Increasing and sustaining discharges by noon - a multi-year process improvement project

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Weight Gain and Glycemic Control in Adults with Type 1 Diabetes in the T1D Exchange Registry

Aim: The impact of weight gain on insulin dosage and glycemic control in adults with type 1 diabetes (T1D) aged 25 years and older was investigated in the T1D Exchange Registry participants. Methods: Participants were categorized into four groups based on their change in weight from T1D Exchange registry enrollment to year 5: stable weight (-5 to <5 lb), gained 5 to <10 lb, gained 10 to <20 lb, or gained ≥20 lb. Those who lost >5 lb were excluded. The primary outcomes were glucose control, as measured by glycosylated hemoglobin (HbA1c), and total daily insulin dose (TDD) at year 5. Linear regression models were used to evaluate the association between weight gain, HbA1c, and TDD. Results: There were 1969 participants included in the analyses. The mean ± standard deviation age was 45 ± 13 years, 57% were female, and 92% were White non-Hispanic. For those with an enrollment HbA1c <8.0%, the mean HbA1c at year 5 was higher for those who gained ≥20 lb compared to those with a stable weight of -5 to <5 lb (7.4% ± 1.1% vs. 7.2% ± 0.8%, respectively; P = 0.005). For this cohort, the mean TDD at year 5 increased from 49 ± 25 to 61 ± 29 U for those who gained ≥20 lb, while decreased from 45 ± 27 to 44 ± 25 U for those with stable weight of -5 to <5 lb (P < 0.001). Among participants with an enrollment HbA1c ≥9.0%, the mean HbA1c at year 5 was statistically insignificant at 8.4% ± 1.3% for those who gained ≥20 lb compared to 9.2% ± 1.7% for those with a stable weight of -5 to <5 lb (P = 0.09). Conclusion: Significant weight gain in adults with T1D who had good to adequate glycemic control was associated with modest deterioration in glucose control despite an increase in TDD. Worsening glucose control may indicate insulin resistance related to weight gain despite significantly increased insulin dosage which was insufficient to maintain adequate glycemic control.

Did the UK's public health shielding policy protect the clinically extremely vulnerable during the COVID-19 pandemic in Wales? Results of EVITE Immunity, a linked data retrospective study

INTRODUCTION

The UK shielding policy intended to protect people at the highest risk of harm from COVID-19 infection. We aimed to describe intervention effects in Wales at 1 year.

METHODS

Retrospective comparison of linked demographic and clinical data for cohorts comprising people identified for shielding from 23 March to 21 May 2020; and the rest of the population. Health records were extracted with event dates between 23 March 2020 and 22 March 2021 for the comparator cohort and from the date of inclusion until 1 year later for the shielded cohort.

RESULTS

The shielded cohort included 117,415 people, with 3,086,385 in the comparator cohort. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). People in the shielded cohort were more likely to be female, aged ≥50 years, living in relatively deprived areas, care home residents and frail. The proportion of people tested for COVID-19 was higher in the shielded cohort (odds ratio [OR] 1.616; 95% confidence interval [CI] 1.597-1.637), with lower positivity rate incident rate ratios 0.716 (95% CI 0.697-0.736). The known infection rate was higher in the shielded cohort (5.9% vs 5.7%). People in the shielded cohort were more likely to die (OR 3.683; 95% CI: 3.583-3.786), have a critical care admission (OR 3.339; 95% CI: 3.111-3.583), hospital emergency admission (OR 2.883; 95% CI: 2.837-2.930), emergency department attendance (OR 1.893; 95% CI: 1.867-1.919) and common mental disorder (OR 1.762; 95% CI: 1.735-1.789).

CONCLUSION

Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders; however, lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.

The Insulin-Only Bionic Pancreas Improves Glycemic Control in Non-Hispanic White and Minority Adults and Children With Type 1 Diabetes

OBJECTIVE

We evaluated the performance of the iLet bionic pancreas (BP) in non-Hispanic Whites ("Whites") and in Blacks, Hispanics, and others ("Minorities").

RESEARCH DESIGN AND METHODS

A multicenter, randomized controlled trial evaluated glycemic management with the BP versus standard of care (SC) in 161 adult and 165 pediatric participants with type 1 diabetes over 13 weeks.

RESULTS

In Whites (n = 240), the mean baseline-adjusted difference in 13-week HbA1c between the BP and SC groups was -0.45% (95% CI -0.61 to -0.29 [-4.9 mmol/mol; -6.6 to -3.1]; P < 0.001), while this difference among Minorities (n = 84) was -0.53% (-0.83 to -0.24 [-6.0 mmol/mol; -9.2 to -2.8]; P < 0.001). In Whites, the mean baseline-adjusted difference in time in range between the BP and SC groups was 10% (95% CI 7-12; P < 0.001) and in Minorities was 14% (10-18; P < 0.001).

CONCLUSIONS

The BP improves glycemic control in both Whites and Minorities and offers promise in decreasing health care disparities.

Effect of Verapamil on Pancreatic Beta Cell Function in Newly Diagnosed Pediatric Type 1 Diabetes: A Randomized Clinical Trial

Importance

In preclinical studies, thioredoxin-interacting protein overexpression induces pancreatic beta cell apoptosis and is involved in glucotoxicity-induced beta cell death. Calcium channel blockers reduce these effects and may be beneficial to beta cell preservation in type 1 diabetes.

Objective

To determine the effect of verapamil on pancreatic beta cell function in children and adolescents with newly diagnosed type 1 diabetes.

Design, Setting, and Participants

This double-blind, randomized clinical trial including children and adolescents aged 7 to 17 years with newly diagnosed type 1 diabetes who weighed 30 kg or greater was conducted at 6 centers in the US (randomized participants between July 20, 2020, and October 13, 2021) and follow-up was completed on September 15, 2022.

Interventions

Participants were randomly assigned 1:1 to once-daily oral verapamil (n = 47) or placebo (n = 41) as part of a factorial design in which participants also were assigned to receive either intensive diabetes management or standard diabetes care.

Main Outcomes and Measures

The primary outcome was area under the curve values for C-peptide level (a measure of pancreatic beta cell function) stimulated by a mixed-meal tolerance test at 52 weeks from diagnosis of type 1 diabetes.

Results

Among 88 participants (mean age, 12.7 [SD, 2.4] years; 36 were female [41%]; and the mean time from diagnosis to randomization was 24 [SD, 4] days), 83 (94%) completed the trial. In the verapamil group, the mean C-peptide area under the curve was 0.66 pmol/mL at baseline and 0.65 pmol/mL at 52 weeks compared with 0.60 pmol/mL at baseline and 0.44 pmol/mL at 52 weeks in the placebo group (adjusted between-group difference, 0.14 pmol/mL [95% CI, 0.01 to 0.27 pmol/mL]; P = .04). This equates to a 30% higher C-peptide level at 52 weeks with verapamil. The percentage of participants with a 52-week peak C-peptide level of 0.2 pmol/mL or greater was 95% (41 of 43 participants) in the verapamil group vs 71% (27 of 38 participants) in the placebo group. At 52 weeks, hemoglobin A1c was 6.6% in the verapamil group vs 6.9% in the placebo group (adjusted between-group difference, -0.3% [95% CI, -1.0% to 0.4%]). Eight participants (17%) in the verapamil group and 8 participants (20%) in the placebo group had a nonserious adverse event considered to be related to treatment.

Conclusions and Relevance

In children and adolescents with newly diagnosed type 1 diabetes, verapamil partially preserved stimulated C-peptide secretion at 52 weeks from diagnosis compared with placebo. Further studies are needed to determine the longitudinal durability of C-peptide improvement and the optimal length of therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04233034.

Effect of Tight Glycemic Control on Pancreatic Beta Cell Function in Newly Diagnosed Pediatric Type 1 Diabetes: A Randomized Clinical Trial

Importance

Near normalization of glucose levels instituted immediately after diagnosis of type 1 diabetes has been postulated to preserve pancreatic beta cell function by reducing glucotoxicity. Previous studies have been hampered by an inability to achieve tight glycemic goals.

Objective

To determine the effectiveness of intensive diabetes management to achieve near normalization of glucose levels on preservation of pancreatic beta cell function in youth with newly diagnosed type 1 diabetes.

Design, Setting, and Participants

This randomized, double-blind, clinical trial was conducted at 6 centers in the US (randomizations from July 20, 2020, to October 13, 2021; follow-up completed September 15, 2022) and included youths with newly diagnosed type 1 diabetes aged 7 to 17 years.

Interventions

Random assignment to intensive diabetes management, which included use of an automated insulin delivery system (n = 61), or standard care, which included use of a continuous glucose monitor (n = 52), as part of a factorial design in which participants weighing 30 kg or more also were assigned to receive either oral verapamil or placebo.

Main Outcomes and Measures

The primary outcome was mixed-meal tolerance test-stimulated C-peptide area under the curve (a measure of pancreatic beta cell function) 52 weeks from diagnosis.

Results

Among 113 participants (mean [SD] age, 11.8 [2.8] years; 49 females [43%]; mean [SD] time from diagnosis to randomization, 24 [5] days), 108 (96%) completed the trial. The mean C-peptide area under the curve decreased from 0.57 pmol/mL at baseline to 0.45 pmol/mL at 52 weeks in the intensive management group, and from 0.60 to 0.50 pmol/mL in the standard care group (treatment group difference, -0.01 [95% CI, -0.11 to 0.10]; P = .89). The mean time in the target range of 70 to 180 mg/dL, measured with continuous glucose monitoring, at 52 weeks was 78% in the intensive management group vs 64% in the standard care group (adjusted difference, 16% [95% CI, 10% to 22%]). One severe hypoglycemia event and 1 diabetic ketoacidosis event occurred in each group.

Conclusions and Relevance

In youths with newly diagnosed type 1 diabetes, intensive diabetes management, which included automated insulin delivery, achieved excellent glucose control but did not affect the decline in pancreatic C-peptide secretion at 52 weeks.

Trial Registration

ClinicalTrials.gov Identifier: NCT04233034.

A Comparison of Continuous Glucose Monitoring Estimated Hemoglobin A1c in Adults with Type 1 or Type 2 Diabetes

Background: The relationship of mean glucose measured with continuous glucose monitoring (CGM) and hemoglobin A1c (HbA1c) shows considerable variability between individuals with diabetes and may be influenced by race-related factors. Whether the relationship of mean glucose with HbA1c varies according to type 1 diabetes (T1D) or type 2 diabetes (T2D) has not been well evaluated. Methods: Data from 343 participants in four clinical trials (191 with T1D and 152 with T2D) were analyzed. Least squares linear regression models were fit with HbA1c as the dependent variable and mean glucose as the independent variable. Results: Mean age was 57 ± 15 years in the T1D cohort and 58 ± 10 years in the T2D cohort. The T1D cohort was 89% White non-Hispanic, 5% African American, 3% Hispanic, and 3% other or mixed race compared with 52%, 16%, 22%, and 9%, respectively, in the T2D cohort. The relationship between CGM-measured mean glucose and laboratory-measured HbA1c significantly differed between T1D and T2D cohorts, with HbA1c on average being higher with T2D than T1D for the same mean glucose (P = 0.002). However, this difference was largely attributable to the difference in the proportion of African Americans between T1D and T2D; and after stratifying by race, the mean glucose-HbA1c relationship showed only a small difference between T1D non-African Americans and T2D non-African Americans. The mean glucose-HbA1c relationship appeared similar for White non-Hispanic and Hispanic individuals. Conclusion: HbA1c on average was higher in T2D than T1D for a given mean glucose, but after accounting for race, there was no meaningful difference in the mean glucose-HbA1c relationship comparing T1D and T2D. The mean glucose-HbA1c relationship differs in African American compared with White individuals, but does not appear to differ comparing White non-Hispanic to Hispanic individuals. The published glucose management indicator formula appears to be suitable for both T1D and T2D.

Assessment of the Glucose Management Indicator Using Different Sampling Durations

We compared the glucose management indicator (GMI) calculated using 14 days of continuous glucose monitor (CGM) data with GMI calculated using <14 days. Analysis included 581 individuals with type 1 diabetes or type 2 diabetes from five clinical trials. The correlation between the 14- and 7-day GMI was 0.95 and the correlation between 14 days versus 10, 5, and 3 days GMI was 0.98, 0.91, and 0.86, respectively. The percentages of GMI values within 0.3% of the 14-day GMI were 98% with 10-day GMI, 87% with 7-day GMI, 77% with 5-day GMI, and 60% with 3-day GMI. Minimal differences were observed between GMI computed using 14 days of data compared with GMI computed with 7 days. Although 10-14 days of CGM data are preferred for computing GMI, for most patients a satisfactory estimate of HbA1c can be obtained with 7 days of data.

Clinical trial participation in a majority-minority, NCI-designated cancer center

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Background: Substantial racial and ethnic disparities exist in clinical trial enrollment. Because oncology has rapidly evolved into a field rife with therapies aimed at specific biologic differences in patients, disparities in the standard of care and treatment outcomes have arisen, mainly in minorities such as Hispanics, African Americans, and Native Americans/Alaskan Natives. These disparities are due mainly to the limited understanding of tumor biology in underrepresented groups. The lack of representation in clinical trial enrollment represents both a grave oversight in oncology and an opportunity to increase treatment options for underserved groups significantly. Methods: Retrospective single-institution analysis including patients enrolled in clinical trials between 2014 and 2018. We use a Negative Binomial generalized linear model to measure the racial and ethnic disparities in Mays Cancer Center's clinical trials accruals from 2014 to 2018. Results: 4724 patients with various tumor types were enrolled in clinical trials at the mays cancer center: Using a Negative Binomial generalized linear model, we discover that clinical trial enrollment is distinct in Blacks (ecoefficient = 0.22, p = 1.38e-09) and Asians (ecoefficient = 0.08, p = 3.03e-20) when compared to Whites. Hispanics and Non-Hispanics do not differ in clinical trial enrollments (ecoefficient = 0.77, p = 1.34e-01). Both Hispanic and Non-Hispanic Asians are greatly underrepresented; Non-Hispanic whites are overrepresented. Hispanics of all races are overrepresented in breast cancer trials as compared with Non-Hispanics (p = 6.89e-18). The inverse is true for genitourinary trials, with Non-Hispanics being overrepresented as compared to Hispanics (p = 9.78e-46). Conclusions: Hispanics were disproportionately enrolled in breast cancer trials, and Non-Hispanics were disproportionately enrolled in GU trials. Mays Cancer Center outperforms similar institutions in the enrollment of Hispanics, yet despite this, Hispanics are still somewhat underrepresented in our trials. Asians broadly are underrepresented in MCC enrollments.

Closed-Loop Therapy and Preservation of C-Peptide Secretion in Type 1 Diabetes

BACKGROUND

Whether improved glucose control with hybrid closed-loop therapy can preserve C-peptide secretion as compared with standard insulin therapy in persons with new-onset type 1 diabetes is unclear.

METHODS

In a multicenter, open-label, parallel-group, randomized trial, we assigned youths 10.0 to 16.9 years of age within 21 days after a diagnosis of type 1 diabetes to receive hybrid closed-loop therapy or standard insulin therapy (control) for 24 months. The primary end point was the area under the curve (AUC) for the plasma C-peptide level (after a mixed-meal tolerance test) at 12 months after diagnosis. The analysis was performed on an intention-to-treat basis.

RESULTS

A total of 97 participants (mean [±SD] age, 12±2 years) underwent randomization: 51 were assigned to receive closed-loop therapy and 46 to receive control therapy. The AUC for the C-peptide level at 12 months (primary end point) did not differ significantly between the two groups (geometric mean, 0.35 pmol per milliliter [interquartile range, 0.16 to 0.49] with closed-loop therapy and 0.46 pmol per milliliter [interquartile range, 0.22 to 0.69] with control therapy; mean adjusted difference, -0.06 pmol per milliliter [95% confidence interval {CI}, -0.14 to 0.03]). There was not a substantial between-group difference in the AUC for the C-peptide level at 24 months (geometric mean, 0.18 pmol per milliliter [interquartile range, 0.06 to 0.22] with closed-loop therapy and 0.24 pmol per milliliter [interquartile range, 0.05 to 0.30] with control therapy; mean adjusted difference, -0.04 pmol per milliliter [95% CI, -0.14 to 0.06]). The arithmetic mean glycated hemoglobin level was lower in the closed-loop group than in the control group by 4 mmol per mole (0.4 percentage points; 95% CI, 0 to 8 mmol per mole [0.0 to 0.7 percentage points]) at 12 months and by 11 mmol per mole (1.0 percentage points; 95% CI, 7 to 15 mmol per mole [0.5 to 1.5 percentage points]) at 24 months. Five cases of severe hypoglycemia occurred in the closed-loop group (in 3 participants), and one occurred in the control group; one case of diabetic ketoacidosis occurred in the closed-loop group.

CONCLUSIONS

In youths with new-onset type 1 diabetes, intensive glucose control for 24 months did not appear to prevent the decline in residual C-peptide secretion. (Funded by the National Institute for Health and Care Research and others; CLOuD ClinicalTrials.gov number, NCT02871089.).

Symptomatic diabetic autonomic neuropathy in type 1 diabetes (T1D): Findings from the T1D exchange

AIMS

We aimed to evaluate the contemporary prevalence of and risk factors for symptomatic diabetic autonomic neuropathy (DAN) in participants with type 1 diabetes (T1D) enrolled in the T1D Exchange Clinic Registry.

METHODS

DAN symptoms and severity were assessed with the Survey of Autonomic Symptoms (SAS) in adults with ≥5 years of T1D participating in the T1D Exchange from years 2010-2017. Associations of demographic, clinical, and laboratory factors with symptomatic DAN were assessed.

RESULTS

Of the 4919 eligible T1D participants, 965 (20%) individuals completed the SAS questionnaire [mean age 40 ± 17 years, median diabetes duration 20 years (IQR: 13,34), 64% female, 90% non-Hispanic White, and 82% with private insurance]. DAN symptoms were present in 166 (17%) of responders with 72% experiencing moderate severity symptoms or worse. Symptomatic DAN participants had higher hemoglobin A1c (p = 0.03), longer duration (p = 0.004), were more likely to be female (p = 0.03), and more likely to have lower income (p = 0.03) versus no DAN symptoms. Symptomatic DAN was associated with diabetic peripheral neuropathy (p < 0.0001), smoking (p = 0.002), cardiovascular disease (p = 0.02), depression (p < 0.001), and opioid use (p = 0.004).

CONCLUSIONS

DAN symptoms are common in T1D. Socioeconomic factors and psychological comorbidities may contribute to DAN symptoms and should be explored further.

Effectiveness of Continuous Glucose Monitoring in Older Adults with Type 2 Diabetes Treated with Basal Insulin

Objective: To evaluate the effectiveness and safety of real-time continuous glucose monitoring (CGM) in adults 65 years old and older with type 2 diabetes (T2D) using basal without bolus insulin. Research Design and Methods: Using data from the MOBILE randomized trial comparing CGM versus blood glucose meter (BGM) monitoring for T2D treated with basal insulin, the treatment effect in participants ≥65 years (range: 65-79 years, N = 42) was compared with the treatment effect in participants <65 years (range: 33-64 years, N = 133). Results: For participants ≥65 years old, mean change in hemoglobin A1c (HbA1c) was -1.08% in the CGM group and -0.38% in the BGM group (adjusted mean difference = -0.65% [95% confidence interval (CI) -1.49 to 0.19]). In contrast, the adjusted mean difference in HbA1c between treatment groups was -0.35% [95% CI -0.77 to 0.07] in the <65 years age group. For time in range 70-180 mg/dL (TIR), mean adjusted treatment group difference was 19% (95% CI 4 to 35, P = 0.01) in ≥65 years old participants and 12% (95% CI 4 to 19, P = 0.003) in those <65 years old. Comparable treatment group differences favoring the CGM group were observed in both the ≥65 and <65 years age groups for mean glucose and less time >180, 250, and 300 mg/dL. Hypoglycemia was low in both groups with little difference between treatment groups in both age groups. Conclusions: In this study of adults with T2D treated with basal insulin without bolus insulin, participants ≥65 years old using CGM had a greater increase in TIR and a reduction in hyperglycemia than those using BGM and the benefit appeared to be at least as great as that observed in younger adults.

Magnitude of Glycemic Improvement in Patients with Type 2 Diabetes Treated with Basal Insulin: Subgroup Analyses from the MOBILE Study

Objective: To determine if type 2 diabetes patients using basal insulin without prandial insulin with worse glycemic control at baseline would have the greatest benefit from using real-time continuous glucose monitoring (CGM). Methods: We conducted a post hoc analysis of the MOBILE Study, a multicenter trial examining the impact of CGM versus self-monitoring with a blood glucose meter (BGM) in patients with type 2 diabetes treated with basal insulin without prandial insulin. Participants were divided into subgroups based on baseline hemoglobin A1c (HbA1c) and baseline time-in-range 70-180 mg/dL (TIR). Change in TIR from baseline was calculated within each subgroup. Results: In subgroups based on baseline HbA1c, compared with the BGM group, the CGM group had 14% greater increase in TIR for participants with baseline HbA1c ≥8.5%, 14% greater increase for baseline HbA1c ≥9.0%, 22% greater increase for baseline HbA1c ≥9.5%, and 32% greater increase for baseline HbA1c ≥10.0% (P-value for interaction = 0.27). The time spent with glucose >250 mg/dL was significantly lower with CGM compared with BGM among participants with higher HbA1c values (P for interaction = 0.004). Results in subgroups based on baseline TIR paralleled the results in subgroups based on baseline HbA1c. Conclusion: While the benefit of CGM on TIR among patients with type 2 diabetes treated with basal insulin is apparent across the range of baseline glycemic control, the greatest impact of CGM is in those with the worst baseline glycemic control, particularly among those with HbA1c ≥10%. Clinical Trial Registration number: NCT03566693.

With or Without Residual C-Peptide, Patients with Type 2 Diabetes Realize Glycemic Benefits from Real-Time Continuous Glucose Monitoring

Real-time continuous glucose monitoring (RT-CGM) is superior to blood glucose monitoring (BGM) for adults with insulin-treated type 2 diabetes (T2D); however, the utility of C-peptide levels for predicting the magnitude of the glycemic benefits is controversial. Data were from a subset of 147 participants in the MOBILE study who were treated with basal-only insulin and who had baseline C-peptide levels ≥0.5 ng/mL. Participants were randomized to treatment with either RT-CGM (n = 100) or BGM (n = 47). Between-group differences in hemoglobin A1c (HbA1c) and time in range (TIR) changes were assessed. The between-group difference in HbA1c favored the RT-CGM group (by 0.58 percentage points, P = 0.004 at 3 months and by 0.42 percentage points, P = 0.04 at 8 months). TIR was 16% higher, and time >180 mg/dL was 16% lower, in the RT-CGM group at 8 months (P = 0.002 for each). In T2D managed with basal insulin, RT-CGM benefits occur for those with residual insulin secretory capacity. Clinical Trial Identifier: NCT03566693.

A Study of Fibre Attrition in the Processing of Long Fibre Reinforced Thermoplastics

A study has been carried out which demonstrates a technique for measuring long fibre lengths. This technique has been used successfully to discuss subtle differences in the fibre length distributions arising in a range of long fibre reinforced thermoplastics. These new materials were processed using a wide range of injection moulding conditions, including such variables as the injection speeds and the preplasticising screw back pressures. This work proposes mechanisms of fibre attrition in the injection moulding process and makes recommendations for the optimisation of fibre lengths in moulded articles. It is shown that alternative polymer matrices in the long glass fibre attrition. It is also demonstrated that this family of long fibre reinforced thermoplastics can be recycled successfully with considerable fibre length advantages over traditional extrusion precompounded short fibre compounds.

A217 TREATMENT ADHERENCE OF CHRONIC HEPATITIS B PATIENTS WITH HEPATOCELLULAR CARCINOMA FROM THE CANHEPB NETWORK

Background

Chronic hepatitis B (CHB) is the most common cause of hepatocellular carcinoma (HCC) worldwide.

Aims

The primary aim of this study is to explore the degree of treatment adherence to the American Association For The Study of Liver Disease (AASLD) HCC treatment guidelines for patients with CHB-HCC.

Methods

This is a retrospective, cross-sectional study of available data (2005–2020) in patients mono-infected with CHB collected from the Canadian HBV Network; a national consortium across 8 Canadian provinces. We analyzed data using descriptive statistics along with parametric and nonparametric statistical methods with a significance level of p < 0.05.

Results

Of the 6500 patients, 132 (2.0%) patients met inclusion criteria. The median age was 64 (IQR: 53.5- 71.5) with 101 (76%) being male. The median ALT was 40 (IQR: 26–59.5) and the median tumor number was 1(IQR: 1- 2) with a median tumor size of 2.6 cm (IQR: 1.9- 4.5). 98 (74.5%) patients were HBeAg negative with a median viral load of 3.8 logs (IQR 1.9 – 5.8). 58 (43%) patients had cirrhosis at diagnosis. 36% of patients were diagnosed with HCC on their first screening imaging whereas 39% were found to have HCC on repeated surveillance imaging. 116 (87.9%) were on treatment at the time of diagnosis or after (70 (60.3%) NA and 46 (39%) Combination therapy with double NA or NA plus interferon). Out of the 132 patients, BCLC stage 0, A, B, and C represented 30 (23%), 42 (32%), 17 (13%), and 5 (4%) patients, respectively, with 38 (28%) patients with unknown BCLC stage. The overall adherence to AASLD guidelines was 61%. The HCC treatment adherence rate for patients with BCLC stage 0, A, B were 63%, 97.5%, and 23.5%, respectively. BCLC stages C and D did not have a sufficient sample size for analysis. The adherence rate ranged from 53% (Eastern Canada) to 71% (Western Canada) across Canada.

Conclusions

In this retrospective nationwide cohort study of patients with CHB-related HCC, the overall treatment adherence rate to AASLD guidelines was low with notable regional differences. Further analysis will determine the cause of regional differences.

Funding Agencies

None

A223 THE CHAIR STAND TEST IS A RELIABLE FRAILTY METRIC FOR PREDICTING WAITLIST MORBIDITY AND MORTALITY IN PATIENTS WITH CIRRHOSIS

Background

Frailty is defined as a clinical state of increased vulnerability to health and age associated stressors. The liver frailty index (LFI), composed of grip strength, chair stand and balance testing, is an accepted predictor of morbidity and mortality in cirrhosis. With the need for COVID-19 related social distancing, many appointments are being carried out virtually. The chair stand subcomponent of the LFI has the potential to be evaluated virtually, with a high reliability as compared to in-person testing noted in other disease populations.

Aims

To determine if the chair stand test is an independent predictor of morbidity and mortality in patients with cirrhosis.

Methods

822 adult patients with cirrhosis were prospectively enrolled from five centers (3 in Canada, 1 in the United States, and 1 in India). Inclusion criteria included adult patients with cirrhosis. 787 of these patients completed a chair stand test at baseline, measured as the time (seconds) a patient takes to rise from sitting with their arms folded across their chest five times (measured in-person). The times were divided into 3 categories: >15 seconds, between 10 and 15 seconds, and <10 seconds. Patients who could not complete 5 chair stands were classified in the >15 seconds category. Primary outcome was all-cause mortality. Secondary outcome was unplanned all-cause hospital admission. Fine-Gray proportional hazard regression models were used to evaluate the association between the chair stand time and the outcomes. We adjusted for baseline age, sex, and MELD score and accounted for liver transplantation as a competing risk. Cumulative incidence functions were used to create a graphical representation of the survival analysis.

Results

Patients were divided into three groups: group 1, <10 seconds (n = 276); group 2, 10–15 seconds (n = 290); and group 3, >15 seconds (n = 221). Mortality was increased in group 3 in comparison to group 1 (HR 3.21, 95% CI: 2.16–4.78, p<0.001). Similarly, the hazard of non-elective hospitalizations was higher in group 3 in comparison to group 1 (HR 2.24, 95% CI: 1.73–2.91, p<0.001). Overall, patients with chair stand times greater than 15 seconds had increased all-cause mortality (HR 2.78, 95% CI 2.01–3.83, p<0.001) and non-elective hospitalizations (HR 1.84, 95% CI 1.48–2.29, p<0.001) when compared to patients with times less than 15 seconds.

Conclusions

A time to complete 5 chair stands of >15 seconds predicts morbidity and mortality in patients with cirrhosis. This test shows promise as a frailty measure that could be evaluated over a virtual platform.

Funding Agencies

None

Abstract TP230: Dietary Behaviors Following Stroke: A Qualitative Study Of Stroke Survivor Perspectives

Purpose: Following a healthy dietary pattern (e.g., Mediterranean diet) is recommended for secondary stroke prevention due to its beneficial effect on stroke risk factors. However, stroke-related disability may hinder the performance of dietary behaviors (i.e., accessing, preparing, and consuming food), which are necessary and preparatory to consuming healthy foods. The purpose of this study was to characterize dietary behaviors in stroke survivors.

Methods: This study is a secondary analysis of focus group data from 15 chronic (≥6 months) community-dwelling stroke survivors and 10 care-partners. We used a qualitative descriptive approach and inductive content analysis to examine how stroke survivors perceive dietary behaviors.

Results: Three key themes emerged (see the table for illustrative quotations). First, changes in body functions/structures (e.g., hemiparesis, balance) result in dietary behavior activity limitations (e.g., difficulty grocery shopping, meal preparation). Second, environmental supports (e.g., care-partners, adaptive equipment) and activity modification (e.g., using pre-cut foods, dining out) are used to overcome dietary behavior limitations. Third, negative affect (e.g., dissatisfaction, frustration) and activity limitations lead to participation limitations (e.g., not being able to perform dietary behaviors independently, not being able to socialize when dining out).

Conclusions: Dietary behaviors are negatively impacted following stroke, but environmental supports and compensatory strategies may be implemented to overcome activity limitations. Despite guidelines that recommend following a healthy dietary pattern, adherence to such guidelines may be difficult due to stroke-related disability. Further research is needed to develop and test interventions to facilitate dietary behaviors to help survivors adhere to these guidelines and reduce risk of recurrent stroke.

The Effect of Discontinuing Continuous Glucose Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin

OBJECTIVE

To explore the effect of discontinuing continuous glucose monitoring (CGM) after 8 months of CGM use in adults with type 2 diabetes treated with basal without bolus insulin.

RESEARCH DESIGN AND METHODS

This multicenter trial had an initial randomization to either real-time CGM or blood glucose monitoring (BGM) for 8 months followed by 6 months in which the BGM group continued to use BGM (n = 57) and the CGM group was randomly reassigned either to continue CGM (n = 53) or discontinue CGM with resumption of BGM for glucose monitoring (n = 53).

RESULTS

In the group that discontinued CGM, mean time in range (TIR) 70-180 mg/dL, which improved from 38% before initiating CGM to 62% after 8 months of CGM, decreased after discontinuing CGM to 50% at 14 months (mean change from 8 to 14 months -12% [95% CI -21% to -3%], P = 0.01). In the group that continued CGM use, little change was found in TIR from 8 to 14 months (baseline 44%, 8 months 56%, 14 months 57%, mean change from 8 to 14 months 1% [95% CI -11% to 12%], P = 0.89). Comparing the two groups at 14 months, the adjusted treatment group difference in mean TIR was -6% (95% CI -16% to 4%, P = 0.20).

CONCLUSIONS

In adults with type 2 diabetes treated with basal insulin who had been using real-time CGM for 8 months, discontinuing CGM resulted in a loss of about one-half of the initial gain in TIR that had been achieved during CGM use.

Noninvasive Glucose Monitor Using Dielectric Spectroscopy

OBJECTIVE

The Alertgy noninvasive continuous glucose monitor (ANICGM) is a novel wristband device that reports glucose levels without entailing skin puncture. This study evaluated the performance of the ANICGM compared to a Food and Drug Administration-approved glucose meter in patients with type 2 diabetes.

METHODS

The ANICGM device measures changes in the electromagnetic field generated by its sensor to produce a dielectric spectrum. The data contained within this spectrum are used in tandem with machine learning algorithms to estimate blood glucose levels. Values from the ANICGM were collected, sent to the Alertgy lab, formatted, and compared with fingerstick blood glucose levels, which were measured using the Accuchek Inform II glucometer. Fifteen patients completed three 120-minute sessions. The mean absolute relative difference (MARD) was calculated.

RESULTS

MARD values were compared between study days 2 and 3. The MARD for day 2 was 18.5% (95% CI, 12.8-42.2%), and the MARD for day 3 was 15.3% (95% CI, 12.3-18.4%). The difference in the MARD between days 2 and 3 was not statistically significant (P = .210).

CONCLUSION

The resulting MARDs suggest that further investigation into the use of dielectric spectroscopy for glucose monitoring should be explored.

How Adults With Stroke Conceptualize Physical Activity: An Exploratory Qualitative Study

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

In this qualitative, phenomenological study, 15 stroke survivors indicated that performing moderate to vigorous physical activity (PA), performing activities of daily living (ADLs), and avoiding sedentary behavior were important types of PA. For adults with stroke for whom moderate PA is challenging, performing ADLs may be an acceptable alternative. OT practitioners can assist clients to decrease sedentary behavior and increase PA through the performance of meaningful activities and occupations.

Primary Author and Speaker: Ryan Bailey

Contributing Authors: Jennifer Stevenson

Stroke Survivor Recommendations for Physical Activity and Dietary Health Behavior Intervention

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

Physical activity and dietary-related behaviors are important for enhancing health and quality of life among adults with stroke, yet the prevalence of these healthy behaviors is low. In this qualitative study, adults with stroke identified how stroke-related physical, cognitive, and sensory deficits impact performance of these healthy behaviors and identified specific adaptive and accessible equipment and compensatory strategies for overcoming these barriers that can be utilized in clinical practice.

Primary Author and Speaker: Ryan Bailey

Contributing Authors: Jennifer Stevenson

Effect of Continuous Glucose Monitoring on Glycemic Control in Patients With Type 2 Diabetes Treated With Basal Insulin: A Randomized Clinical Trial

IMPORTANCE

Continuous glucose monitoring (CGM) has been shown to be beneficial for adults with type 2 diabetes using intensive insulin therapy, but its use in type 2 diabetes treated with basal insulin without prandial insulin has not been well studied.

OBJECTIVE

To determine the effectiveness of CGM in adults with type 2 diabetes treated with basal insulin without prandial insulin in primary care practices.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 15 centers in the US (enrollment from July 30, 2018, to October 30, 2019; follow-up completed July 7, 2020) and included adults with type 2 diabetes receiving their diabetes care from a primary care clinician and treated with 1 or 2 daily injections of long- or intermediate-acting basal insulin without prandial insulin, with or without noninsulin glucose-lowering medications.

INTERVENTIONS

Random assignment 2:1 to CGM (n = 116) or traditional blood glucose meter (BGM) monitoring (n = 59).

MAIN OUTCOMES AND MEASURES

The primary outcome was hemoglobin A1c (HbA1c) level at 8 months. Key secondary outcomes were CGM-measured time in target glucose range of 70 to 180 mg/dL, time with glucose level at greater than 250 mg/dL, and mean glucose level at 8 months.

RESULTS

Among 175 randomized participants (mean [SD] age, 57 [9] years; 88 women [50%]; 92 racial/ethnic minority individuals [53%]; mean [SD] baseline HbA1c level, 9.1% [0.9%]), 165 (94%) completed the trial. Mean HbA1c level decreased from 9.1% at baseline to 8.0% at 8 months in the CGM group and from 9.0% to 8.4% in the BGM group (adjusted difference, -0.4% [95% CI, -0.8% to -0.1%]; P = .02). In the CGM group, compared with the BGM group, the mean percentage of CGM-measured time in the target glucose range of 70 to 180 mg/dL was 59% vs 43% (adjusted difference, 15% [95% CI, 8% to 23%]; P < .001), the mean percentage of time at greater than 250 mg/dL was 11% vs 27% (adjusted difference, -16% [95% CI, -21% to -11%]; P < .001), and the means of the mean glucose values were 179 mg/dL vs 206 mg/dL (adjusted difference, -26 mg/dL [95% CI, -41 to -12]; P < .001). Severe hypoglycemic events occurred in 1 participant (1%) in the CGM group and in 1 (2%) in the BGM group.

CONCLUSIONS AND RELEVANCE

Among adults with poorly controlled type 2 diabetes treated with basal insulin without prandial insulin, continuous glucose monitoring, as compared with blood glucose meter monitoring, resulted in significantly lower HbA1c levels at 8 months.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03566693.

Long-term trends in critical care admissions in Wales

As national populations age, demands on critical care services are expected to increase. In many healthcare settings, longitudinal trends indicate rising numbers and proportions of patients admitted to ICU who are older; elsewhere, including some parts of the UK, a decrease has raised concerns with regard to rationing according to age. Our aim was to investigate admission trends in Wales, where critical care capacity has not risen in the last decade. We used the Secure Anonymised Information Linkage Databank to identify and characterise critical care admissions in patients aged ≥ 18 years from 1 January 2008 to 31 December 2017. We categorised 85,629 ICU admissions as youngest (18-64 years), older (65-79 years) and oldest (≥ 80 years). The oldest group accounted for 15% of admissions, the older age group 39% and the youngest group 46%. Relative to the national population, the incidence of admission rates per 10,000 population in the oldest group decreased significantly over the study period from 91.5/10,000 in 2008 to 77.5/10,000 (a relative decrease of 15%), and among the older group from 89.2/10,000 in 2008 to 75.3/10,000 in 2017 (a relative decrease of 16%). We observed significant decreases in admissions with high comorbidity (modified Charlson comorbidity index); increases in the proportion of older patients admitted who were considered 'fit' rather than frail (electronic frailty index); and decreases in admissions with a medical diagnosis. In contrast to other healthcare settings, capacity constraints and surgical imperatives appear to have contributed to a relative exclusion of older patients presenting with acute medical illness.

Abstract P50: Obesity and Diabetes Are Associated With Increased Risk for Disability Among Community-Dwelling Stroke Survivors

Introduction: Stroke-related disability is common. Obesity and diabetes are associated with disability in the general population, but the elevated risk of disability in stroke survivors who also experience these conditions has not been reported. The purpose of this study was to examine prevalence of 6 disability types among stroke survivors stratified by obesity and diabetes statuses.

Methods: Data from 37,955 non-institutionalized stroke survivors aged >18 years from the 2017 and 2018 Behavioral Risk Factor Surveillance System (BRFSS), a U.S.-based annual telephone survey, were analyzed. Self-reported disability types included deaf or difficulty hearing (deaf); blind or difficulty seeing (blind); difficulty concentrating, remembering, or making decisions (cognition); difficulty walking or climbing stairs (mobility), difficulty dressing or bathing (dressing); and difficulty doing errands alone (alone). Prevalence of disability types were computed using linear regression, and odds ratios (adjusted for demographic characteristics) among survivors with obesity (vs. normal weight) and diabetes (vs. no diabetes) were computed using logistic regression.

Results: Prevalence of obesity and diabetes were 35.7% (95% CI: 29.5%-41.8%) and 24.8% (95% CI: 21.3%-28.3%), respectively. Prevalence was highest for mobility (36.0%), cognition (33.7%) and alone (28.3%) disability types. Compared to survivors with normal weight, survivors with obesity had elevated AORs for mobility (1.68) and dressing (1.55) disability; and compared to survivors without diabetes, survivors with diabetes had elevated AORs for all disability types (range: 1.17-1.71) (see Table).

Conclusion: Obesity and diabetes increase risk for self-reported disability above the risk associated with stroke alone. Tailored interventions for stroke survivors with these conditions may be needed for decreasing disability and improving quality of life, and should be developed and explored.

Risk Factors for Cardiovascular Disease (CVD) in Adults with Type 1 Diabetes: Findings from Prospective Real-life T1D Exchange Registry

CONTEXT

Cardiovascular disease (CVD) is a major cause of mortality in adults with type 1 diabetes.

OBJECTIVE

We prospectively evaluated CVD risk factors in a large, contemporary cohort of adults with type 1 diabetes living in the United States.

DESIGN

Observational study of CVD and CVD risk factors over a median of 5.3 years.

SETTING

The T1D Exchange clinic network.

PATIENTS

Adults (age ≥ 18 years) with type 1 diabetes and without known CVD diagnosed before or at enrollment.

MAIN OUTCOME MEASURE

Associations between CVD risk factors and incident CVD were assessed by multivariable logistic regression.

RESULTS

The study included 8,727 participants (53% female, 88% non-Hispanic white, median age 33 years [interquartile ratio {IQR} = 21, 48], type 1 diabetes duration 16 years [IQR = 9, 26]). At enrollment, median HbA1c was 7.6% (66 mmol/mol) (IQR = 6.9 [52], 8.6 [70]), 33% used a statin, and 37% used blood pressure medication. Over a mean follow-up of 4.6 years, 325 (3.7%) participants developed incident CVD. Ischemic heart disease was the most common CVD event. Increasing age, body mass index, HbA1c, presence of hypertension and dyslipidemia, increasing duration of diabetes, and diabetic nephropathy were associated with increased risk for CVD. There were no significant gender differences in CVD risk.

CONCLUSION

HbA1c, hypertension, dyslipidemia and diabetic nephropathy are important risk factors for CVD in adults with type 1 diabetes. A longer follow-up is likely required to assess the impact of other traditional CVD risk factors on incident CVD in the current era.

Nucleic Acid Extraction and Sequencing from Low-Biomass Synthetic Mars Analog Soils for In Situ Life Detection

Recent studies regarding the origins of life and Mars-Earth meteorite transfer simulations suggest that biological informational polymers, such as nucleic acids (DNA and RNA), have the potential to provide unambiguous evidence of life on Mars. To this end, we are developing a metagenomics-based life-detection instrument which integrates nucleic acid extraction and nanopore sequencing: the Search for Extra-Terrestrial Genomes (SETG). Our goal is to isolate and sequence nucleic acids from extant or preserved life on Mars in order to determine if a particular genetic sequence (1) is distantly related to life on Earth, indicating a shared ancestry due to lithological exchange, or (2) is unrelated to life on Earth, suggesting convergent origins of life on Mars. In this study, we validate prior work on nucleic acid extraction from cells deposited in Mars analog soils down to microbial concentrations (i.e., 10⁴ cells in 50 mg of soil) observed in the driest and coldest regions on Earth. In addition, we report low-input nanopore sequencing results from 2 pg of purified Bacillus subtilis spore DNA simulating ideal extraction yields equivalent to 1 ppb life-detection sensitivity. We achieve this by employing carrier sequencing, a method of sequencing sub-nanogram DNA in the background of a genomic carrier. After filtering of carrier, low-quality, and low-complexity reads we detected 5 B. subtilis reads, 18 contamination reads (including Homo sapiens), and 6 high-quality noise reads believed to be sequencing artifacts.

Prevalence of Five Unhealthy Lifestyle Behaviors Among Adults With and Without Stroke, Behavioral Risk Factor Surveillance System, 2015

Date Presented 04/05/19

Data from the 2015 Behavioral Risk Factor Prevalence Surveillance System were analyzed to investigate the prevalence of five unhealthy behaviors among US adults with and without stroke. Prevalence of low fruit and vegetable consumption, low physical activity, and smoking were higher in adults with stroke; heavy alcohol consumption was lower; and there was no difference for excess weight. Occupation-based lifestyle interventions are needed to modify these unhealthy behaviors in adults with stroke.

Primary Author and Speaker: Ryan Bailey

Contributing Authors: Allison Phad

Examining daily physical activity in community-dwelling adults with stroke using social cognitive theory: an exploratory, qualitative study

Purpose: A better understanding of psychosocial factors underlying daily physical activity (i.e. physical activity performed throughout the day) in stroke survivors could be used to develop interventions to promote post-stroke physical activity, particularly in individuals for whom exercise is difficult.Methods: In-depth qualitative interviews were conducted with 15 ambulatory, community-dwelling stroke survivors. Interview transcripts were analyzed using directed content analysis, guided by Social Cognitive Theory, to investigate outcomes expectations, self-efficacy, self-regulation, and social-support for daily physical activity.Results: Participants reported that physical and mental health, and independence and recovery, were important outcomes expectations. Self-efficacy was enhanced through mental perceptions and mastery experiences. Planning, problem-solving, reviewing performance, and establishing routines that require physical activity were important self-regulation strategies. Social support provided praise and encouragement and physical assistance, but was also a barrier when friends and family were overprotective.Conclusions: Participants reported that the investigated Social Cognitive Theory constructs were important psychosocial factors for daily physical activity. Future research and clinical investigations should empirically test the use of strategies to modify these factors for promoting daily physical activity in community-dwelling adults with stroke.Implications for rehabilitationInterventions to increase physical activity after stroke are needed.Outcomes expectations, self-efficacy, self-regulation, and social support were reported by participants as important psychosocial factors underlying daily physical activity.These psychosocial factors should be explored with individual patients and clients to determine which are most deficient, and where amenable to change, targeted for intervention to promote daily physical activity.

The Burden of Functional Disabilities for Middle-Aged and Older Adults in the United States

OBJECTIVES

Understanding the role of functional capacity on longevity is important as the population in the United States ages. The purpose of this study was to determine the burden of instrumental activities of daily living (IADL) and activities of daily living (ADL) disabilities for a nationally-representative sample of middle-aged and older adults in the United States.

DESIGN

Longitudinal-Panel.

SETTING

Core interviews were often performed in person or over the telephone.

PARTICIPANTS

A sub-sample of 31,055 participants aged at least 50 years from the 1998-2014 waves of the Health and Retirement Study who reported having a functional disability were included.

MEASUREMENTS

Ability to perform IADLs and ADLs were self-reported at each wave. The National Death Index was used to ascertain date of death. The number of years of life that were lost (YLLs) and years lived with a disability (YLDs) were summed for the calculation of disability-adjusted life years (DALYs). Sampling weights were used in the analyses to make the DALYs nationally-representative. The results for YLLs, YLDs, and DALYs are reported in thousands.

RESULTS

Of the participants included, 14,990 had an IADL disability and 13,136 had an ADL disability. Men and women with an IADL disability had 236,037 and 233,772 DALYs, respectively; whereas, there were 178,594 DALYs for males and 253,630 DALYs for females with an ADL disability. Collectively, there were 469,809 years of healthy life lost from IADL impairments, and 432,224 years of healthy life lost from ADL limitations.

CONCLUSIONS

These findings should be used to inform healthcare providers and guide interventions aiming to preserve the functional capacity of aging adults. Prioritizing health-related resources for mitigating the burden of functional disabilities may help aging adults increase their quality of life and life expectancy over time.

The Safety Explorer Suite: Interactive Safety Monitoring for Clinical Trials

BACKGROUND

Frequent and thorough monitoring of patient safety is a requirement of clinical trials research. Safety data are traditionally reported in a tabular or listing format, which often translates into many pages of static displays. This poses the risk that clinically relevant signals will be obscured by the sheer volume of data reported. Interactive graphics enable the delivery of the vast scope of information found in traditional reports, but allow the user to interact with the charts in real time, focusing on signals of interest.

METHODS

Clinical research staff, including biostatisticians, project managers, and a medical monitor, were consulted to guide the development of a set of interactive data visualizations that enable key safety assessments for participants. The resulting "Safety Explorer" is a set of 6 interactive, web-based, open source tools designed to address the shortcomings of traditional, static reports for safety monitoring.

RESULTS

The Safety Explorer is freely available on GitHub as individual JavaScript libraries: Adverse Event Explorer, Adverse Event Timelines, Safety Histogram, Safety Outlier Explorer, Safety Results Over Time, and Safety Shift Plot; or in a single combined framework: Safety Explorer Suite. The suite can also be utilized through its R interface, the safetyexploreR package.

CONCLUSIONS

The Safety Explorer provides interactive charts that contain the same information available in standard displays, but the interactive interface allows for improved exploration of patterns and comparisons. Medical Monitors, Safety Review Boards, and Project Teams can use these tools to effectively track and analyze key safety variables and study endpoints.

Physical Activity After Stroke: Exploring Self-Efficacy, Self-Regulation, Social Support, and Outcome Expectations

Date Presented 3/31/2017

Physical activity is important for the prevention of recurrent stroke and overall health in people with stroke. In this study, patient perceptions of self-efficacy, self-regulation, social support, and outcome expectations related to physical activity were examined.

Primary Author and Speaker: Ryan Bailey

Effectiveness of Evidence-Based Asthma Interventions

BACKGROUND AND OBJECTIVES

Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial that resulted in evidence-based asthma interventions in community health centers.

METHODS

Children (aged 5-12 years; N = 590) with moderate to severe asthma were enrolled from 3 intervention and 3 geographically/capacity-matched control sites in high-risk, low-income communities located in Arizona, Michigan, and Puerto Rico. The asthma intervention was tailored to the participant's allergen sensitivity and exposure, and it comprised 4 visits over the course of 1 year. Study visits were documented and monitored prospectively via electronic data capture. Asthma symptoms and health care utilization were evaluated at baseline, and at 6 and 12 months.

RESULTS

A total of 314 intervention children and 276 control children were enrolled in the study. Allergen sensitivity testing (96%) and home environmental assessments (89%) were performed on the majority of intervention children. Overall study activity completion (eg, intervention visits, clinical assessments) was 70%. Overall and individual site participant symptom days in the previous 4 weeks were significantly reduced compared with control findings (control, change of -2.28; intervention, change of -3.27; difference, -0.99; P < .001), and this result was consistent with changes found in the rigorous evidence-based interventions.

CONCLUSIONS

Evidence-based interventions can be successfully adapted into primary care settings that serve impoverished, high-risk populations, reducing the morbidity of asthma in these high-need populations.

Behaviour of Perforated Plates under Plane Stress

A theoretical method is developed for determining the elastic behaviour of end-loaded plates completely perforated with closely spaced circular holes forming a square or diagonal pattern. The general method of solution has been verified by experimental work for particular types of loading. The following problems are considered in detail: (1) Unequal uniform applied extensions in the × and y directions; (2) Uniform applied shear. Using a digital computer, complete solutions have been obtained for the stress distribution in plates with holes having pitch to diameter ratios of 1·2, 1·4, 1·7, 2·0, and 3·0, respectively. These solutions have been used to obtain design curves for (1) effective Young's modulus; (2) effective shear modulus; (3) effective Poisson's ratio; (4) variation of applied load; (5) variation of stress across ligaments; (6) stress concentration factors. For plates with a square or diagonal system of holes, the above curves are sufficiently extensive to be applicable to all problems likely to occur in practice.

Measuring Real-World Upper-Extremity Activity of Stroke Survivors in the Outpatient Setting

Date Presented 4/9/2016

The use of unbiased methods to quantify upper extremity (UE) performance in daily life is critical for stroke rehabilitation. This case series evaluated the relationship between change in UE functional capacity and UE performance using bilateral wrist-worn accelerometers for persons with UE paresis poststroke.

Primary Author and Speaker: Caitlin Doman

Additional Authors and Speakers: Kimberly Waddell,

Contributing Authors: Ryan Bailey, Jennifer Moore, T. George Hornby, Catherine Lang