisory Panel; Self; Pancreum, SAB Biotherapeutics. K. Yabut: None. C. Anez-Zabala: None. R. Lal: Consultant; Self; Abbott. E. Sheehan: None. M. Basina: None. K.K. Hood: Consultant; Self; Lilly Diabetes. Research Support; Self; Dexcom, Inc. Speaker's Bureau; Self; Johnson & Johnson Diabetes Institute. A. Bernier: None. L.G. Baer: None. S.L. Filipp: None. C. Wang: None. M. Town: None. M.J. Gurka: None. D.M. Maahs: Advisory Panel; Self; Novo Nordisk Inc. Consultant; Self; Abbott, Sanofi. Research Support; Self; Dexcom, Inc., Tandem Diabetes Care. Funding The Leona M. and Harry B. Helmsley Charitable Trust

BACKGROUND: Many traditional assessments of risk for coronary heart disease (CHD) and diabetes require laboratory studies performed after at least an 8-hour fast. However, obtaining fasting samples is less convenient and may result in fewer opportunities for risk assessment and targeted treatment. We hypothesized that metabolic syndrome (MetS) severity would remain linked to future CHD and diabetes even when assessed from non-fasting samples. METHODS: Participants in the Atherosclerosis Risk in Communities study were assessed at 4 visits and followed for 20-years of adjudicated CHD outcomes. We used a race/ethnicity-specific MetS severity Z-score (MetS-Z) calculated from the five traditional components of MetS: waist circumference, systolic blood pressure, HDL, triglycerides and glucose. In prior studies, this Z-score—as calculated from fasting samples—was associated with future CHD and diabetes independent of the individual MetS components. In the current analysis, we assessed risk of adjudicated CHD outcomes using Cox proportional hazard models for baseline MetS-Z calculated from a) fasting (≥8 hours) samples at Visit 1 or b) non-fasting samples at any of the 4 study visits. We assessed incident diabetes risk using logistic regression for fasting vs. non-fasting samples from Visit 1 for risk of diabetes by Visit 4. All analyses were adjusted for sex, race, education, income and current smoking. RESULTS: MetS Z-scores across visits were overall similar between fasting and non-fasting groups (all values when drawn from both fasting and non-fasting samples -0.1 - 0.4), with the exception of individuals non-fasting at Visit 4, who had higher MetS-Z values already at Visit 1. MetS-Z scores were linked to future CHD when calculated from both fasting and non-fasting measurements, with hazard ratio (HR) for fasting MetS-Z 1.53 (95% confidence interval [CI] 1.42, 1.66) and for non-fasting MetS-Z 1.28 (CI 1.08, 1.51). MetS-Z at Visit 1 also remained linked to future diabetes when measured from non-fasting samples, with HR for fasting MetS-Z 3.10 (CI 2.88, 3.35) and for non-fasting MetS-Z 1.92 (CI 1.05, 3.51). CONCLUSIONS: As a marker of long-term risk for chronic disease, MetS-Z remained linked to future CHD and diabetes when assessed from non-fasting samples. A score such as this, calculated through the electronic health record, may allow for identification of at-risk individuals and serve as a motivation toward interventions to improve risk.

Background Type 2 diabetes mellitus (T2 DM ) is considered a cardiovascular disease ( CVD ) risk equivalent, thereby linking assessment of cardiometabolic risk with that of CVD risk over time. Our goal was to determine how commonly used CVD risk scores and metabolic syndrome (MetS) severity performed in predicting T2 DM with and without ultimate CVD . Methods and Results We assessed data from 8273 participants of the ARIC (Atherosclerosis Risk in Communities) Study, using the pooled cohort atherosclerotic CVD risk score, the Framingham Risk Score, and a MetS severity Z score to assess their association with future risk for CVD alone, T2 DM alone, or both over 20 years of follow‐up. Baseline levels of all scores were significantly associated with isolated incident T2 DM (odds ratios [ OR s] for each 1‐ SD increase: atherosclerotic CVD =1.7, Framingham risk score=1.7, MetS Z score=5.1). All 3 baseline scores were also significantly associated with isolated incident CVD (atherosclerotic CVD OR =2.4, Framingham risk score OR =2.3, MetS Z ‐score OR =1.8), with the 2 CVD scores remaining significant independent of MetS severity. MetS severity was strongly associated with future T2 DM leading to CVD (MetS Z ‐score OR =7.0, atherosclerotic CVD OR =3.9, Framingham risk score OR =3.5). Furthermore, changes in MetS severity were independently associated with future T2 DM ‐ CVD progression. Conclusions CVD risk scores are associated with risk for future isolated T2 DM in addition to isolated CVD . However, MetS severity (both baseline and changes over time) was more strongly associated with T2 DM , including T2 DM ultimately leading to CVD . Following MetS severity within patients over time may identify those at greatest risk of combined cardiometabolic disease.

We enrolled 98 infants (gestational age

OBJECTIVE Pancreas size is reduced in patients at type 1 diabetes onset and in autoantibody (AAB)-positive donors without diabetes. We sought to determine whether pancreas volume (PV) imaging could improve understanding of the loss of pancreas size in first-degree relatives (FDRs) of patients with type 1 diabetes. We also examined relationships among PV, AAB status, and endocrine and exocrine functions. RESEARCH DESIGN AND METHODS We conducted a cross-sectional study that included five groups: AAB− control subjects (no diabetes and no first- or second-degree relatives with type 1 diabetes) (N = 49), AAB− FDRs (N = 61), AAB+ FDRs (N = 67 total: n = 31 with a single positive AAB [AAB+ single] and n = 36 with multiple positive AABs [AAB+ multiple]), and patients with recent-onset type 1 diabetes ( RESULTS All FDR groups had significantly lower RPV adjusted for BMI (RPVBMI) than control subjects (all P < 0.05). Patients with type 1 diabetes had lower RPVBMI than AAB− FDR (P < 0.0001) and AAB+ multiple (P ≤ 0.013) subjects. Transformed data indicated that trypsinogen levels were lowest in patients with type 1 diabetes. CONCLUSIONS This study demonstrates, for the first time, all FDRs having significantly smaller RPVBMI compared with AAB− control subjects. Furthermore, RPVBMI was significantly lower in patients with recent-onset type 1 diabetes than in the AAB− FDR and AAB+ multiple groups. As such, RPVBMI may be a novel noninvasive biomarker for predicting progression through stages of type 1 diabetes risk. This study highlights the potential paracrine relationships between the exocrine and endocrine pancreas in progression to type 1 diabetes in subjects at risk.

While useful for prediction of cardiovascular disease (CVD), risk estimators such as the Framingham Risk Score (FRS) and the Atherosclerotic CVD (ASCVD) calculator have not been evaluated for prediction of incident type 2 diabetes (T2D) and progression to CVD, or for how changes in scores over time predict future risk. We evaluated these scores alongside a metabolic syndrome (MetS) severity Z-score (http://mets.health-outcomes-policy.ufl.edu), using data from 8,026 participants in the Atherosclerosis Risk in Communities (ARIC) study without T2D or CVD by Visit 2. We characterized individuals by incident T2D by V4 (mean years from V1 = 8.9), and whether they had an adjudicated CVD event by V4 ("early" CVD) or a "late" CVD event (after V4; mean total follow-up = 20.7 years). For each disease category, we estimated mean scores at V1 and changes in score, V2-V1 (Figure 1). MetS severity distinguished those developing T2D vs. not and future CVD vs. not. FRS and ASCVD distinguished CVD development in each incident T2D group, but trends were not as discernible across T2D status. We then standardized FRS and ASCVD scores to allow for comparisons of OR’s, using logistic regression to model odds of each disease category by each score, including V1 and the (V2-V1) change (OR’s in Figure 1). While CVD scores predict future CVD, MetS severity, based both on baseline levels and change in score, better predicts individuals who go on to develop T2D and further progress to CVD. Disclosure M.J. Gurka: None. S.L. Filipp: None. T.A. Pearson: Consultant; Self; Bayer AG. M.D. DeBoer: None.

While a metabolic syndrome severity Z-score (MetS-Z) predicts incident type 2 diabetes (T2D) in observational cohorts, it is unclear whether MetS-Z can track response to medical intervention and whether changes in MetS-Z during treatment reflect altered risk for T2D. We evaluated data from the Diabetes Prevention Program, which randomized individuals with glucose intolerance (age 51±11 years) to receive: placebo (n=882), metformin 850 mg bid (n=867), or an intensive lifestyle modification program (n=827). We assessed levels of MetS-Z and the individual MetS components during 3 years of intervention (Figure), revealing 1-year decreases in MetS-Z among those treated with lifestyle (effect size -0.6), metformin (-0.3) and placebo (-0.1), driven by improvements in the individual MetS components. We assessed how change in MetS-Z affected T2D risk, finding that each 1-point increase in a participant’s effect size of MetS Z between 0 and 1 year (difference per participant/baseline SD) increased odds of incident T2D by year 3 by 70% (adjusting for intervention group; Figure). This positive association was found in individual models and in a joint model that included changes in MetS-Z and in each MetS component—suggesting independent associations of changes in MetS-Z with future T2D risk. These data support MetS-Z as an important outcome to follow for response to medical treatment in research studies and clinical care. Disclosure M.D. DeBoer: None. S.L. Filipp: None. M.J. Gurka: None.

Pancreatic size is significantly reduced in new-onset type 1 diabetes (T1D) patients and one study reported decreased weight in T1D-related autoantibody (AAb) positive nondiabetic organ donors. We proposed that pancreas volume (PV) could provide important information regarding progression to T1D onset. The relationship between PV and autoantibody status was determined. Study design included 4 groups: T1D patients < 1 year of diagnosis; AAb+ first-degree relatives (FDR); AAb- FDR; and AAb- controls. Fasting subjects underwent pancreas magnetic resonance imaging (MRI) and images were analyzed by radiologists blinded to group. Relative PV (RPV=PV/BMI) was analyzed utilizing a linear mixed model accounting for age, gender, and family clustering with Tukey correction for multiple comparisons. A total of 223 subjects were enrolled with overall age of 19.6±10.5 years (45% males). RPV was significantly higher in controls (n=49) than AAb- FDR (n=60), AAb+ FDR (n=62 (single AAb+ n=30, multiple AAb+ n=32)) and recent onset T1D (n=52) (Figure). RPV was also significantly higher in AAb- FDR and AAb+ FDR vs. recent onset T1D (Figure). Pancreas MRI demonstrates smaller RPV in AAb- FDR than age-matched controls and patients with recent onset T1D have lower RPV than those FDR with established autoimmunity. Pancreas MRI may improve our understanding of the natural history of T1D. Disclosure M. Campbell-Thompson: None. M.A. Atkinson: Other Relationship; Self; Patent Issued. S.L. Filipp: None. M.J. Gurka: None. R. Beegle: None. D. Schatz: None. M.J. Haller: None.

Cardiovascular disease (CVD) and type 2 diabetes remain significant public health concerns. Targeting of prevention efforts by geographical location has been suggested by the Institute of Medicine to coincide with the presence of area-based risk. The metabolic syndrome (MetS) is a stronger risk factor than is obesity for the prediction of future CVD and diabetes, yet its prevalence has not previously been described geographically. Our objective is to determine geographical variation in the prevalence of obesity, MetS, and diabetes among US adults. We assessed the prevalence of obesity, MetS, and diabetes by US census division, and the prevalence of obesity, MetS, and diabetes for each sex and racial/ethnic group by US region among 9826 US non-Hispanic white, non-Hispanic black, and Hispanic adults aged 20–65 years participating in the National Health and Nutrition Examination Survey 1999–2014. We also compared a sex- and race/ethnicity-specific MetS severity score by geographical area. The prevalence of obesity, MetS, and diabetes varied by US census division and region, with overall similarity by geographical area in the prevalence of each of these conditions. The prevalence of MetS was particularly high (≥35%) in the West North Central, West South Central, and East South Central and low (30%) in the Pacific, New England, and Mid-Atlantic divisions. Some of the geographical variation appeared due to differences among non-Hispanic white females, who had a high prevalence of MetS (>32%) in the Midwest and South and a low prevalence of MetS (24%) in the West and Northeast. Geographical differences in MetS imply variation in the risk for future CVD and diabetes, with more elevated risk in the center of the United States. As MetS is a stronger risk factor for prediction of CVD and T2DM than is obesity, these differences are potentially important for prompting public health efforts toward surveillance and prevention in high-risk areas.

Background The severity of the metabolic syndrome (MetS) is significantly associated with future coronary heart disease (CHD) among individuals without baseline Type 2 diabetes. However, the validity of assessing MetS severity among individuals with diabetes is unknown. Objective To assess for differences in MetS severity by timing of Type 2 diabetes diagnosis and to assess for associations between MetS severity and future CHD among individuals with diabetes. Methods We analyzed data from participants of the Atherosclerosis Risk in Communities study, including 1419 with- and 7241 without diabetes, followed during 4 visits and adjudicated CHD diagnoses over a 20-year period. We used Cox-regression techniques to assess hazard ratios (HR) of CHD based on a sex- and race/ethnicity-specific MetS-severity Z-score (standard MetS score) and a similar MetS-severity score formulated without incorporating glucose as a component of MetS (no-glucose MetS score). Results For both the standard- and no-glucose MetS-severity scores, scores were highest in the baseline-diabetes group, lowest in the never-diabetes group and intermediate in the incident-diabetes groups. Among participants with diabetes, increasing MetS-severity score at baseline was associated with incident CHD, using both the standard MetS score (HR 1.29, 95% confidence interval [CI] 1.21, 1.39) and the no-glucose score (HR 1.42, CI 1.24, 1.62) (both p

The purpose of this study was to determine whether a patient satisfaction survey in the outpatient clinic setting using questions with either a positive or negative tone would produce consistent responses. This was a prospective study using a 20-question paper survey delivered to medical students who were asked to rate on a scale of 1 to 10 to what degree they either agree or disagree with statements regarding their most recent personal outpatient clinic health care visit (any medical specialty). The same survey was administered again through an e-mail link 1 week later. One hundred fifty (77%) students completed the 20-item survey and 53 (35%) of the participating students completed the follow-up e-mail survey. Seven of the 10 question pairs on the paper survey revealed statistically significant differences in responses based on tone, with greater values for disagreement with negatively toned questions than values representing agreement with positive-toned questions. The match rates for similar questions posed on the paper survey and then the e-mail survey 1 week later ranged between 27.8% and 56.6%. This study demonstrated that, with an outpatient health care patient satisfaction survey, disagreement with a negative-toned question was stronger than agreement with a positive-toned question. There was poor correlation between survey responses when first posed on a paper survey and then repeated on a digital survey 1 week later. These findings suggest that the wording of survey questions may affect responses and that survey answers change with time and across delivery platforms.

Completion rates of the human papillomavirus (HPV) vaccine series among U.S. adolescents are below public health targets. We explored parent-reported reasons for their children's non-completion of the HPV vaccine series using a nationally representative online survey of parents of children aged 9–17 years, fielded in October 2012. Among the 1,653 parents who responded, the proportion reporting that their child would definitely continue with the HPV vaccine series among those who had started the series ranged from 28% to 54%. The most common reason cited by parents for non-completion of the series was their child's fear of needles, followed by lack of awareness about additional doses and safety concerns. These findings demonstrate the need to encourage adoption of strategies addressing needle fears, utilize reminders for parents about subsequent doses, and emphasize recent HPV vaccine safety data in discussions with parents.

Objective: Efforts to increase human papillomavirus (HPV) vaccine coverage rates in adolescents include finding ways to improve discussions between clinicians and parents. One potentially important piece of information for these discussions is the HPV vaccination status of older siblings. Methods: A nationally representative online panel was used to conduct a cross-sectional survey of parents of children aged 9 to 17 years in October 2012. Results: Overall, 768 adolescents (35%) had ≥1 older sister aged 10 to 26 years. Male and female adolescents with an older sister who had received no HPV vaccine doses demonstrated higher rates of having no doses themselves, compared with those who had no older sister or those who had an older sister who had received ≥1 HPV vaccine dose. Conclusions: Discussing the HPV vaccination status of older sisters may be a useful strategy for providers to differentiate HPV vaccine messages to parents of unvaccinated younger siblings.

Human papillomavirus (HPV) vaccination coverage among adolescent females is well below national public health goals. Many known barriers to HPV vaccine receipt can be addressed in parent-physician conversations. This study sought to explore parent experiences and attitudes related to HPV vaccination of adolescent girls, focused on interactions with providers. We conducted a cross-sectional survey of parents using a nationally representative online panel. Among parents with ≥1 daughter aged 11 to 17 years, provider recommendations for HPV vaccine and specified age to begin the HPV vaccine series were associated with HPV vaccine status. Parents who reported their daughters were unlikely to complete the HPV series were more likely to have had no discussion of HPV vaccine with the provider. Efforts to increase HPV vaccination rates among adolescent females should continue to focus on improving provider discussion of HPV vaccine.

In 2013, approximately one-third of US adolescent males age 13-17 y had received ≥1 doses of HPV vaccines and only 14% had received ≥3 doses. This study used a nationally representative, online survey to explore experiences and attitudes related to HPV vaccination among parents with adolescent sons. Analyses compared the perspective of parents who do not intend to initiate HPV vaccine for ≥1 adolescent son to that of parents who are likely to initiate or continue HPV vaccination. Of 809 parents of sons age 11-17 years, half were classified as Unlikely to Initiate HPV vaccination and 39% as Likely to Vaccinate. A higher proportion of the Likely to Vaccinate group felt their son's doctor was knowledgeable about HPV vaccine, did a good job explaining its purpose, and spent more time discussing HPV vaccine; in contrast, over half of the Unlikely to Initiate group had never discussed HPV vaccine with their child's doctor. The majority of parents in both groups showed favorable attitudes to adolescent vaccination in general, with lower levels of support for HPV vaccine-specific statements. Physician-parent communication around HPV vaccine for adolescent males should build on positive attitude toward vaccines in general, while addressing parents' HPV vaccine-specific concerns.

Background. The current specialty-centric hypertension paradigm is unsustainable given the high prevalence of primary hypertension in adolescents. Objective. To describe specialists’ perspectives on referral and comanagement for adolescents with hypertension. Methods. Cross-sectional mailed survey of a national sample of 397 pediatric cardiologists and 389 pediatric nephrologists, conducted January to May 2014. Results. Response rate was 61%. Both specialties agreed that primary care providers can make the hypertension diagnosis, try lifestyle changes, and comanage monitoring of patient blood pressure control and medication side effects, but they felt antihypertensive medication use should mainly occur in the specialty setting. Conclusions. Our study suggests specialist support for changing the hypertension paradigm to encourage primary care providers, in collaboration with specialists, to diagnose hypertension, initiate lifestyle changes, and monitor progress and side effects. Future work should focus on supporting primary care physician comanagement of adolescents with hypertension.