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Background: Diabetic ketoacidosis (DKA) is a major cause of emergencies in youth with type 1 diabetes constituting a health burden. Nonadherence and knowledge gaps are key contributors. Patients with mild ketosis and dehydration are typically managed in the EC without multidisciplinary evaluation. Objective: We developed a quality improvement initiative to improve access and reduce emergency center (EC) visits for pediatric patients with type I diabetes with mild ketosis not tolerating oral intake, and to deliver family centered multidisciplinary education addressing diabetes knowledge gaps and psychosocial barriers. Methods: A multidisciplinary focus group of physicians, nurses, certified diabetes educators (CDE), and social workers (SW), determined criteria for patients who could be cared for in Urgent Care Bay (UCB) rather than EC. Eligible patients with type 1 diabetes were >5 years old who could not tolerate oral intake, and had low-to-moderate ketones. SW identified and addressed psychosocial barriers to optimal diabetes management. CDE assessed and provided structured education addressing knowledge gaps. Results: Of 17 referred patients, 9 were seen in UCB (8 by CDE; 7 by SW). None required transfer to EC. SW referred 4 patients to psychology: 2 seen in UCB, 2 referred to community psychology. Time spent in multidisciplinary UCB visit was not longer than traditional EC-managed visits. Conclusion: This multidisciplinary approach may help pediatric patients with diabetes with mild ketosis who are not tolerating oral intake. Multidisciplinary teaching and psychosocial interventions provided while patients are only mildly sick may help patients avoid future admissions. It remains to be seen whether this comprehensive model of education and hydration of mildly sick patients with diabetes will provide cost effectiveness in terms of overall EC admissions. Disclosure G.K. Kim: None. A. Mixon: None. M.A. Marshall: None. M.E. Taub: None. M. Jaramillo: None. D. Scroggins: None. N. Bansal: None. L. Karaviti: None. S. Mckay: None.

Background: Adolescents with type 1 diabetes mellitus (T1D) are at increased risk for depressive symptoms relative to youth without diabetes, which is associated with poor diabetes outcomes (Hood et al, 2014). As part of ongoing Quality Improvement initiatives at Texas Children’s Hospital (TCH), we evaluated two validated depression screening measures, the PHQ-2 and PHQ-9: Modified for Teens, to standardize our depression screening process. Objectives: We sought to (1) review screening outcomes from youth with T1D who completed both the PHQ-2 and PHQ-9, (2) determine which measure provided the greatest sensitivity to identifying depressive symptoms, and (3) create a standardized process for implementation of the more sensitive screen. Methods: Data was collected by a chart review of PHQ-2 and PHQ-9 scores for all patients with T1D age 12-17 seen at TCH Endocrine clinic sites between January 1 –December 31, 2017. A positive screen was defined as PHQ-2 score ≥ 3 and PHQ-9 score ≥ 5. We then created an algorithm based on the more sensitive screen for referrals to mental health services. Results: Of 961 eligible patients, 84% were screened using PHQ-2 and 15% using both the PHQ-2 and PHQ-9. Of the patients who completed both measures, the positive screening rate was 20% in PHQ-9 vs. 4% in PHQ-2. None of the patients with “moderate” PHQ-9 (≥5-9) screened positive on the PHQ-2, and only 1 patient with “severe” PHQ-9 (≥10) score screened positive on PHQ-2. Of the 3 patients who endorsed suicidality on the PHQ-9, none had a positive PHQ-2. 80% of patients who received both screens completed the screens within 2 months of each other. Discussion: PHQ-2 depression screen may be less sensitive than PHQ-9 for capturing depressive symptoms in youth with T1D. We have created a standardized algorithm implementing PHQ-9 into the clinic flow and looking at optimizing mental health referrals. Hood KK, Lawrence JM, Anderson A, Bell R, et al. Metabolic and inflammatory links to depression in youth with diabetes. Diabetes Care 2012;35:2443-2446. Disclosure G.K. Kim: None. S. Relan: None. M. Tosur: None. S. Agarwal: None. I. Jindal: None. T. Patel Moorjani: None. K. Fegan-Bohm: None. K.A. Gallagher: None. K. Hendrix: None.

Macrophages treated with hydrogen peroxide exhibit increased Mer-dependent signaling resulting in enhanced cellular survival in an oxidative stress environment. The MerTK plays several important roles in normal macrophage physiology, including regulation of cytokine secretion and clearance of apoptotic cells. Mer signaling in other cell types, including malignant cells that ectopically overexpress the RTK, leads to downstream prosurvival pathway activation. We explored the hypothesis that Mer has a prosurvival role in macrophages exposed to oxidative stress. H2O2 treatment of peritoneal exudate murine macrophages and J774 cells rapidly stimulated Mer phosphorylation in a concentration-dependent manner. Mer phosphorylation was dependent on the ligand Gas6, as treatment with warfarin or MerFc (a fusion protein of the extracellular domain of Mer and the Fc portion of human Ig), inhibitors of Gas6 activity, blocked H2O2-mediated activation of Mer. Antiapoptotic signals including pAkt and pErk 1/2 were increased dramatically (threefold and 4.5-fold, respectively) in WT Mer-positive macrophages compared with Mer KO macrophages stimulated with H2O2. In a consistent manner, Mer expression led to decreased cleavage of proapoptotic indicators PARP and Caspase-3. Furthermore, Mer provided up to twofold enhanced cellular survival to primary macrophages exposed to H2O2. These data represent the first report of Mer activation in response to oxidative stress and demonstrate the ability of Mer RTK to promote macrophage survival in disease states that involve an oxidative stress environment.

Ethnic identity is a significant factor related to self-concept and psychological development and similar to other aspects of identity, is of particular importance during the adolescent years when there is increased vulnerability to drug involvement. However, much of the research relative to adolescent drug use has focused on the annual and current prevalence rates among particular ethnic groups with little attention to ethnic or group identity issues. However, it is important to study and compare ethnic and group identity and its correlates to drug use. This article presents face-to-face interview questionnaire measures of ethnic identity as measured by affirmation and belongingness, ethnic identity achievement, ethnic behavior, and other group orientation [1], and drug use as measured by misuse, abuse, and chemical dependency diagnoses [2]. The questionnaires were administered to 127 (60 Ethnic, 67 White) adolescents from ethnically diverse schools in a large urban school district in the Pacific Northwest. The relationship of ethnic identity to drug use was examined. This study indicates that the questionnaire measures can be used to examine similarities and differences in ethnic identity and drug use among adolescents from different ethnic groups. A key finding of this study was that white adolescents scored lower in ethnic identity than did members of the four ethnic minority groups and the mixed racial group. However, the most significant key finding was that in the ethnic minority sample high levels of cultural identity were associated with heavy drug use. The results of this study suggest that social influences may play a larger role in the development of heavy drug use irrespective of the nature and origins of these social influences.

Although statistics from various surveys differ, it is acknowledged that drug abuse is increasing among young Asian Americans. This increase is particularly noteworthy among those who reside in urban centres, where there is greater exposure to social influences (Lin, 1986). Extensive exposure of Asian adolescents to Western youth drug culture contributes to a higher risk of developing drug problems. The internalizing of Western culture puts young Asians at risk of engaging in delinquent acts that lead to drug arrests, school dropout, and a greater frequency and duration of drug use. In a nine-month tracking study of Asian youth, their drug use and cultural influences were assessed using the Adolescent Substance Battery. It is suggested that the transition to Western culture disrupts the hierarchical family structure, interdependence, and self-identity of young Asian Americans.

The treatment of cutaneous lupus erythematosus is centered upon formulating a regimen of topical and systemic therapies designed to reduce disease activity and minimize cosmetic damage. Sun avoidance and sunscreen are important preventative measures proven to minimize cutaneous lupus erythematosus exacerbations. Limited disease is typically managed with topical corticosteroids or calcineurin inhibitors. Antimalarial therapy is the gold standard of systemic therapy. Many other treatments have been studied in patients with recalcitrant cutaneous lupus erythematosus, and their use must be evaluated based on individual risk-benefit concerns. R-salbutamol and pulsed dye laser therapy have proven to be effective topical alternatives. Additional systemic agents include retinoids, immunosuppressants, immunomodulators, biologics, and other experimental therapies with novel modes of action. According to the Oxford Centre for Evidence-based Medicine criteria for evaluating the strength of evidence supporting an individual treatment measure, no therapy for cutaneous lupus erythematosus has achieved Level 1 status. This demonstrates the need for randomized, controlled trials and systematic reviews of all cutaneous lupus erythematosus interventions in order to meet increasing standards and demand for evidence-based practice.

Current evidence suggests that post-adolescent acne in women is on the rise. Acne in this subgroup of patients commonly follows a specific pattern that can often be treatment resistant and/or prone to relapse, including after oral isotretinoin therapy. With a plethora of medications to choose from for acne treatment, many of which have been used in the past by patients without success, dermatology practitioners often find oral contraceptives and spironolactone to be of benefit in otherwise healthy adult females. Also, some of these patients may have concurrent hormonal anomalies such as polycystic ovarian syndrome or other underlying endocrine disorders, which should also be appropriately worked up by the clinician and managed accordingly. This article reviews some of the underlying pathophysiological factors, available treatment options, and screening guidelines to assist clinicians in the management of acne in adult females.

Psoriasis is a commonly encountered dermatosis with a variety of internal and external paradoxical factors contributing to the clinical course of the disease. There are several drugs described in the literature that have been associated with the initiation, exacerbation, and aggravation of psoriasis. Understanding the pathophysiology can provide clues to treatment and management of drug-induced and drug-aggravated psoriasis, which may be indistinguishable from idiopathic psoriasis. The clinical manifestations of drug-associated psoriasis can range from plaque-type psoriasis to severe erythroderma, thus warranting astute and sustained clinical observation.

The Asian population in the United States is expected to increase in the next 50 years. Concurrently, there is an overall rise in the incidence of melanoma. It is therefore crucial to obtain a better understanding of this deadly skin cancer in this minority population, as little information is currently available and prognosis remains poor. Through a review of the literature, this paper explores melanoma in the Asian population, including the most common subtype encountered, prognosis, theories on pathogenesis, and molecular biology.

There are some patients that, despite their continued use of optimized topical and systemic medication and skin care regimens, exhibit at least partial persistence of acne vulgaris (AV) lesions that is bothersome and treatment-resistant to pharmacologic approaches. Additionally, professional, public and governmental concern regarding "antibiotic resistance" has led to interest in therapeutic alternatives other than antibiotics. These challenges drive research into non-pharmacologic approaches to AV treatment, including laser and light-based approaches.

Astrocytomas account for the majority of malignant brain tumors diagnosed in both adult and pediatric patients. The therapies available to treat these neoplasms are limited, and the prognosis associated with high-grade lesions is extremely poor. Mer (MerTK) and Axl receptor tyrosine kinases (RTK) are expressed at abnormally high levels in a variety of malignancies, and these receptors are known to activate strong antiapoptotic signaling pathways that promote oncogenesis. In this study, we found that Mer and Axl mRNA transcript and protein expression were elevated in astrocytic patient samples and cell lines. shRNA-mediated knockdown of Mer and Axl RTK expression led to an increase in apoptosis in astrocytoma cells. Apoptotic signaling pathways including Akt and extracellular signal–regulated kinase 1/2, which have been shown to be activated in resistant astrocytomas, were downregulated with Mer and Axl inhibition whereas poly(ADP-ribose) polymerase cleavage was increased. Furthermore, Mer and Axl shRNA knockdown led to a profound decrease of astrocytoma cell proliferation in soft agar and a significant increase in chemosensitivity in response to temozolomide, carboplatin, and vincristine treatment. Our results suggest Mer and Axl RTK inhibition as a novel method to improve apoptotic response and chemosensitivity in astrocytoma and provide support for these oncogenes as attractive biological targets for astrocytoma drug development. Mol Cancer Ther; 9(5); 1298–307. ©2010 AACR.

Between-group and within-group differences in perceptions of behavior were examined among 74 Asian Americans and 111 European Americans. Participants rated videotaped interactions of Asian American mothers and daughters. Asian Americans, and a more homogeneous sample of Chinese Americans, perceived less maternal control and more reciprocity than did European Americans. Intra-cultural variations in perceptions were also evident, as within-group analyses revealed differences in perceptions based on the generational status of Asian Americans and the degree of multicultural experience of European Americans. Overall, findings suggest that perceptions of behavior are shaped as much by within-group differences in familiarity and experience with the target culture as by between-group differences in ethnicity. Implications for theories of child socialization, multicultural counseling, and observational research are discussed.