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Regular use of continuous glucose monitoring (CGM) in type 1 diabetes management increases the achievement of glycemic targets and reduces health care utilization, specifically emergency department (ED) visits. This retrospective chart review examined the effects of CGM use in patients with type 1 diabetes in a pediatric ED. Use of CGM was associated with several differences in patient management in the ED. This work is a first step toward development of guidelines for the appropriate use of CGM in the pediatric ED. In the future, CGM use in type 1 diabetes may lead to reduced ED-specific health care costs.

BACKGROUND In the U.S., there are over 37 million people with diabetes (PwD), but only 8,000 endocrinologists. Therefore, many PwD receive care exclusively from primary care providers (PCPs). To democratize knowledge regarding insulin-requiring diabetes through tele-education, Stanford University and the University of Florida developed Project Extension for Community Healthcare Outcomes (ECHO) Diabetes. OBJECTIVE ECHO Diabetes uses a Hub and Spoke model connecting specialists (the “Hub”) with PCPs (the “Spokes”). One-hour, weekly sessions include Hub diabetes didactic presentations and Spoke de-identified case presentations. Lessons learned during these sessions target provider knowledge and confidence surrounding diabetes management and patient care. METHODS Spokes were asked to provide short descriptions of PwD whose diabetes management improved directly or indirectly from their providers’ participation and/or their involvement with a Diabetes Support Coach (DSC). We provide a case series to describe individuals and outcomes. Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry. RESULTS A case series of 11 PwD was compiled from 10 PCPs and one DSC from California and Florida between 2021 and 2022. The principal impact of ECHO Diabetes is the education amplified from PCPs and DSCs to PwD. In all cases, PwD reported increased engagement and improved diabetes management. Several cases reflected increased access to diabetes technology, improvement in glycemic outcomes, and positive trends in mental health measures. CONCLUSIONS This case series elucidates the potential value of the ECHO Diabetes program to PwD who receive their diabetes care from PCPs. Those matched with a DSC saw clinically significant improvements in HbA1c and mental health outcomes. CLINICALTRIAL Not applicable - Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry.

IntroductionIn the US, many individuals with diabetes do not have consistent access to endocrinologists and therefore rely on primary care providers (PCPs) for their diabetes management. Project ECHO (Extension for Community Healthcare Outcomes) Diabetes, a tele-education model, was developed to empower PCPs to independently manage diabetes, including education on diabetes technology initiation and use, to bridge disparities in diabetes.MethodsPCPs (n=116) who participated in Project ECHO Diabetes and completed pre- and post-intervention surveys were included in this analysis. The survey was administered in California and Florida to participating PCPs via REDCap and paper surveys. This survey aimed to evaluate practice demographics, protocols with adult and pediatric T1D management, challenges, resources, and provider knowledge and confidence in diabetes management. Differences and statistical significance in pre- and post-intervention responses were evaluated via McNemar’s tests.ResultsPCPs reported improvement in all domains of diabetes education and management. From baseline, PCPs reported improvement in their confidence to serve as the T1D provider for their community (pre vs post: 43.8% vs 68.8%, p=0.005), manage insulin therapy (pre vs post: 62.8% vs 84.3%, p=0.002), and identify symptoms of diabetes distress (pre vs post: 62.8% vs 84.3%, p=0.002) post-intervention. Compared to pre-intervention, providers reported significant improvement in their confidence in all aspects of diabetes technology including prescribing technology (41.2% vs 68.6%, p=0.001), managing insulin pumps (41.2% vs 68.6%, p=0.001) and hybrid closed loop (10.2% vs 26.5%, p=0.033), and interpreting sensor data (41.2% vs 68.6%, p=0.001) post-intervention.DiscussionPCPs who participated in Project ECHO Diabetes reported increased confidence in diabetes management, with notable improvement in their ability to prescribe, manage, and troubleshoot diabetes technology. These data support the use of tele-education of PCPs to increase confidence in diabetes technology management as a feasible strategy to advance equity in diabetes management and outcomes.

Newborn screening and therapies for Pompe disease (glycogen storage disease type II, acid maltase deficiency) will continue to expand in the future. It is thus important to determine whether enzyme activity or type of pathogenic genetic variant in GAA can best predict phenotypic severity, particularly the presence of infantile-onset Pompe disease (IOPD) versus late-onset Pompe disease (LOPD). We performed a retrospective analysis of 23 participants with genetically-confirmed cases of Pompe disease. The following data were collected: clinical details including presence or absence of cardiomyopathy, enzyme activity levels, and features of GAA variants including exon versus intron location and splice site versus non-splice site. Several combinations of GAA variant types for individual participants had significant associations with disease subtype, cardiomyopathy, age at diagnosis, gross motor function scale (GMFS), and stability of body weight. The presence of at least one splice site variant (c.546 G > C/p.T182 = , c.1076-22 T > G, c.2646 + 2 T > A, and the classic c.-32-13T > G variant) was associated with LOPD, while the presence of non-splice site variants on both alleles was associated with IOPD. Enzyme activity levels in isolation were not sufficient to predict disease subtype or other major clinical features. To extend the findings of prior studies, we found that multiple types of splice site variants beyond the classic c.-32-13T > G variant are often associated with a milder phenotype. Enzyme activity levels continue to have utility for supporting the diagnosis when the genetic variants are ambiguous. It is important for newly diagnosed patients with Pompe disease to have complete genetic, cardiac, and neurological evaluations.

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.

Introduction In response to the coronavirus disease 2019 (COVID-19) pandemic, state and local governments implemented mitigation strategies, including lockdowns, thereby averting the typical fall/winter 2020 bronchiolitis season and reducing the incidence of respiratory viruses, such as respiratory syncytial virus (RSV). Florida implemented a strict lockdown from April 1, 2020, to April 30, 2020. The removal of lockdown precautions on September 25, 2020, was followed by an atypical out-of-season surge of bronchiolitis in April 2021. Anecdotally, this surge appeared to be associated with both increased poly-viral coinfections and disease severity. Objective To determine if the bronchiolitis out-of-season surge differed from historical seasonal case patterns. Methods A single-center retrospective cohort study of admissions to the pediatric intensive care unit (PICU) with International Classification of Diseases, Tenth Revision (ICD-10) codes of bronchiolitis, from December 9, 2019, to February 29, 2020 (12 weeks, pre-lockdown group or PreLD), was compared to March 29, 2021, to June 19, 2021 (12 weeks, post-lockdown group or PostLD). Variables used for comparison were gender, ethnicity, age, viral coinfections, viruses detected, PICU length of stay, hospital length of stay, mortality, maximum respiratory support needed, mechanical ventilation days, extracorporeal life support (ECLS) days, and severity of disease measured by Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and Pediatric Sequential Organ Failure Assessment (pSOFA). Categorical data were analyzed using Fisher's exact test, and a t-test was used for continuous variables. A two-sided p0.05 was considered significant. Results A total of 135 subjects were analyzed from the two cohorts. More patients were admitted during the PostLD phase (87 vs. 48). The PostLD group had a higher age at admission (11.2 ± 12.3 vs. 6.6 ± 7.5, p = 0.0075), but there were no differences in gender or race/ethnicity. The PostLD group also exhibited a higher proportion of RSV infections (73 vs. 16, p0.0001) and poly-viral infections (p0.0001). Higher coronavirus OC43 (9 vs. 0, p = 0.0263) and parainfluenza types 1-4 (human parainfluenza virus (HPIV)) (19 vs. 1, p = 0.0017) detections, yet fewer human metapneumovirus (HMPV) detections (0 vs. 4, p = 0.0147), were observed PostLD. No differences were found in hospital length of stay, PICU length of stay, mortality, mechanical ventilation days, ECLS days, or severity of illness scores based on PELOD-2 or pSOFA scores. Conclusion In the bronchiolitis out-of-season surge, there were an increased number of admissions to the PICU. Those patients were older, and more likely to have RSV, as well as a coinfection with coronavirus OC43 or HPIV, yet less likely to have HMPV. No difference in length of stay or disease severity was demonstrated.

This study assesses the association of race/ethnicity with the Patient-Reported Outcomes Measurement Information System (PROMIS®) in childhood-onset systemic lupus erythematosus (cSLE) patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry.cSLE patients enrolled in the CARRA Registry within two years of cSLE diagnosis who met ACR and/or SLICC classification criteria for lupus were included. Baseline demographics, laboratory, and disease features as well as patient-reported outcomes were obtained. Multivariable linear regression analysis was used to examine the association of race and ethnicity with PROMIS scores at registry enrolment.425 cSLE patients met inclusion criteria: 83.8% were female, 30.6% non-Hispanic White, 29.7% Black, 22.1% Hispanic. The mean age at diagnosis was 13.9 years (SD 2.5). Household income and highest parental education varied by race/ethnic group, as did frequency of rash, leukopenia, and anti-Smith antibodies. The cohort had low-moderate baseline disease activity (SLEDAI mean: 6.0 [SD 6.7]). The overall PROMIS Global Health mean T-score was 38.6 (SD 6.5), more than one standard deviation below the general population mean of 50. There was no association between race/ethnicity and PROMIS scores in multivariable linear regression analysis.In this multiethnic paediatric lupus cohort, PROMIS global health was lower when compared with the general paediatric US population. Moreover, PROMIS global health, pain interference, and physical function mobility did not vary across races/ethnicities.

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.

The United States has the highest number of total cases and deaths due to coronavirus disease 2019 (COVID-19) worldwide (Johns Hopkins COVID Dashboard, 2021). Despite COVID-19 vaccine availability, uptake in the United States has been slow and vaccine hesitancy has been a significant barrier to achieving widespread vaccine uptake. Understanding determinants of vaccine acceptance is essential to implement successful population health interventions to increase COVID-19 vaccination.We developed an anonymous cross-sectional parent survey to assess factors associated with parent and child COVID-19 vaccine acceptance and hesitancy during the initial pediatric vaccine rollout amongst adolescents 16 years +. The survey was sent via email to 25,308 parents registered to the Alachua County Public School System in May 2021 and remained active until July 2021.There were a total of 2,620 survey responses. Overall, 31.5 % of parents with children ages 16 years + reported their child had received the COVID-19 vaccine, 65.2 % reported their (eligible) child had not received the vaccine, and 3.3 % reported their child was scheduled for the vaccine. A majority of parents (60.9 %) reported they planned to vaccinate all of their children once the COVID-19 vaccine was available for their children's age. COVID-19 vaccine uptake in adolescents ages 16 + reported by Hispanic and White parents was two times higher than that reported by Black parents. Parent COVID-19 and influenza vaccine uptake were associated with increased child COVID-19 vaccination. The most commonly reported reasons why parents chose not to have their child vaccinated against COVID-19 were concerns about long-term negative side effects (75.7 %) and a negative reaction (56.5 %). Medical providers were reported as the most trusted source of information.Our study provides insight into determinants of vaccine acceptance, vaccine hesitancy, and trusted sources of information that may be helpful to develop targeted interventions to increase youth COVID-19 vaccination.

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.

ObjectiveThe American Board of Pediatrics’ (ABP) maintenance of certification (MOC) programme seeks to continue educating paediatricians throughout their careers by encouraging lifelong learning and continued improvement. The programme includes four parts, each centring on a different aspect of medical practice. Part 4 MOC centres on quality improvement (QI). Surveys by the ABP suggest that paediatricians are dissatisfied with aspects of part 4, but their reasons are unclear. This study sought to explore factors contributing to dissatisfaction with part 4 by focusing on performance improvement modules (PIMs), a popular means of achieving part 4 credit.MethodsThe study used cross-sectional purposive sampling drawing from US physicians working in a range of practice settings: private outpatient, hospital, academic and low-income clinics. The sampling frame was divided by practice characteristics and satisfaction level, derived from a five-point Likert item asking about physician satisfaction regarding a recent PIM. In-depth interviews were conducted with 21 physicians, and the interview data were coded, categorised into themes and analysed using a framework analysis approach.ResultsPaediatricians expressed nuanced views of PIMs and remain globally dissatisfied with part 4, although reasons for dissatisfaction varied. Concerns with PIMs included: (1) excessive time and effort; (2) limited improvement and (3) lack of clinically relevant topics. While most agreed that QI is important, participants felt persistently dissatisfied with the mechanics of doing PIMs, especially when QI tasks fell outside of their typical work regimen.ConclusionsPaediatricians agreed that part 4, PIMs, and QI efforts in general still lack clinical relevance and need to be more easily incorporated into practice workflow. Clinicians specifically felt that PIMs must be directly integrated with physicians’ practice settings in terms of topic, data quality and metrics, and must address practice differences in time and monetary resources for completing large or complex projects.

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.

Newborn screening and therapies for Pompe disease (glycogen storage disease type II, acid maltase deficiency) will continue to expand in the future. It is thus important to determine whether enzyme activity or type of pathogenic genetic variant in GAA can best predict phenotypic severity, particularly the presence of infantile-onset Pompe disease (IOPD) versus late-onset Pompe disease (LOPD). We performed a retrospective analysis of 23 participants with genetically-confirmed cases of Pompe disease. The following data were collected: clinical details including presence or absence of cardiomyopathy, enzyme activity levels, and features of GAA variants including exon versus intron location and splice site versus non-splice site. Several combinations of GAA variant types for individual participants had significant associations with disease subtype, cardiomyopathy, age at diagnosis, gross motor function scale (GMFS), and stability of body weight. The presence of at least one splice site variant (c.546 G C/p.T182 = , c.1076-22 T G, c.2646 + 2 T A, and the classic c.-32-13T G variant) was associated with LOPD, while the presence of non-splice site variants on both alleles was associated with IOPD. Enzyme activity levels in isolation were not sufficient to predict disease subtype or other major clinical features. To extend the findings of prior studies, we found that multiple types of splice site variants beyond the classic c.-32-13T G variant are often associated with a milder phenotype. Enzyme activity levels continue to have utility for supporting the diagnosis when the genetic variants are ambiguous. It is important for newly diagnosed patients with Pompe disease to have complete genetic, cardiac, and neurological evaluations.

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.

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