OBJECTIVE

To determine the risk of cardiovascular disease (CVD), microvascular complications, and mortality in patients with type 2 diabetes who subsequently develop obstructive sleep apnea (OSA) compared with patients with type 2 diabetes without a diagnosis of OSA.

RESEARCH DESIGN AND METHODS

This age-, sex-, BMI-, and diabetes duration–matched cohort study used data from a U.K. primary care database from 1 January 2005 to 17 January 2018. Participants aged ≥16 years with type 2 diabetes were included. Exposed participants were those who developed OSA after their diabetes diagnosis; unexposed participants were those without diagnosed OSA. Outcomes were composite CVD (ischemic heart disease [IHD], stroke/transient ischemic attack [TIA], heart failure [HF]), peripheral vascular disease (PVD), atrial fibrillation (AF), peripheral neuropathy (PN), diabetes-related foot disease (DFD), referable retinopathy, chronic kidney disease (CKD), and all-cause mortality. The same outcomes were explored in patients with preexisting OSA before a diagnosis of type 2 diabetes versus diabetes without diagnosed OSA.

RESULTS

A total of 3,667 exposed participants and 10,450 matched control participants were included. Adjusted hazard ratios for the outcomes were as follows: composite CVD 1.54 (95% CI 1.32, 1.79), IHD 1.55 (1.26, 1.90), HF 1.67 (1.35, 2.06), stroke/TIA 1.57 (1.27, 1.94), PVD 1.10 (0.91, 1.32), AF 1.53 (1.28, 1.83), PN 1.32 (1.14, 1.51), DFD 1.42 (1.16, 1.74), referable retinopathy 0.99 (0.82, 1.21), CKD (stage 3–5) 1.18 (1.02, 1.36), albuminuria 1.11 (1.01, 1.22), and all-cause mortality 1.24 (1.10, 1.40). In the prevalent OSA cohort, the results were similar, but some associations were not observed.

CONCLUSIONS

Patients with type 2 diabetes who develop OSA are at increased risk of CVD, AF, PN, DFD, CKD, and all-cause mortality compared with patients without diagnosed OSA. Patients with type 2 diabetes who develop OSA are a high-risk population, and strategies to detect OSA and prevent cardiovascular and microvascular complications should be implemented.

OBJECTIVE

Type 2 diabetes develops for many years before diagnosis. We aimed to reveal early metabolic features characterizing liability to adult disease by examining genetic liability to adult type 2 diabetes in relation to metabolomic traits across early life.

RESEARCH DESIGN AND METHODS

Up to 4,761 offspring from the Avon Longitudinal Study of Parents and Children were studied. Linear models were used to examine effects of a genetic risk score (162 variants) for adult type 2 diabetes on 229 metabolomic traits (lipoprotein subclass–specific cholesterol and triglycerides, amino acids, glycoprotein acetyls, others) measured at age 8 years, 16 years, 18 years, and 25 years. Two-sample Mendelian randomization (MR) was also conducted using genome-wide association study data on metabolomic traits in an independent sample of 24,925 adults.

RESULTS

At age 8 years, associations were most evident for type 2 diabetes liability (per SD-higher) with lower lipids in HDL subtypes (e.g., –0.03 SD, 95% CI –0.06, –0.003 for total lipids in very large HDL). At 16 years, associations were stronger with preglycemic traits, including citrate and with glycoprotein acetyls (0.05 SD, 95% CI 0.01, 0.08), and at 18 years, associations were stronger with branched chain amino acids. At 25 years, associations had strengthened with VLDL lipids and remained consistent with previously altered traits, including HDL lipids. Two-sample MR estimates among adults indicated persistent patterns of effect of disease liability.

CONCLUSIONS

Our results support perturbed HDL lipid metabolism as one of the earliest features of type 2 diabetes liability, alongside higher branched-chain amino acid and inflammatory levels. Several features are apparent in childhood as early as age 8 years, decades before the clinical onset of disease.

OBJECTIVE

This study evaluated the ability of the Building, Relating, Assessing, and Validating Outcomes (BRAVO) risk engine to accurately project cardiovascular outcomes in three major clinical trials—BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), Canagliflozin Cardiovascular Assessment Study (CANVAS), and Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction (DECLARE-TIMI 58) trial—on sodium–glucose cotransporter 2 inhibitors (SGLT2is) to treat patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Baseline data from the publications of the three trials were obtained and entered into the BRAVO model to predict cardiovascular outcomes. Projected benefits of reducing risk factors of interest (A1C, systolic blood pressure [SBP], LDL, or BMI) on cardiovascular events were evaluated, and simulated outcomes were compared with those observed in each trial.

RESULTS

BRAVO achieved the best prediction accuracy when simulating outcomes of the CANVAS and DECLARE-TIMI 58 trials. For the EMPA-REG OUTCOME trial, a mild bias was observed (~20%) in the prediction of mortality and angina. The effect of risk reduction on outcomes in treatment versus placebo groups predicted by the BRAVO model strongly correlated with the observed effect of risk reduction on the trial outcomes as published. Finally, the BRAVO engine revealed that most of the clinical benefits associated with SGLT2i treatment are through A1C control, although reductions in SBP and BMI explain a proportion of the observed decline in cardiovascular events.

CONCLUSIONS

The BRAVO risk engine was effective in predicting the benefits of SGLT2is on cardiovascular health through improvements in commonly measured risk factors, including A1C, SBP, and BMI. Since these benefits are individually small, the use of the complex, dynamic BRAVO model is ideal to explain the cardiovascular outcome trial results.

OBJECTIVE

We analyzed data from inpatients with diabetes admitted to a large university hospital to predict the risk of hypoglycemia through the use of machine learning algorithms.

RESEARCH DESIGN AND METHODS

Four years of data were extracted from a hospital electronic health record system. This included laboratory and point-of-care blood glucose (BG) values to identify biochemical and clinically significant hypoglycemic episodes (BG ≤3.9 and ≤2.9 mmol/L, respectively). We used patient demographics, administered medications, vital signs, laboratory results, and procedures performed during the hospital stays to inform the model. Two iterations of the data set included the doses of insulin administered and the past history of inpatient hypoglycemia. Eighteen different prediction models were compared using the area under the receiver operating characteristic curve (AUROC) through a 10-fold cross validation.

RESULTS

We analyzed data obtained from 17,658 inpatients with diabetes who underwent 32,758 admissions between July 2014 and August 2018. The predictive factors from the logistic regression model included people undergoing procedures, weight, type of diabetes, oxygen saturation level, use of medications (insulin, sulfonylurea, and metformin), and albumin levels. The machine learning model with the best performance was the XGBoost model (AUROC 0.96). This outperformed the logistic regression model, which had an AUROC of 0.75 for the estimation of the risk of clinically significant hypoglycemia.

CONCLUSIONS

Advanced machine learning models are superior to logistic regression models in predicting the risk of hypoglycemia in inpatients with diabetes. Trials of such models should be conducted in real time to evaluate their utility to reduce inpatient hypoglycemia.

OBJECTIVE

Preanalytical processing of blood samples can affect plasma glucose measurement because on-going glycolysis by cells prior to centrifugation can lower its concentration. In June 2017, ACT Pathology changed the processing of oral glucose tolerance test (OGTT) blood samples for pregnant women from a delayed to an early centrifugation protocol. The effect of this change on the rate of gestational diabetes mellitus (GDM) diagnosis was determined.

RESEARCH DESIGN AND METHODS

All pregnant women in the Australian Capital Territory (ACT) are recommended for GDM testing with a 75-g OGTT using the World Health Organization diagnostic criteria. From January 2015 to May 2017, OGTT samples were collected into sodium fluoride (NaF) tubes and kept at room temperature until completion of the test (delayed centrifugation). From June 2017 to October 2018, OGTT samples in NaF tubes were centrifuged within 10 min (early centrifugation).

RESULTS

A total of 7,509 women were tested with the delayed centrifugation protocol and 4,808 with the early centrifugation protocol. The mean glucose concentrations for the fasting, 1-h and 2-h OGTT samples were, respectively, 0.24 mmol/L (5.4%), 0.34 mmol/L (4.9%), and 0.16 mmol/L (2.3%) higher using the early centrifugation protocol (P < 0.0001 for all), increasing the GDM diagnosis rate from 11.6% (n = 869/7,509) to 20.6% (n = 1,007/4,887).

CONCLUSIONS

The findings of this study highlight the critical importance of the preanalytical processing protocol of OGTT blood samples used for diagnosing GDM. Delay in centrifuging of blood collected into NaF tubes will result in substantially lower rates of diagnosis than if blood is centrifuged early.

OBJECTIVE

This study aims to evaluate the association of energy and macronutrient intake at dinner versus breakfast with disease-specific and all-cause mortality in people with diabetes.

RESEARCH DESIGN AND METHODS

A total of 4,699 people with diabetes who enrolled in the National Health and Nutrition Examination Survey from 2003 to 2014 were recruited for this study. Energy and macronutrient intake was measured by a 24-h dietary recall. The differences () in energy and macronutrient intake between dinner and breakfast ( = dinner – breakfast) were categorized into quintiles. Death information was obtained from the National Death Index until 2015. Cox proportional hazards regression models were developed to evaluate the survival relationship between and diabetes, cardiovascular disease (CVD), and all-cause mortality.

RESULTS

Among the 4,699 participants, 913 deaths, including 269 deaths due to diabetes and 314 deaths due to CVD, were documented. After adjustment for potential confounders, compared with participants in the lowest quintile of in terms of total energy and protein, participants in the highest quintile were more likely to die due to diabetes (hazard ratio [HR]_energy 1.92, 99% CI 1.08–3.42; HR_protein 1.92, 99% CI 1.06–3.49) and CVD (HR_energy 1.69, 99% CI 1.02–2.80; HR_protein 1.96, 99% CI 1.14–3.39). The highest quintile of total fat was related to CVD mortality (HR 1.67, 99% CI 1.01–2.76). Isocalorically replacing 5% of total energy at dinner with breakfast was associated with 4% and 5% lower risk of diabetes (HR 0.96, 95% CI 0.94–0.98) and CVD (HR 0.95, 95% CI 0.93–0.97) mortality, respectively.

CONCLUSIONS

Higher intake of energy, total fat, and protein from dinner than breakfast was associated with greater diabetes, CVD, and all-cause mortality in people with diabetes.

OBJECTIVE

In patients with type 2 diabetes (T2D) and critical limb ischemia (CLI), migration of circulating CD34⁺ cells predicted cardiovascular mortality at 18 months after revascularization. This study aimed to provide long-term validation and mechanistic understanding of the biomarker.

RESEARCH DESIGN AND METHODS

The association between CD34⁺ cell migration and cardiovascular mortality was reassessed at 6 years after revascularization. In a new series of T2D-CLI and control subjects, immuno-sorted bone marrow CD34⁺ cells were profiled for miRNA expression and assessed for apoptosis and angiogenesis activity. The differentially regulated miRNA-21 and its proapoptotic target, PDCD4, were titrated to verify their contribution in transferring damaging signals from CD34⁺ cells to endothelial cells.

RESULTS

Multivariable regression analysis confirmed that CD34⁺ cell migration forecasts long-term cardiovascular mortality. CD34⁺ cells from T2D-CLI patients were more apoptotic and less proangiogenic than control subjects and featured miRNA-21 downregulation, modulation of several long noncoding RNAs acting as miRNA-21 sponges, and upregulation of the miRNA-21 proapoptotic target PDCD4. Silencing miR-21 in control subject CD34⁺ cells phenocopied the T2D-CLI cell behavior. In coculture, T2D-CLI CD34⁺ cells imprinted naïve endothelial cells, increasing apoptosis, reducing network formation, and modulating the TUG1 sponge/miRNA-21/PDCD4 axis. Silencing PDCD4 or scavenging reactive oxygen species protected endothelial cells from the negative influence of T2D-CLI CD34⁺ cells.

CONCLUSIONS

Migration of CD34⁺ cells predicts long-term cardiovascular mortality in T2D-CLI patients. An altered paracrine signaling conveys antiangiogenic and proapoptotic features from CD34⁺ cells to the endothelium. This damaging interaction may increase the risk for life-threatening complications.

OBJECTIVE

To examine whether low baseline diastolic blood pressure (DBP) modifies the effects of intensive systolic blood pressure (SBP) lowering on cardiovascular outcomes in type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP), a two-by-two factorial randomized controlled trial, examined effects of SBP (<120 vs. <140 mmHg) and glycemic (HbA_1c <6% vs. 7.0–7.9% [<42 vs. 53–63 mmol/mol]) control on cardiovascular events in T2DM (N = 4,731). We examined whether effects of SBP control on cardiovascular composite were modified by baseline DBP and glycemic control.

RESULTS

Intensive SBP lowering decreased the risk of the cardiovascular composite (hazard ratio [HR] 0.76 [95% CI 0.59–0.98]) in the standard glycemic arm but not in the intensive glycemic arm (HR 1.06 [95% CI 0.81–1.40]). Spline regression models relating the effects of the intervention on the cardiovascular composite across the range of baseline DBP did not show evidence of effect modification by low baseline DBP for the cardiovascular composite in the standard or intensive glycemic arms. The relation between the effect of the intensive SBP intervention and baseline DBP was similar between glycemic arms for the cardiovascular composite three-way interaction (P = 0.83).

CONCLUSIONS

In persons with T2DM, intensive SBP lowering decreased the risk of cardiovascular composite end point irrespective of baseline DBP in the setting of standard glycemic control. Hence, low baseline DBP should not be an impediment to intensive SBP lowering in patients with T2DM treated with guidelines recommending standard glycemic control.

OBJECTIVE

The LEADER trial (ClinicalTrials.gov reg. no. NCT01179048) demonstrated a reduced risk of cardiovascular (CV) events for patients with type 2 diabetes who received the glucagon-like peptide 1 receptor agonist liraglutide versus placebo. The mechanisms behind this CV benefit remain unclear. We aimed to identify potential mediators for the CV benefit observed with liraglutide in the LEADER trial.

RESEARCH DESIGN AND METHODS

We performed exploratory analyses to identify potential mediators of the effect of liraglutide on major adverse CV events (MACE; composite of CV death, nonfatal myocardial infarction, or nonfatal stroke) from the following candidates: glycated hemoglobin (HbA_1c), body weight, urinary albumin-to-creatinine ratio (UACR), confirmed hypoglycemia, sulfonylurea use, insulin use, systolic blood pressure, and LDL cholesterol. These candidates were selected as CV risk factors on which liraglutide had an effect in LEADER such that a reduction in CV risk might result. We used two methods based on a Cox proportional hazards model and the new Vansteelandt method designed to use all available information from the mediator and to control for confounding factors.

RESULTS

Analyses using the Cox methods and Vansteelandt method indicated potential mediation by HbA_1c (up to 41% and 83% mediation, respectively) and UACR (up to 29% and 33% mediation, respectively) on the effect of liraglutide on MACE. Mediation effects were small for other candidates.

CONCLUSIONS

These analyses identify HbA_1c and, to a lesser extent, UACR as potential mediators of the CV effects of liraglutide. Whether either is a marker of an unmeasured factor or a true mediator remains a key question that invites further investigation.

OBJECTIVE

To determine the effect of tirzepatide, a dual agonist of glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptors, on biomarkers of nonalcoholic steatohepatitis (NASH) and fibrosis in patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

Patients with T2DM received either once weekly tirzepatide (1, 5, 10, or 15 mg), dulaglutide (1.5 mg), or placebo for 26 weeks. Changes from baseline in alanine aminotransferase (ALT), aspartate aminotransferase (AST), keratin-18 (K-18), procollagen III (Pro-C3), and adiponectin were analyzed in a modified intention-to-treat population.

RESULTS

Significant (P < 0.05) reductions from baseline in ALT (all groups), AST (all groups except tirzepatide 10 mg), K-18 (tirzepatide 5, 10, 15 mg), and Pro-C3 (tirzepatide 15 mg) were observed at 26 weeks. Decreases with tirzepatide were significant compared with placebo for K-18 (10 mg) and Pro-C3 (15 mg) and with dulaglutide for ALT (10, 15 mg). Adiponectin significantly increased from baseline with tirzepatide compared with placebo (10, 15 mg).

CONCLUSIONS

In post hoc analyses, higher tirzepatide doses significantly decreased NASH-related biomarkers and increased adiponectin in patients with T2DM.

OBJECTIVE

Despite evidence of a relationship among obstructive sleep apnea (OSA), metabolic dysregulation, and diabetes, it is uncertain whether OSA treatment can improve metabolic parameters. We sought to determine effects of long-term continuous positive airway pressure (CPAP) treatment on glycemic control and diabetes risk in patients with cardiovascular disease (CVD) and OSA.

RESEARCH DESIGN AND METHODS

Blood, medical history, and personal data were collected in a substudy of 888 participants in the Sleep Apnea Cardiovascular End Points (SAVE) trial in which patients with OSA and stable CVD were randomized to receive CPAP plus usual care, or usual care alone. Serum glucose and glycated hemoglobin A_1c (HbA_1c) were measured at baseline, 6 months, and 2 and 4 years and incident diabetes diagnoses recorded.

RESULTS

Median follow-up was 4.3 years. In those with preexisting diabetes (n = 274), there was no significant difference between the CPAP and usual care groups in serum glucose, HbA_1c, or antidiabetic medications during follow-up. There were also no significant between-group differences in participants with prediabetes (n = 452) or in new diagnoses of diabetes. Interaction testing suggested that women with diabetes did poorly in the usual care group, while their counterparts on CPAP therapy remained stable.

CONCLUSIONS

Among patients with established CVD and OSA, we found no evidence that CPAP therapy over several years affects glycemic control in those with diabetes or prediabetes or diabetes risk over standard-of-care treatment. The potential differential effect according to sex deserves further investigation.

OBJECTIVE

The role of U300 glargine insulin for the inpatient management of type 2 diabetes (T2D) has not been determined. We compared the safety and efficacy of glargine U300 versus glargine U100 in noncritically ill patients with T2D.

RESEARCH DESIGN AND METHODS

This prospective, open-label, randomized clinical trial included 176 patients with poorly controlled T2D (admission blood glucose [BG] 228 ± 82 mg/dL and HbA_1c 9.5 ± 2.2%), treated with oral agents or insulin before admission. Patients were treated with a basal-bolus regimen with glargine U300 (n = 92) or glargine U100 (n = 84) and glulisine before meals. We adjusted insulin daily to a target BG of 70–180 mg/dL. The primary end point was noninferiority in the mean difference in daily BG between groups. The major safety outcome was the occurrence of hypoglycemia.

RESULTS

There were no differences between glargine U300 and U100 in mean daily BG (186 ± 40 vs. 184 ± 46 mg/dL, P = 0.62), percentage of readings within target BG of 70–180 mg/dL (50 ± 27% vs. 55 ± 29%, P = 0.3), length of stay (median [IQR] 6.0 [4.0, 8.0] vs. 4.0 [3.0, 7.0] days, P = 0.06), hospital complications (6.5% vs. 11%, P = 0.42), or insulin total daily dose (0.43 ± 0.21 vs. 0.42 ± 0.20 units/kg/day, P = 0.74). There were no differences in the proportion of patients with BG <70 mg/dL (8.7% vs. 9.5%, P > 0.99), but glargine U300 resulted in significantly lower rates of clinically significant hypoglycemia (<54 mg/dL) compared with glargine U100 (0% vs. 6.0%, P = 0.023).

CONCLUSIONS

Hospital treatment with glargine U300 resulted in similar glycemic control compared with glargine U100 and may be associated with a lower incidence of clinically significant hypoglycemia.

CNN reports that a study confirms that early autism intervention in toddlers is effective. A study was completed with a program called the Early Start Denver Model (ESDM). This program involves about twenty hours a week in the child's own home. It involves play and parents can easily learn some of the skills that can be applied in other settings. The study compared a group of toddlers that were given ESDM intervention to a group of toddlers receiving typical community interventions. Both groups showed improvement, but the ESDM group improved IQ by 18 points compared to 8 points with traditional interventions. The study is reporting that some of the children "virtually caught up to the typical kids their age." However, they are not claiming it is a cure for autism. According to the article they are working on a replication study to determine if there are similar results. Personally, I'm looking forward to the results of the replication study and want to find out more about this method. From what I understand it is less of a time constraint than ABA therapy.

This study also demonstrated the need for early intervention, which also includes early identification. When children are diagnosed early, they can begin receiving interventions that are proven effective. The study showed that current methods are working, but there may be a new program that can be even more effective on the horizon.

I'd love to hear more from my readers if you have any experience with ESDM or more information about it.

This guest post is written by Angela Peterson who writes on the topic of Online Psychology Degrees and can be emailed at angela_peterson@rediffmail.com

It’s not easy raising a child, and when he or she is affected by a severe disorder or disease, you have a greater challenge ahead of you. You have to put in extra effort, energy and thought into your child’s development and progress, one aspect of which includes their education. Some parents of children with special needs may be tempted to overprotect by keeping them in cloistered environments and limiting their interaction with the outside world. This usually only hampers the child instead of helping them. If you’re a parent with a child who has special needs, here’s some strategies:

* Understand your child: Some children may be able to express themselves while others are limited because of their disability. Whatever the case, understand your child and know that they have a mind of their own even if they are unable to speak it. Instead of forcing your will on them, get to know what they wish to do and cater to their needs as much as possible as long as it does not cause them any harm.

* Be patient: It’s a tough task, but you need to have an enormous amount of patience with your child. You need to condition yourself to be patient through practice and experience, otherwise you and your child will be subject to a great deal of stress.

* Decide on their education: There are many options for providing education to your special needs child, so look for what is available in your area. If you plan to homeschool, you will need to do some research before you’re up to the task. Many feel that it’s better to let the professionals handle this task who are trained and more experienced. Also, your child gets to mingle with other children and interact with them on a regular basis, which is very important to his or her social development.

*Think about inclusive classrooms: Parents often want their special needs children to attend regular schools. Learn about inclusive classrooms and determine if it is a good fit for your child. Consider if your child is up to the task of being educated with general education children and if he/she can cope with the curriculum in such classrooms. Although teachers in inclusive classrooms are trained to deal with children with special needs, there may be times when your child could be bullied or teased by the other kids for not being like them. Take all these facts into consideration before you decide on an inclusive classroom for your child.


Children with special needs need all the help and support they can get from parents and teachers, and it’s up to you to decide on the best form of education for them.

By Guest Blogger, Penny Williams of {a mom’s view of ADHD}

ADHD children do better with routine. It’s a proven fact. In a brain characteristically in chaos, the order routine provides is soothing. They need to know what to expect in advance and have time to make the mental transition as well.

Everything goes more smoothly for my son when he knows what’s coming and when, and everything falls apart when our schedule changes unexpectedly. As parents of neurologically different children, we make their world more comfortable by publicizing the family schedule and sticking to a routine as much as a family can. We have a routine for getting up and ready for school in the morning. We have a bedtime routine. We even have an {unpopular} dinnertime routine. Why should homework time be any different?

It has taken me two years to establish a fairly comfortable homework routine for Luke, my 8-year-old, third grade son who has ADHD and sensory integration issues. Two years of a lot of trial and error. And we aren’t set yet, nor do I predict we will be for many years. As the full extent of Luke’s written expression disorder has been revealed this year, the homework routine has changed quite a bit, but for the better.

Like Clockwork

I’ve experimented quite a bit with the time of day that we do homework. It was quickly apparent that waiting until after dinner (and after medications had worn off) was not going to work for Luke (or for me). We then tried right after school and at 4 pm, which is about 30 minutes after we arrive home from school. I liked the idea of some free time for Luke to unwind and a break from schoolwork that the 4 pm schedule offered. However, it hasn’t always worked out. In 30 minutes time he can get engrossed in something fun and then it’s a battle to get him to stop and do homework. I feel a little like a schoolmarm making him do homework the minute we get home, but he does his best work at that time.

Now sure we don’t always come straight home from school. Sometimes I’m working and grandma picks him up. Sometimes we have afterschool activities or just need to run to the grocery store. But Luke knows that we do homework when we return home from school, whatever time that may read on the clock. He has come to expect it.

Even Homework Needs a Home

Give homework papers and supplies a home and keep them in the same spot. When I say, “time to do homework,” Luke immediately goes to his homework spot. Well, not immediately. Even the best laid plan will not cure the typical resistance to homework. We keep Luke’s homework folder, pencils, etc. on his end of the snack bar. Up until a month or so ago, he sat there or just behind at the dining table to do his homework. We kept all needs there so he wouldn’t have the distraction of getting up to fetch something.

____________________________________________

Consider a Homework Toolkit: The toolkit will be some sort of box or desktop organizer, even an actual toolbox, with every single item necessary to complete homework, prepped and ready to go:

• pencils (sharpened -- sharpening pencils is a favorite procrastination technique of children),

• pencil sharpener (in case it breaks),

• pencil grips (if used),

• markers,

• colored pencils (sharpened),

• appropriate scissors,

• notebook paper,

• construction paper or blank copy paper,

• calculator,

• ruler,

• dictionary,

• index cards,

• highlighter,

• tape,

• glue stick,

• post-it notes,

• clip board (if not working at a table or desktop),

• anything else your child may use for homework

____________________________________________

Now that Luke has some technological accommodations for his written expression disability, he does his spelling homework on the computer. When I announce “homework time,” he gets his folder off the snack bar and brings it to my desk to work on my computer. (I am looking for a good place in my office to create a new homework spot now that things have changed.) He’s great with technology, and typing is so much easier for him than hand writing assignments was, so this change has actually allowed me to stop standing over him, constantly nagging, during homework for the first time since he started school. It’s wonderful!

He finishes his spelling assignment and then takes his book to the sofa and I set the timer for reading. If you don’t have a timer or don’t use one with your ADHD child, I super-strongly recommend its implementation. My favorite is the Time Timer, but any household timer will work. When the timer sounds at the end of his 15 minutes, he jumps up, completes his homework log, and then puts the homework folder back in its home on the snack back (with a little prodding and a lot of reminders).

Don’t Make Them Bite Off More Than They can Chew

Homework is designed to prove to a teacher that a child has mastered the subject matter and is sometimes an exercise in repetition for knowledge retention. Every child in the class is given the same homework, regardless of their differences, unless there’s already an IEP or 504 Plan to the contrary. It’s your duty as your child’s advocate and #1 cheerleader to be sure the homework is appropriate for your child. Yes, this is negotiable, either through teamwork with the teacher or through a formal IEP or 504 Plan.

Scaling the amount of homework to your child’s differences and needs is a crucial element in the success of the homework routine. For example, Luke reads for 15 minutes each day while the original 3^rd grade homework structure called for 20 minutes. There was a lot of resistance and inability to finish 20 minutes of reading but 15 minutes is just the right amount for Luke. While he is above grade level in reading, he is allowed to have me read aloud to him if that’s what it takes to get the assignment finished. I have found that he often asks me to read to him just to have time together. I agree, but on the condition that we take turns reading aloud by alternating paragraphs. He usually ends up reading most of it himself anyway, just with me alongside him.

Spelling is also a regular homework task. He has 15 words each week and his teacher suggests a list of activities from which to complete three. We alter these activities to accommodate his handwriting issues. He types all activities which means there are some that don’t apply to him (like writing each word in cursive three times). Sometimes there aren’t three on the list that can be typed so I let him pick from activities he’s done previous weeks.

Also, get creative and tailor homework to the way your child learns. Luke is a visual and tactile learner so we make homework visual and hands-on as much as we can – it was easier to do so in the younger grades. Use dried macaroni for math or even spelling. Does your child love to paint? Let them paint their spelling words or their illustration for their writing assignments. Painting letters is actually a common therapy tool for children that struggle with handwriting. What about play dough? I purchased a box of cookie cutters with all the letters and numbers for play dough play. You could do spelling and math with these. It will take longer but make homework more interesting and fun.

Luke’s teacher is perfectly content with our customization of the homework plan. Since they don’t get a grade on homework in third grade, it’s easy to make this change. Similar alterations can be made for middle school and high school homework too though. For instance, a student should be allowed to complete a percentage of the problems on a math worksheet to show they have mastered the content when the entire assignment will take too long or is overwhelming. Shortening the assignments will reduce their anxiety too, making it easier to work and study in the first place.

Don’t Forget Good Study Habits

Good study habits are even more crucial for children with ADHD and learning disabilities. There are some general ground rules that should always be followed:

1. TV and other distractions must be turned off. However, music in the background actually helps some children focus. It is a distraction for me, but Luke and his sister both do homework better with music on, especially when listening with headphones. Experiment with this and see what is best for your child.

2. Praise and reward often (typically more often than feels natural).

3. Take breaks as needed. Who says you have to finish homework in one sitting? Allow your child to get up and stretch, get a snack, jump on the trampoline, etc. Just don’t allow them any screen time during breaks because you won’t likely get back to the homework amicably.

There is so much more than the few ideas I've covered here, especially for older children. Take a look at these other resources on the subject of homework with ADHD children:

• Family Education, full of amazing homework tips, tricks, helps, templates, checklists, and how to's. Here's the Family Education homework section. They even have a section on ADHD.

• Homework Help! A system that works for ADHD children, AdditudeMag.com article

• ADHD and Homework Time from 4ADHD.com

• Help a child with ADHD do homework

• How to Help Children with ADHD End Homework Hassles

Penny Williams is the creator and editor of {a mom's view of ADHD}, where she writes candidly about the everyday experiences of parenting her young ADHD son. In her immersion in all things ADHD since her son's diagnosis, Penny has published, My ADHD Story: Love Notes, Blah, Blah, Blah!, and Teachers We Love: Learning for All in ADDitude Magazine, the #1 national publication dedicated to ADHD. She has been quoted in Parenting.com's Family Health Guide on ADHD and The High Desert Pulse, Summer/Fall 2010, When Ritalin Works.

Penny Williams from A Mom's view of ADHD and I decided to join forces this month in an attempt to reach more people through our blogs. I believe that many of my readers would find her blog helpful and I also felt that I could offer some insight into the school perspective to her readers. Penny wrote Make Homework Routine a few weeks ago. If you found that helpful, check out her blog full of more strategies! A Mom's View of ADHD is an excellent resource for parents of children with ADHD. It's written from by a parent going through it and provides excellent insight and strategies. I highly recommend it as a place for parents to go to connect and gain support.

Be sure to check out my article, Support for ADHD in the Schools. I discussed the options available for receiving support in the schools for ADHD such as an IEP or a 504 Plan.

Do you understand the scores from cognitive assessments, academic assessments, and behavior rating scales? Understanding the basics of these assessments and what the test scores mean is extremely important when your child has been evaluated for special education. If you are like most parents and have lots of questions, I've written up the basics and compiled them onto one page. Read all about Understanding Test Scores at School Psychologist Files.

Over the last few years I have been very busy working with teachers to create individualized behavior plans for several different elementary school students. There have been amazingly successful plans where some of the most significant behavior problems in the school have turned it around. Children who made daily trips to the office are only there now to receive praise from the administration. Teachers previously brought to tears from the behaviors have stopped me in the hall to say "Oh my goodness, he's like a different kid!" Students who were close to being sent to a day placement school are now succeeding in a regular classroom. It's very encouraging if I focus on those students. However, there have also been some plans that have been revised and revised and revised and the student is still struggling and the teacher is still severely frustrated. I have been reflecting on why some behavior plans work and others don't. Of course one of the biggest factors is the student. All students are different and the motivation for the misbehavior or lacking skill is different in each student. While this is important to consider, this particular article does not focus on this. I'm going to focus today on the teacher's role in making the behavior plan successful.

• Focus on the Positive!!! The behavior plans that have had the most dramatic success are plans that allow the teacher to focus on the positive. Classroom consequences are still in place, but are not connected to the plan. Here is an example: Johnny's teachers will offer positive reinforcement frequently in the classroom by giving Johnny a “warm fuzzy” pom pom when he is caught engaging in a desired behavior. Johnny will chose the bag to keep the “warm fuzzies” in and carry the bag with him to every class. Once the bag is full, he receives an immediate reward. There is no limit to how many “warm fuzzies” he can earn in a day. He does not loose “warm fuzzies” that he has already earned. All teachers and staff who work with Johnny can give him “warm fuzzies” for his bag. This plan works because Johnny who was used to receiving a lot of negative feedback, is now getting positive attention frequently throughout the day. He receives something tangible (the warm fuzzy) that he can put into his bag. This begins to change his perception of himself, which changes his behavior, which changes his teacher's perception of him, which can potentially change his future. Plans that offer positive rewards completely separate from the classroom consequences seem to have the most significant effects.




• Be Consistent. Teachers who are able to be consistent and are able to follow through every time have the most success with the plan. Oppositional children are excellent at pushing limits to see how far they can push. Consistent teachers have more success because they don't offer the wiggle room.




• Be Flexible. This is not the opposite of being consistent. This is having flexibility in your expectations and stating them upfront. If the student was able to behave like everyone else in the class she would be. She may need some flexibility in some areas. For example you may need to have area for her to work in the classroom for times she needs to cool down and get away from a stimulus. The teacher may need to allow her extra time to finish projects if it is the transition that sets her off. Being flexible and willing to make acceptable changes for the student sets everyone up for success.




• Remember that all students are different. The behaviors may be exactly the same as a student you had two years ago. However, that doesn't mean that the motivation for the behavior or the lacking skills are the same. What works for one student may not work for the next. That is the reason for the individualized plan. I strongly recommend doing a formal Functional Behavioral Assessment and a Behavior Intervention Plan.

Teachers have a HUGE part in making the Behavior Plan sucessful. It is the teacher who has to follow through and implement it consistently every day. It is the teacher who has to push forward even when it appears it isn't working at first. It is the teacher who has a tremendous positive impact on the student when the behavior starts turning around. It is the teacher who does the work to change lives!

Dedicated to the lady at Walmart with the screaming kid and all of us "good parents" who have been that lady at Walmart.

One of the most difficult behaviors for parents or teachers to address is explosive behavior, a child who has little control over emotions and "melts down" in the classroom or at home.  It is frustrating, it is embarrassing, it is anxiety producing, it causes intense emotions in ourselves.  Parents agonize over why it happens or what they did wrong?  Often the parents are blamed or judged by bystanders in stores, family members, friends, or school staff.  However, I have seen parents with a variety of parenting styles have kids with poor emotional control, including those who are strict, those who are quick to give in, those who spank, those who use time out, those who take away privileges, and a whole lot of parents who feel like they have tried everything.  I know children with very little emotional control from homes that are falling apart, from homes that are loving and supportive, from poor families, from affluent families, from parents who have no clue how to parent, from parents with excellent skills, even from School Psychologists.  This is not to say that parenting styles do not have a role in this, but there IS more to it.  We have to stop judging each other and get to the root of the problem.  

What is the Root of the Problem?

The problem, the reason some children "explode" or act out with little emotional control, is because he or she is lacking a skill.  Emotional control is a skill.  Most kids will learn this skill through consistent discipline strategies, but some do not. 

Another way to look at it.

We don't tell our kids how to read and then expect them to do it.  We show them step by step.  Some kids will pick it up easy, others will need to be taught and retaught and retaught and will need extensive help in doing so.  Do we blame ourselves?  Do we look at our friends judgementally and think to ourselves "look at the book she is using, it's all wrong?"  No, we assume the child has a problem learning to read and we find a way to teach him.  WE HAVE TO START LOOKING AT BEHAVIOR IN THE SAME WAY.  When a child is exploding, the first step should not be to label the child or blame the parent.  Lets start looking for the skill that is lacking.  When we find that skill, lets teach it.

It's NOT always a control issue.  Sometimes kids act out because they have not been taught to obey and respect authority, but sometimes they act out in spite of good training at home.  The explosions lead to self esteem problems in the child and the child feeling like a "bad kid," which in turn makes explosions bigger and more frequent.  Have you ever looked at a screaming child and demanded he control himself right now or "act your age."  It's a common thing to do.  Have you ever looked at a child with a Learning Disability and said "read on your grade level, now!" or "I have told you and told you how to read, why aren't you reading?"  Of course you haven't.  We work with the reader at his level and patiently try different strategies to improve reading.  We can't demand them to be good readers and we can't demand that a child who does not have the skills to control his emotions "act his age."  These explosive kids need skills and truth be told, we who work with these kids need skills. 

If you are a parent with a child who acts "out of control" stop blaming yourself.  It isn't necessarily because you spanked or didn't spank or were too strict or too lenient.  Your child is lacking the skills she needs to control her emotions.  Also, realize you are going to need to learn new skills to help your child learn the lacking skills.  You are no longer in the Parenting 101 class, you need to move on to the Advanced skill- teaching parenting class. 

The BEST book I have read on this topic is The Explosive Child by Ross Greene.  He addresses the skills these children might be lacking and he has great strategies to address the issue. (see Amazon link below)

If you are a teacher and have an "explosive child" in your class, rethink your perspective of the student.  The child needs to learn skills, so lets focus on teaching the skills and being patient with the children who are slower to learn emotional control.  We as school staff can not make excuses or blame the parents.  We have to reach the child at her level.  We teach a child to read at her level.  We must teach a child to control emotions at her level as well. 

Challenge for Everyone
Let us stop labeling these kids with emotional skill deficits as "bad kids" and stop judging the parents.  Let's be honest with ourselves and recognize we all have shortcomings and could use skills in certain areas.  Maybe our kids need skills in emotional control, maybe we do, maybe we need skills in teaching emotional control, or maybe we need skills in some other area all together.  Let's be patient with our children and our peers and ourselves. Let's stop criticizing ourselves and others and start learning and teaching new skills.   We don't live in a world with bad kids, we live in a world will kids who need skills, so let's teach.

Our senses help us understand and navigate our world. They help us feel, see, taste, etc. When one or more of those processes is more or less sensitive to world, life feels different to that person. It is hard to understand what it feels like to have sensory differences unless you have sensory differences. It’s easy to tell someone to ignore a noise that doesn’t seem excessively annoying to you. It’s hard to understand when someone has an intense need for pressure unless you have a similar need. Having these sensory differences can be anxiety producing and stressful. In a classroom, it can make that person less attentive or have a more difficult time sitting still. Kids don’t always have the words or understanding to express what they are feeling. As a result, children who have sensory processing issues are often misunderstood. Sensory issues are often associated with children who have an Autism Spectrum Disorder. There is also an association between Attention Deficit Hyperactivity Disorder and sensory issues. Many times a child will have sensory issues and not have any other disability. Those children may have Sensory Processing disorder, which is a neurological disorder that makes processing and responding to sensory information more difficult. A person with Sensory Processing Disorder may be more or less sensitive than most people to any or all of the senses. Sensory Processing Disorder is not yet widely understood by the majority of people. Most people have an idea about what Autism is or ADHD, but people often do not know about Sensory Processing Disorder. Many school professionals have not learned about it and do not understand it. Many parents have never heard of it. If you have any concerns that your child may have difficulty with sensory processing, I strongly recommend The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder, Revised Edition This book was explains the various types of sensory processing and helps parents to understand what their child may be feeling. It is transformative for a parent to finally understand what is going on with their child. Strategies for the Classroom:

 Often making small changes to the environment can help a child regulate his own body and focus in the classroom. A seating disk fits on a chair and is filled with air. It allows a child to wiggle in his seat, without moving around and causing a distraction. The bumps and the movement can provide the sensory input needed to help a child focus better. The ball chair also allows movement and is good for low tone as well. Weighted lap pads help provide proprioceptive input that helps establish increased body awareness, improves attention span and concentration, and has calming benefits.   Strategies for home: Trampolines provide deep pressure. Also, it is great exercise. For some children, when they start having difficulty regulating his or her body, jumping on the trampoline helps provide the needed pressure and will calm the body after a few minutes. The Body Sock is made of tight material that pushes back against the child's movement. This can help children with coordination and spatial positioning.

 Disclaimer: I am not an Occupational Therapist and am not an expert in this area. I am writing this article to raise awareness in sensory issues that can have a huge impact in the classroom and within a family. Sometimes, minor accommodations can make significant improvements in the life of a child, which I have witnessed firsthand. I encourage any parents who think his or her child may have a sensory issue to seek help through an Occupational Therapist. In most cases, this will fall outside of Special Education and schools, unless the sensory issues are associated with a disability, such as Autism. Some schools are more proactive than others and have more Occupational Therapy support than others. Because OT services are not mandated outside of an IEP or 504 Plan, many schools will not be equipped to help you with this. It is recommended that you seek support through an OT, who can provide individual strategies to use in the classroom and at home.

With the Trump administration having announced the end of the DACA program, Congress is facing growing calls to protect unauthorized immigrants who came to the U.S. as children. This fact sheet examines DREAM Act bills introduced in Congress as of mid-2017, offering estimates of who might earn conditional legal status—and ultimately legal permanent residence—based on educational, professional, and other requirements in the legislation.

2017 saw the introduction of several bills—two of them by Senate Republicans in the weeks following the Trump administration’s announcement that it would terminate the Deferred Action for Childhood Arrivals (DACA) program—that would provide a pathway to conditional and then legal permanent residence to unauthorized immigrants brought to the United States as children, if they meet a range of educational, professional, and other criteria.

On paper, the Diversity Visa Program is not set up to bring in the highly skilled; applicants need only a high school diploma (or equivalent) or two years of mid-level work experience. Yet as this commentary explains, the green-card lottery has become a channel for entry of the highly skilled—with half of recipients coming to the United States in recent years having a college degree.

This Migration Policy Institute Europe webinar examines possible scenarios for how social, economic, and technological trends could affect jobs, labor market policy, education and social policies, and migrant integration. Speakers also explored the potential of coding schools for refugees to help alleviate skills shortages and provide a pathway to work.

This fact sheet and accompanying interactive data tools provide characteristics of the estimated 11.3 million unauthorized immigrants in the United States, using a unique MPI methodology that assigns legal status to U.S. Census Bureau data. The fact sheet and tools offer statistics on these immigrants’ origins, U.S. destinations, educational attainment, English proficiency, employment, income, home ownership, and more.

Mexicans migrate to Canada in much smaller numbers than to the United States, yet over the last 30 years the country has become an increasingly attractive destination. Canada prioritizes highly skilled, educated Mexicans for permanent residency, but also attracts temporary workers from Mexico. This article examines Mexican migration to Canada and how it has been shaped by visa requirements, trade policy, and more.

A federal court on Thursday denied a motion to block an Arkansas directive preventing patients from receiving abortion care.

The Trump administration failed to conduct effective screening of passengers from South Korea and Italy for the coronavirus when those countries were experiencing rapid expansion in COVID-19 cases.

The United States economy shed more than 20 million jobs last month, the greatest month-to-month decline in history, the Labor Department said Friday in its monthly employment analysis.

California, Iowa, Pennsylvania and Rhode Island are among states that are loosening coronavirus restrictions Friday to gradually revive their economies.

More than 4 million American homeowners are past due on their mortgage, a figure that's been fueled by the coronavirus pandemic, industry data showed Friday.

The Supreme Court on Friday granted a Justice Department request to temporarily block release of secret grand jury material from special counsel Robert Mueller's probe to Congress.

Gujarat university, second MBBS examination, forensic medicine question papers, January 2015

The mission of Medip Academy Resources site is to provide teaching and learning materials to medical students (UG and PG) and medical professionals. Medip Academy Resources is a platform for sharing University Examination Papers, Medical Educational Materials, Practical Guides, MCQs, Problem solving etc. The resources available on this site are easily searchable and free to download. URL: http://www.medipacademy.com/resources Email: resources@medipacademy.com How to add a resource? Please share your useful resource by email to resources@medipacademy.com Happy Sharing! Dr. Bhaven Kataria Department of Pharmacology, GMERS Medical College, Sola Ahmedabad, Gujarat, India

A 29 years old female presented to us in the metabolic clinic of the University of Port Harcourt Teaching Hospital (UPTH) on account of a week history of easy fatigability, weakness, and lower extremity muscle cramps associated with numbness and tingling sensation in the peri-oral area, fingers and toes. Two weeks prior to the onset of her presenting symptoms, she had visited a local pharmaceutical shop on account of a distressing epigastric discomfort and was subsequently placed on daily oral omeprazole 20mg daily for a month by a pharmacist. She had been on the omeprazole medication for two weeks before her present symptoms manifested. Her past medical history was not suggestive of hypoparathyroidism nor pancreatitis. She was married with three children and has an uneventful family, social and obstetric histories. On examination, she was a healthy well-oriented young female with positive Trousseau’s, Chvostek’s and epigastric tenderness signs. Further Laboratory evaluation revealed she had low plasma magnesium, low plasma albumin-corrected calcium, and low serum parathyroid hormone levels, while other laboratory parameters were essentially normal. A diagnosis of omeprazole-induced electrolyte disorders (hypomagnesaemia and hypocalcaemia) associated with hypoparathyroidism was made following the review of her clinical examination and laboratory findings. She was subsequently managed with oral magnesium supplements following the withdrawal of the omeprazole medication (replaced with oral ranitidine), monitored weekly, and full recovery was achieved after three weeks.

Halley's Comet only orbits the sun once every 75 years, but each year in early May, the Earth passes through some of the debris that it left behind.

Intensive farming, characterized by the overuse of antibiotics, large numbers of animals and limited genetic diversity, increases the odds of animal pathogens making the jump to humans and triggering an epidemic.

Over the last 40 years, climate change has been influencing where tropical cyclones form, according to a new study.

Test results suggest N95 masks can be safely disinfected through heating 50 times before their filtration efficiency begins to decline.

While the coordinated attacks of Velociraptor dinosaurs depicted in the 1993 blockbuster made for compelling movie viewing, a study published this week claims raptors most likely hunted solo, not in packs.

Artificial intelligence requires a lot of energy. Simply solving a puzzle can require the equivalent of the energy produced by three nuclear plants in a single hour.

China produces a whole lot of stuff -- stuff that gets bought by the rest of the world. In 2019, China exported approximately $2.5 trillion dollars worth of goods.

When it came to selecting bones for leather-making tools, Neanderthals were surprisingly choosy. New archaeological analysis shows Neanderthals preferentially selected bovine rib bones to make a tool called a lissoir.

New research suggests flies that are unable to fly sleep more as they learn to adapt to their disability.

This webinar, organized by MPI and the Zolberg Institute on Migration and Mobility at The New School, discussed the state of play around the globe surrounding COVID-19 and examined where migration management and enforcement tools may be useful and where they may be ill-suited to advancing public health goals. 

MPI has released a major study that describes and analyzes today’s immigration enforcement programs, as they have developed and grown in the 25 years since IRCA launched the current enforcement era.

Release of a major report that describes and analyzes the immigration enforcement system in the United States as it has developed and grown in the quarter century since the Immigration Reform and Control Act of 1986 launched the current era of enforcement.

MPI has completed an analysis of the major provisions in the 2013 framework, comparing them to provisions of the legislation the Senate considered in 2006 and 2007. 

This fact sheet is formatted as a chart comparing the framework of comprehensive immigration reform outlined in the 2013 Senate immigration bill against provisions included in bills considered by the Senate in 2006 and 2007.

MPI experts participate in a video chat shortly after the Migration Policy Institute released an analysis comparing the major provisions of the Senate bill to those of the individual House bills considered to date in House committees. 

This report analyzes how governments ought to best allocate their resources to address the risks associated with migration—the "immigration harms" that undermine the positive economic and social benefits of immigration—including choosing which threats to tackle and where to prioritize enforcement efforts. Immigration policymakers can learn from other public policy regulation efforts to ensure that regulatory actions advance the public interest.