Traffic-related air pollution, chronic stress, and changes in exhaled nitric oxide and lung function among a panel of children with asthma living in an underresourced community

We examined associations between short-term exposure to traffic-related air pollutants (TRAP) and airway inflammation and lung function in children with asthma, and whether these associations are modified by chronic psychological stress. Residents of underresourced port-adjacent communities in New Jersey were concerned about the cumulative impacts of exposure to TRAP, particularly diesel-engine truck emissions, and stress on exacerbation of asthma among children. Children with asthma aged 9-14 (n = 35) were recruited from non-smoking households. We measured each participant's (1) continuous personal exposure to black carbon (BC, a surrogate of TRAP) at 1-min intervals, (2) 24-h integrated personal exposure to nitrogen dioxide (NO2), (3) daily fractional exhaled nitric oxide (FeNO), and (4) lung function for up to 30 consecutive days. Personal BC was recorded by micro-aethalometers. We measured daily FeNO using the NIOX MINO, forced expiratory volume in one second (FEV1), and forced vital capacity (FVC) using Easy One Frontline spirometers. Chronic stress was measured with the UCLA Life Stress Interview for Children. The association was examined using linear mixed-effect models. In the fully adjusted model, an interquartile range (IQR) increase in BC at lag 0-6 h before the FeNO measurement was associated with 8 % (95 % CI: 3 % - 12 %) increase in FeNO, whereas an IQR increase in BC at lag 7-12 h and lag 0-24 h were associated with 6 % (95 % CI: 2 % - 11 %) and 7 % (2 % - 12 %) FeNO increases, respectively. There were no significant lung function changes per IQR increase in BC. No interactions were observed between chronic stress and BC on FeNO. Chronic stress was negatively associated with individual average FeNO levels. Our findings suggest that higher levels of BC exposure within the prior 24 h increased airway inflammation levels in children with asthma, with the strongest effect observed within the first 6 h.

Prolactinoma and Adenomyosis - More than Meets the Eye: A Case Report

Background/Objective

To report a case of adenomyosis in a woman with hyperprolactinemia which resolved after initiation of dopamine agonist therapy.

Case Report

A 35-year-old woman with a history of Graves' disease was referred for evaluation of hyperthyroidism in March 2020. She was started on methimazole and thyroid function normalized. The patient also had a history of a pituitary microadenoma and was previously treated with cabergoline which was stopped after 12 months as she became pregnant.In July 2020, the patient began to have polymenorrhea. Hyperprolactinemia was thought to be an unlikely cause as it most often causes hypogonadotropic hypogonadism with amenorrhea. A pelvic ultrasound demonstrated a bulky uterus with adenomyosis. Gynecology recommended treating adenomyosis by lowering her prolactin levels. She was started on cabergoline 0.25 mg weekly in October 2021. Within 2 months of initiation of cabergoline, she had resolution of symptoms and radiological resolution of adenomyosis.

Discussion

Prolactin has been implicated in the pathogenesis of adenomyosis, endometriosis and leiomyomas suggesting that a decrease in prolactin levels may suppress these lesions. The pathogenesis of adenomyosis has been related to direct prolactin effects in the promotion of gland/cell proliferation and function.

Conclusion

We conclude that prolonged elevation in prolactin may result in the development of adenomyosis and subsequent prolonged abnormal uterine bleeding. Dopamine agonists, like cabergoline, inhibit the synthesis and secretion of prolactin from the pituitary gland and may have a role in the management of adenomyosis in patients with hyperprolactinemia.

[MDT management of nonalcoholic fatty liver disease]

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the clinic and is closely associated with obesity and related metabolic diseases such as type 2 diabetes, cardiovascular and cerebrovascular diseases, and chronic renal disease. The clinical harm is becoming increasingly severe. Multidisciplinary diagnosis and treatment (MDT) management is an effective way to improve the efficiency of NAFLD prevention and treatment, but the specific implementation path remains to be explored. This article reviews the theoretical basis, implementation path, dilemmas, and challenges of MDT management for NAFLD patients in order to provide a reference for better NAFLD prevention and treatment.

[Comparison of the efficacy of thulium fiber laser and holmium laser lithotripsy in the treatment of upper urinary tract stones]

Objective: To compare the efficacy of thulium fiber laser (TFL) and holmium laser (HL) in the treatment of upper urinary tract stones. Methods: A total of 76 patients diagnosed with upper urinary tract stones by radiographic examination and who required ureteroscopy lithotripsy or retrograde intrarenal stone surgery were prospectively enrolled from the Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine between January 2022 and June 2022. Patients were divided into TFL group (n=38) and HL group (n=38) in a 1∶1 ratio according to the randomization schedule. The perioperative outcomes and stone-free rate of two groups were recorded and compared. Results: Finally, the clinical data of 71 patients were completely collected, including 55 males and 16 females, with a mean age of (45.7±14.1) years old. There were 36 patients in TFL group and 35 patients in HL group, and there was no significant difference in age, body mass index, gender, Charlson comorbidity index, stone site, stone location, stone size and stone density between two groups (all P>0.05). All the surgeries were successfully performed with no intraoperative complications. There were no significant differences between the two groups in terms of operation time, stone displacement during lithotripsy, visual field clarity, changes in hemoglobin, leukocyte, and C-reactive protein, and length of postoperative hospital stay (all P>0.05), but the laser action time[M (Q1,Q3)] in the TFL group was 30.0 (20.0, 48.8)s, which was significantly shorter than that in the HL group [90.0 (50.0, 120.0)s, P<0.001]. The stone-free rates of TFL group and HL group were 97.2% (35/36) and 88.6% (31/35), and there was no significant difference (P=0.337). The postoperative complication incidences of TFL group and HL group were 36.1% (13/36)and 22.9% (8/35), respectively, and the difference was not significant either (P=0.221). For ureter stones, the laser action time in TFL group was 22.5 (20.0, 43.8)s, which was significantly shorter than that in HL group [80.0 (50.0, 120.0)s, P<0.001]. For stones with maximum diameter≤10 mm, the laser action time in TFL group was 20.0 (10.0, 25.0)s, which was significantly shorter than that in HL group [50.0 (40.0, 80.0)s, P<0.001]. For stones with maximum diameter>10 mm, the laser action time in TFL group was 60.0(42.5, 180.0)s, which was significantly shorter than that in HL group [180.0(120.0, 210.0)s, P=0.035]. For stones with density≤1 000 CT, the laser action time in TFL group was 30.0 (20.0, 45.0)s, which was significantly shorter than that in HL group [95.0 (47.5, 120.0), P=0.001]. For stones with density>1 000 CT, the laser action time in TFL group was 30.0 (20.0, 90.0)s, which was significantly shorter than that in HL group [80.0 (55.0, 180.0)s, P=0.033]. Conclusion: TFL lithotripsy is an effective and safe surgical procedure for the treatment of upper urinary tract stones, with similar clinical efficacy but shorter laser action time compared to HL lithotripsy.

[Progress in the pharmacological treatment of tobacco dependence in special populations]

Schizophrenic and pregnant smokers with tobacco dependence had always been excluded from most large treatment trials for nicotine dependence. As weight gain was found to be common after smoking cessation, obese people were more likely to have a reduced willingness to quit smoking and an increased risk of relapse. This article reviewed the latest research progress in pharmacological treatment of tobacco dependence in schizophrenia, pregnant women, and obese people.

[Effects of tensile force on the vascular lumen formation in three-dimensional printed tissue]

Objective: To explore the effects of tensile force on vascular lumen formation in three-dimensional printed tissue. Methods: The experimental research method was used. Human umbilical vein endothelial cells (HUVECs) were extracted from discarded umbilical cord tissue of 3 healthy women (aged 22 to 35 years) who gave birth in the Department of Gynaecology and Obstetrics of Suzhou Ruihua Orthopaedic Hospital from September 2020 to May 2021. Human skin fibroblasts (HSFs) were extracted from discarded normal skin tissue of 10 male patients (aged 20 to 45 years) who underwent wound repair in the Department of Hand Surgery of Suzhou Ruihua Orthopaedic Hospital from September 2020 to September 2022. After identification of the two kinds of cells, the 4th to 6th passage of cells were taken for the follow-up experiments. HUVECs and HSFs were used as seed cells, and polycaprolactone, gelatin, hyaluronic acid, and fibrin were used as scaffold materials, and the three-dimensional printed vascularized tissue was created by three-dimensional bioprinting technology. The printed tissue with polycaprolactone scaffold of 6 and 10 mm spacing, and without polycaprolactone scaffold were set as 6 mm spacing polycaprolactone group, 10 mm spacing polycaprolactone group, and non-polycaprolactone group, respectively. After 4 days of culture, the printed tissue in 10 mm spacing polycaprolactone group was selected to detect the cell survival by cell viability detection kit, and the cell survival rate was calculated. After 14 days of culture, the printed tissue in three groups were taken, and the shape change of tissue was observed by naked eyes; immunofluorescence staining was performed to observe the arrangement of filamentous actin, and lumen diameter, total length, and number of branches of vessel in the tissue. The tissue with micro-spring structure in the above-mentioned three groups was designed, printed, and cultured for 9 days, and the tensile force applied in the printed tissue was measured according to the force-displacement curve. The number of samples was all 3 in the above experiments. Data were statistically analyzed with one-way analysis of variance and Tukey test. Results: After 4 days of culture, the cell survival rate in printed tissue in 10 mm spacing polycaprolactone group was (91.3±2.2)%. After 14 days of culture, the shape change of printed tissue in non-polycaprolactone group was not obvious, while the shape changes of printed tissue in 6 mm spacing polycaprolactone group and 10 mm spacing polycaprolactone group were obvious. After 14 days of culture, the arrangement of filamentous actin in the printed tissue in non-polycaprolactone group had no specific direction, while the arrangement of filamentous actin in the printed tissue in 6 mm spacing polycaprolactone group and 10 mm spacing polycaprolactone group had a specific direction. After 14 days of culture, The vascular lumen diameters of the printed tissue in 6 mm spacing polycaprolactone group and 10 mm spacing polycaprolactone group were (6.0±1.3) and (10.8±1.3) μm, respectively, which were significantly larger than 0 μm in non-polycaprolactone group (P<0.05), and the vascular lumen diameter of printed tissue in 10 mm spacing polycaprolactone group was significantly larger than that in 6 mm spacing polycaprolactone group (P<0.05); the total length and number of branches of blood vessel in the printed tissue in 6 mm spacing polycaprolactone group and 10 mm spacing polycaprolactone group were significantly shorter or less than those in non-polycaprolactone group (P<0.05), and the total length and number of branches of blood vessel in the printed tissue in 10 mm spacing polycaprolactone group were significantly shorter or less than those in 6 mm spacing polycaprolactone group. After 9 days of culture, the tensile forces applied in the printed tissue in 6 mm spacing polycaprolactone group and 10 mm spacing polycaprolactone group were (2 340±59) and (4 284±538) μN, respectively, which were significantly higher than 0 μN in non-polycaprolactone group (P<0.05), and the tensile force applied in the printed tissue in 10 mm spacing polycaprolactone group was significantly higher than that in 6 mm spacing polycaprolactone group (P<0.05). Conclusions: The three-dimensional printed scaffold structure can exert different tensile force in the printed tissue, and the vascular lumen diameter of the printed tissue can be regulated by adjusting the tensile force.

Assessing the sustainability and scalability of a diabetes eHealth innovation: a mixed-methods study

BACKGROUND

To date, little is known about the sustainability and scalability of MyDiabetesPlan, an eHealth innovation designed to facilitate shared decision-making within diabetes care. To avoid the possibility of its short-lived implementation and promote wider adoption so as to promote patient-centred diabetes care, it is critical to understand MyDiabetesPlan's sustainability and scalability in order to ensure its long-term impact at a greater scale. We sought to identify the sustainability and scalability potential of MyDiabetesPlan and its limiting factors.

METHODS

Using a concurrent triangulation mixed-methods approach, data were collected from 20 individuals involved in the development and implementation of MyDiabetesPlan. The National Health Services Sustainability Model (NHSSM) and the Innovation Scalability Self-administered Questionnaire (ISSaQ) were administered using a 'think-aloud' approach and subsequently, short semi-structured interviews were conducted. Mean aggregate scores and stakeholder-specific scores were generated for the NHSSM and ISSaQ, to quantitatively determine facilitating and limiting factors to sustainability and scalability. Content analysis occurred iteratively with qualitative data, to examine commonalities and differences with the quantitative findings.

RESULTS

The top facilitating factor to sustaining MyDiabetesPlan was "Staff involvement and training to sustain the process.", whereas the top limiting factors were: "Adaptability of Improved Process", "Senior Leadership Engagement" and "Infrastructure for Sustainability". The top three facilitating factors for scale-up were "Acceptability", "Development with Theory" and "Consistency with Policy Directives." Conversely, the top three limiting factors were "Financial and Human Resources", "Achievable Adoption" and "Broad Reach". Qualitative findings corroborated the limiting/facilitating factors identified.

CONCLUSIONS

Addressing staff involvement throughout the dynamic care contexts, and resource constraints impacting scale-up can enhance the sustainability and scalability of MyDiabetesPlan. As such, future plans will focus on garnering organizational leadership buy-in and support, which may address the resource constraints associated with sustainability and scalability and improve the capacity for adequate staff involvement. eHealth researchers will be able to prioritize these limiting factors from the outset of their tool development to purposefully optimize its sustainability and scalability performance.

Effective web-based clinical practice guidelines resources: recommendations from a mixed methods usability study

BACKGROUND

Clinical practice guidelines (CPG) are an important knowledge translation resource to help clinicians stay up to date about relevant clinical knowledge. Effective communication of guidelines, including format, facilitates its implementation. Despite the digitalization of healthcare, there is little literature to guide CPG website creation for effective dissemination and implementation. Our aim was to assess the effectiveness of the content and format of the Diabetes Canada CPG website, and use our results to inform recommendations for other CPG websites.

METHODS

Fourteen clinicians (family physicians, nurses, pharmacists, and dieticians) in diabetes care across Canada participated in this mixed-methods study (questionnaires, usability testing and interviews). Participants "thought-aloud" while completing eight usability tasks on the CPG website. Outcomes included task success rate, completion time, click per tasks, resource used, paths, search attempts and success rate, and error types. Participants were then interviewed.

RESULTS

The Diabetes Canada CPG website was found to be usable. Participants had a high task success rate of 79% for all tasks and used 144 (standard deviation (SD) = 152) seconds and 4.6 (SD = 3.9) clicks per task. Interactive tools were most frequently used compared to full guidelines and static tools. Misinterpretation accounted for 48% of usability errors. Participants overall found the website intuitive, with effective content and design elements.

CONCLUSION

Different versions of CPG information (e.g. interactive tools, quick reference guide, static tools) can help answer clinical questions more quickly. Effective web design should be assessed during CPG website creation for effective guideline dissemination and implementation.

Comparative efficacy and complications of long-acting and intermediate-acting insulin regimens for adults with type 1 diabetes: an individual patient data network meta-analysis

OBJECTIVE

To examine the comparative efficacy and complications of long-acting and intermediate-acting insulin for different patient characteristics for type 1 diabetes mellitus (T1DM).

DESIGN

Systematic review and individual patient data (IPD) network meta-analysis (NMA).

DATA SOURCES

MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched through June 2015.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) on adults with T1DM assessing glycosylated haemoglobin (A1c) and severe hypoglycaemia in long-acting and intermediate-acting insulin regimens.

DATA EXTRACTION AND SYNTHESIS

We requested IPD from authors and funders. When IPD were not available, we used aggregate data. We conducted a random-effects model, and specifically a one-stage IPD-NMA for those studies providing IPD and a two-stage IPD-NMA to incorporate those studies not providing IPD.

RESULTS

We included 28 RCTs plus one companion report, after screening 6680 titles/abstracts and 205 full-text articles. Of the 28 RCTs, 27 studies provided data for the NMA with 7394 participants, of which 12 RCTs had IPD on 4943 participants. The IPD-NMA for A1c suggested that glargine once daily (mean difference [MD]=-0.31, 95% confidence interval [CI]: -0.48 to -0.14) and detemir once daily (MD=-0.25, 95% CI: -0.41 to -0.09) were superior to neutral protamine Hagedorn (NPH) once daily. NPH once/two times per day improved A1c compared with NPH once daily (MD=-0.30, 95% CI: -0.50 to -0.11). Results regarding complications in severe hypoglycaemia should be considered with great caution due to inconsistency in the evidence network. Accounting for missing data, there was no evidence of inconsistency and long-acting insulin regimens ranked higher regarding reducing severe hypoglycaemia compared with intermediate-acting insulin regimens (two-stage NMA: glargine two times per day SUCRA (Surface Under the Cumulative Ranking curve)=89%, detemir once daily SUCRA=77%; one-stage NMA: detemir once daily/two times per day SUCRA=85%). Using multiple imputations and IPD only, complications in severe hypoglycaemia increased with diabetes-related comorbidities (regression coefficient: 1.03, 95% CI: 1.02 to 1.03).

CONCLUSIONS

Long-acting insulin regimens reduced A1c compared with intermediate-acting insulin regimens and were associated with lower severe hypoglycaemia. Of the observed differences, only glargine once daily achieved a clinically significant reduction of 0.30%. Results should be interpreted with caution due to very low quality of evidence.

PROSPERO REGISTRATION NUMBER

CRD42015023511.

The Cost-Effectiveness of Intermediate-Acting, Long-Acting, Ultralong-Acting, and Biosimilar Insulins for Type 1 Diabetes Mellitus: A Systematic Review

OBJECTIVES

The incidence of type 1 diabetes mellitus is increasing every year requiring substantial expenditure on treatment and complications. A systematic review was conducted on the cost-effectiveness of insulin formulations, including ultralong-, long-, or intermediate-acting insulin, and their biosimilar insulin equivalents.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, HTA, and NHS EED were searched from inception to June 11, 2021. Cost-effectiveness and cost-utility analyses were included if insulin formulations in adults (≥ 16 years) with type 1 diabetes mellitus were evaluated. Two reviewers independently screened titles, abstracts, and full-text articles, extracted study data, and appraised their quality using the Drummond 10-item checklist. Costs were converted to 2020 US dollars adjusting for inflation and purchasing power parity across currencies.

RESULTS

A total of 27 studies were included. Incremental cost-effectiveness ratios ranged widely across the studies. All pairwise comparisons (11 of 11, 100%) found that ultralong-acting insulin was cost-effective compared with other long-acting insulins, including a long-acting biosimilar. Most pairwise comparisons (24 of 27, 89%) concluded that long-acting insulin was cost-effective compared with intermediate-acting insulin. Few studies compared long-acting insulins with one another.

CONCLUSIONS

Long-acting insulin may be cost-effective compared with intermediate-acting insulin. Future studies should directly compare biosimilar options and long-acting insulin options and evaluate the long-term consequences of ultralong-acting insulins.

Trends in glucose testing among individuals without diabetes in Ontario between 2010 and 2017: a population-based cohort study

BACKGROUND

Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups.

METHODS

Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease).

RESULTS

Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groups p < 0.001) and lower in younger than older age groups (except those aged ≥ 80 yr). South Asian people had the highest testing rates, although among people aged 70 years or older, testing was highest in the general population (p < 0.001). Among people with hypertension, hyperlipidemia and cardiovascular disease, annual testing rates were also stable, but only 58% overall among people with hypertension.

INTERPRETATION

We found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing.

[A case of chronic refractory wound in the abdomen caused by residual foreign body]

A 59-year-old male patient with local sinus tract formation due to residual foreign body was admitted to the Second Affiliated Hospital of Zhejiang University College of Medicine on December 17, 2018. The examination showed that the residual foreign body was the component of a sticky cloth implanted when the patient underwent appendectomy 27 years ago. Hypertrophic scar developed at the right-lower abdominal incision for appendectomy 23 years ago and the secondary infection after cicatrectomy resulted in non-healing of the wound. The chronic refractory wound healed completely after surgical treatment in our hospital after this admission. The postoperative pathological examination revealed local inflammatory granuloma. This case suggests that chronic refractory wound is likely to form when secondary infection occurs following the surgical procedure near the implant, and aggressive surgery is an effective way to solve this problem.

Virtual Specialist Care during the COVID-19 Pandemic: A Multi-Method Study of Patient Experience

Background

Transitioning nonemergency, ambulatory medical care to virtual visits in light of the COVID-19 global pandemic has been a massive shift in philosophy and practice that naturally came with a steep learning curve for patients, physicians, and clinic administrators.

Objective

We undertook a multimethod study to understand the key factors associated with successful and less successful experiences of virtual specialist care, particularly as they relate to the patient experience of care.

Methods

This study was designed as a multimethod patient experience study using survey methods, descriptive qualitative interview methodology, and administrative virtual care data collected by the hospital decision support team. Six specialty departments participated in the study (endoscopy, orthopedics, neurology, hematology, rheumatology, and gastroenterology). All patients who could speak and read English and attended a virtual specialist appointment in a participating clinic at St. Michael’s Hospital (Toronto, Ontario, Canada) between October 1, 2020, and January 30, 2021, were eligible to participate.

Results

During the study period, 51,702 virtual specialist visits were conducted in the departments that participated in the study. Of those, 96% were conducted by telephone and 4% by video. In both the survey and interview data, there was an overall consensus that virtual care is a satisfying alternative to in-person care, with benefits such as reduced travel, cost, time, and SARS-CoV-2 exposure, and increased convenience. Our analysis further revealed that the specific reason for the visit and the nature and status of the medical condition are important considerations in terms of guidance on where virtual care is most effective. Technology issues were not reported as a major challenge in our data, given that the majority of “virtual” visits reported by our participants were conducted by telephone, which is an important distinction. Despite the positive value of virtual care discussed by the majority of interview participants, 50% of the survey respondents still indicated they would prefer to see their physician in person.

Conclusions

Patient experience data collected in this study indicate a high level of satisfaction with virtual specialty care, but also signal that there are nuances to be considered to ensure it is an appropriate and sustainable part of the standard of care.

Evaluation of Experiences and Impact of Patient Engagement on e-Health Research: A Qualitative Study

BACKGROUND

Health technology has increasingly moved toward adopting a "user-centred design" approach to include the user/patient throughout the innovation and design process; however, few studies have evaluated the patient's experience of such an engagement.

OBJECTIVE

The aim of this study was to explore the role of patient engagement (PE) within e-health innovation research.

METHOD

Using qualitative descriptive methodology, semi-structured interviews were conducted with eight participants (patient partners and research/development team members).

FINDINGS

Key themes were centred on enablers of, challenges to and methods of improving PE.

CONCLUSION

PE must be prioritized from study conception, explicitly programmed into study conduct and valued by integrating patient partner input.

Dual-energy CT perfusion imaging for differentiating invasive thymomas, thymic carcinomas, and lymphomas in adults

AIM

To evaluate the role of dual-energy computed tomography perfusion (DECTP) imaging in differentiating invasive thymomas (ITs), thymic cancers (TCs), and lymphomas in adults.

MATERIALS AND METHODS

Ninety-five patients with solid masses in the prevascular mediastinum who underwent DECTP examinations were enrolled in this study. The perfusion parameters (blood flow, BF; blood volume, BV; mean transit time, MTT; permeability surface, PS) and spectral parameters (water concentration, WC; iodine concentration, IC; normalised iodine concentration, NIC; the slope of spectral radiodensity [Hounsfield units] curve, λ_HU) of the lesions were analysed.

RESULTS

There were no differences in the MTT or WC values among ITs, TCs, and lymphomas (all p>0.05). The IC, NIC, and λ_HU values in the optimal arterial and venous phases and PS values of TCs were higher than those of ITs and lymphomas (all p<0.05), and there were no differences between ITs and lymphomas (all p>0.05). The BF and BV values of lymphomas were lower than those of ITs and TCs (all p<0.05), and there were no differences between ITs and TCs (all p>0.05). The cut-off values for BF and BV used to differentiate lymphomas from ITs and TCs were 42.83 ml/min/100 g and 4.66 ml/100 g, respectively (area under the receiver operating characteristic curve: 0.847 and 0.839; sensitivity, 80.6% and 82.1%; specificity, 75% and 71.4%; accuracy, 78.9% and 81.1%).

CONCLUSIONS

The perfusion and spectral parameters of DECTP imaging help to identify ITs, TCs, and lymphomas, and BF and BV values help to differentiate lymphomas from ITs and TCs.

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial

Background

MyDiabetesPlan is a web-based, interactive patient decision aid that facilitates patient-centred, diabetes-specific, goal-setting and shared decision-making (SDM) with interprofessional health care teams.

Objective

Assess the feasibility of (1) conducting a cluster randomized controlled trial (RCT) and (2) integrating MyDiabetesPlan into interprofessional primary care clinics.

Methods

We conducted a cluster RCT in 10 interprofessional primary care clinics with patients living with diabetes and at least two other comorbidities; half of the clinics were assigned to MyDiabetesPlan and half were assigned to usual care. To assess recruitment, retention, and resource use, we used RCT conduct logs and financial account summaries. To assess intervention fidelity, we used RCT conduct logs and website usage logs. To identify barriers and facilitators to integration of MyDiabetesPlan into clinical care across the IP team, we used audiotapes of clinical encounters in the intervention groups.

Results

One thousand five hundred and ninety-seven potentially eligible patients were identified through searches of electronic medical records, of which 1113 patients met the eligibility criteria upon detailed chart review. A total of 425 patients were randomly selected; of these, 213 were able to participate and were allocated (intervention: n = 102; control: n = 111), for a recruitment rate of 50.1%. One hundred and fifty-one patients completed the study, for a retention rate of 70.9%. A total of 5745 personnel-hours and $6104 CAD were attributed to recruitment and retention activities. A total of 179 appointments occurred (out of 204 expected appointments—two per participant over the 12-month study period; 87.7%). Forty (36%), 25 (23%), and 32 (29%) patients completed MyDiabetesPlan at least twice, once, and zero times, respectively. Mean time for completion of MyDiabetesPlan by the clinician and the patient during initial appointments was 37 min. From the clinical encounter transcripts, we identified diverse strategies used by clinicians and patients to integrate MyDiabetesPlan into the appointment, characterized by rapport building and individualization. Barriers to use included clinician-related, patient-related, and technical factors.

Conclusion

An interprofessional approach to SDM using a decision aid was feasible. Lower than expected numbers of diabetes-specific appointments and use of MyDiabetesPlan were observed. Addressing facilitators and barriers identified in this study will promote more seamless integration into clinical care.

Trial registration Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: February 11, 2015. Protocol version: Version 1; February 26, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01673-w.

Perceptions and correlates of distress due to the COVID-19 pandemic and stress management strategies among people with diabetes: a mixed methods study

Background

Greater risk of adverse health outcomes and public health measures have increased distress among people with diabetes during the coronavirus-2019 (COVID-19) pandemic. The objectives of this study were to explore how the experiences of people with diabetes during the COVID-19 pandemic differ according to sociodemographic characteristics and identify diabetes-related psychosocial correlates of COVID distress.

Methods

Patients with type 1 or 2 diabetes were recruited from clinics and community health centres in Toronto, Ontario, as well as patient networks. Participants were interviewed to explore the experiences of people with diabetes with varied sociodemographic and clinical identities, with respect to wellness (physical, emotional, social, financial, occupational), level of stress and management strategies. Multiple linear regression was used to assess the relationships between diabetes distress, diabetes self-efficacy and resilient coping with COVID distress.

Results

Interviews revealed that specific aspects of psychosocial wellness affected by the pandemic, and stress and illness management strategies utilized by people with diabetes differed based on socioeconomic status, gender, type of diabetes and race. Resilient coping (β=−0.0517; 95% confidence interval [CI], −0.0918 to −0.0116; p=0.012), diabetes distress (β=0.0260; 95% CI, 0.0149 to 0.0371; p<0.0001) and diabetes self-efficacy (β=−0.0184; 95% CI, −0.0316 to −0.0052; p=0.007) were significantly associated with COVID distress.

Conclusions

Certain subgroups of people with diabetes have experienced a disproportionate amount of COVID distress. Assessing correlates of COVID distress among people with diabetes will help inform interventions such as diabetes self-management education to address the psychosocial distress caused by the pandemic.

Comparative Efficacy and Safety of Ultra-Long-Acting, Long-Acting, Intermediate-Acting, and Biosimilar Insulins for Type 1 Diabetes Mellitus: a Systematic Review and Network Meta-Analysis

BACKGROUND

Increasing availability of competing biosimilar alternatives makes it challenging to make treatment decisions. The purpose of this review is to evaluate the comparative efficacy and safety of ultra-long-/long-/intermediate-acting insulin products and biosimilar insulin compared to human/animal insulin in adults with type 1 diabetes mellitus (T1DM).

METHODS

MEDLINE, EMBASE, CENTRAL, and grey literature were searched from inception to March 27, 2019. Randomized controlled trials (RCTs), quasi-experimental studies, and cohort studies of adults with T1DM receiving ultra-long-/long-/intermediate-acting insulin, compared to each other, as well as biosimilar insulin compared to human/animal insulin were eligible for inclusion. Two reviewers independently screened studies, abstracted data, and appraised risk-of-bias. Pairwise meta-analyses and network meta-analyses (NMA) were conducted. Summary effect measures were mean differences (MD) and odds ratios (OR).

RESULTS

We included 65 unique studies examining 14,200 patients with T1DM. Both ultra-long-acting and long-acting insulin were superior to intermediate-acting insulin in reducing A1c, FPG, weight gain, and the incidence of major, serious, or nocturnal hypoglycemia. For fasting blood glucose, long-acting once a day (od) was superior to long-acting twice a day (bid) (MD - 0.44, 95% CI: - 0.81 to - 0.06) and ultra-long-acting od was superior to long-acting bid (MD - 0.73, 95% CI - 1.36 to - 0.11). For weight change, long-acting od was inferior to long-acting bid (MD 0.58, 95% CI: 0.05 to 1.10) and long-acting bid was superior to long-action biosimilar od (MD - 0.90, 95% CI: - 1.67 to - 0.12).

CONCLUSIONS

Our results can be used to tailor insulin treatment according to the desired results of patients and clinicians and inform strategies to establish a competitive clinical market, address systemic barriers, expand the pool of potential suppliers, and favor insulin price reduction.

PROSPERO REGISTRATION

CRD42017077051.

"In my age, we didn't have the computers": Using a complexity lens to understand uptake of diabetes eHealth innovations into primary care-A qualitative study

BACKGROUND

Shared decision-making is a central component of person-centred care and can be facilitated with the use of patient decision aids (PtDA). Barriers and facilitators to shared decision-making and PtDA use have been identified, yet integration of PtDAs into clinical care is limited. We sought to understand why, using the concepts of complexity science.

METHODS

We conducted 60-minute in-depth interviews with patients with diabetes, primary care physicians, nurses and dietitians who had participated in a randomized controlled trial examining the impact of MyDiabetesPlan (an online goal-setting PtDA). Relying on a qualitative description approach, we used a semi-structured interview guide to explore participants' experiences with using MyDiabetesPlan and how it was integrated into the clinical encounter and clinical care. Audiotapes were transcribed verbatim, then coded independently by two analysts.

FINDINGS

17 interviews were conducted (5 physicians, 3 nurses, 2 dietitians, 7 patients). Two themes were developed: (1) MyDiabetesPlan appeared to empower patients by providing tailored patient-important information which engaged them in decision-making and self-care. Patients' use of MyDiabetesPlan was however impacted by their competing medical conditions, other life priorities and socioeconomic context. (2) MyDiabetesPlan emphasized to clinicians a patient-centred approach that helped patients assume greater ownership for their care. Clinicians' use of MyDiabetesPlan was impacted by pre-existing clinical tools/workplans, workflow, technical issues, clinic administrative logistics and support, and time. How clinicians adapted to these barriers influenced the degree to which MyDiabetesPlan was integrated into care.

CONCLUSIONS

A complexity lens (that considers relationships between multiple components of a complex system) may yield additional insights to optimize integration of PtDA into clinical care. A complexity lens recognizes that shared decision-making does not occur in the vacuum of a clinical dyad (patient and clinician), and will enable us to develop a family of interventions that address the whole process, rather than individual components.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02379078.

Near-GeV Electron Beams at a Few Per-Mille Level from a Laser Wakefield Accelerator via Density-Tailored Plasma

A simple, efficient scheme was developed to obtain near-gigaelectronvolt electron beams with energy spreads of few per-mille level in a single-stage laser wakefield accelerator. Longitudinal plasma density was tailored to control relativistic laser-beam evolution, resulting in injection, dechirping, and a quasi-phase-stable acceleration. With this scheme, electron beams with peak energies of 780-840 MeV, rms energy spreads of 2.4‰-4.1‰, charges of 8.5-23.6 pC, and rms divergences of 0.1-0.4 mrad were experimentally obtained. Quasi-three-dimensional particle-in-cell simulations agreed well with the experimental results. The dechirping strength was estimated to reach up to 11  TeV/mm/m, which is higher than previously obtained results. Such high-quality electron beams will boost the development of compact intense coherent radiation sources and x-ray free-electron lasers.

Impact of Clinical Practice Guidelines on Blood Glucose Test Strip Prescription Rates in Manitoba and Saskatchewan (Canada): An Interrupted Time-Series Analysis

OBJECTIVES

Our aim in this study was to assess the impact of the Diabetes Canada Dissemination & Implementation strategy on population-level prescription rates of blood glucose test strips.

METHODS

We extracted all diabetes-related drugs and test strip claims in Manitoba and Saskatchewan between January 1, 2000 and September 30, 2015 from the Canadian Institute for Health Information's National Prescription Drug Utilization Information System. The primary outcome was the proportion of the cohort in each quarter who had been dispensed strips in accordance with the Diabetes Canada 2013 guidelines. We conducted an interrupted time-series analysis examining prescribing trends overall and by drug groups.

RESULTS

The overall average sample size per quarter was 57,576 (standard deviation [SD]=12,320) and 49,533 (SD=10,206) individuals; the average age was 62.1 (SD=0.3) and 63.8 (SD=0.3) years, and the average proportion of total beneficiaries in the sample was 12.7% (SD=1.9%) and 12.6% (SD=1.7%) for Manitoba and Saskatchewan, respectively. On average preintervention, 27.9% (SD=0.68%, Manitoba) and 31.9% (SD=0.73%, Saskatchewan) of the sampled patients used strips according to the guidelines. On average postintervention, 26.5% (SD=0.29%, Manitoba) and 30.6% (SD=0.53%, Saskatchewan) of the patients used strips according to the guidelines. None of the interrupted time-series models reached statistical significance (p values ranging from 0.44 to 0.98 for Manitoba and 0.13 to 0.81 for Saskatchewan, depending on drug group).

CONCLUSIONS

The guideline and its Dissemination & Implementation strategy did not change strip prescribing. Potential reasons include complexity of the recommendations, lack of penetrance to primary care physicians and/or disagreement with recommendations.

[Teicoplanin-induced hypersensitivity syndrome in a diabetic foot patient with malignant ulcer]

A 58-year-old male patient with diabetic foot ulcer was admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine on December 11, 2018. The patient was treated with local debridement, vacuum sealing drainage treatment, and dressing change and discharged after basic wound healing. On January 15, 2019, the patient was hospitalized again due to local infection and rupture of wound surface. He underwent a surgical debridement on the third day after second admission and was given intravenous infusion of 0.4 g teicoplanin twice daily. Histopathological examination after surgery showed keratinizing squamous-cell carcinoma. An extended squamous-cell carcinoma resection plus autologous split-thickness skin grafting and vacuum sealing drainage treatment was carried out on the 10th day after second admission. The patient's whole body turned red after surgery with rash, recurrent fever over 39 ℃, leucopenia, and thrombocytopenia. A multi-disciplinary consultation of physicians attributed these symptoms to teicoplanin-induced hypersensitivity syndrome. After withdrawal of teicoplanin and administration of hormone, the patient's temperature returned to normal, and the leucocyte count and platelet count recovered gradually. The patient was cured and discharged on the 49th day after second admission. The case presented reminds us of need to strictly follow the indications of teicoplanin prior to medication, be resolute to the administration and withdrawal, and be alert to adverse drug reactions when above-mentioned abnormalities occur, meanwhile, infection and rheumatic diseases are excluded.

Beyond pros and cons - developing a patient decision aid to cultivate dialog to build relationships: insights from a qualitative study and decision aid development

BACKGROUND

An individualized approach using shared decision-making (SDM) and goal setting is a person-centred strategy that may facilitate prioritization of treatment options. SDM has not been adopted extensively in clinical practice. An interprofessional approach to SDM with tools to facilitate patient participation may overcome barriers to SDM use. The aim was to explore decision-making experiences of health professionals and people with diabetes (PwD), then develop an intervention to facilitate interprofessional shared decision-making (IP-SDM) and goal-setting.

METHODS

This was a multi-phased study. 1) Feasibility: Using a descriptive qualitative study, individual interviews with primary care physicians, nurses, dietitians, pharmacists, and PwD were conducted. The interviews explored their experiences with SDM and priority-setting, including facilitators and barriers, relevance of a decision aid for priority-setting, and integration of SDM and a decision aid into practice. 2) Development: An evidence-based SDM toolkit was developed, consisting of an online decision aid, MyDiabetesPlan, and implementation tools. MyDiabetesPlan was reviewed by content experts for accuracy and comprehensiveness. Usability assessment was done with 3) heuristic evaluation and 4) user testing, followed by 5) refinement.

RESULTS

Seven PwD and 10 clinicians participated in the interviews. From interviews with PwD, we identified that: (1) approaches to decision-making were diverse and dynamic; (2) a trusting relationship with the clinician and dialog were critical precursors to SDM; and, (3) goal-setting was a dynamic process. From clinicians, we found: (1) complementary (holistic and disease specific) approaches to the complex patient were used; (2) patient-provider agendas for goal-setting were often conflicting; (3) a flexible approach to decision-making was needed; and, (4) conflict could be resolved through SDM. Following usability assessment, we redesigned MyDiabetesPlan to consist of data collection and recommendation stages. Findings were used to finalize a multi-component toolkit and implementation strategy, consisting of MyDiabetesPlan, instructional card and videos, and orientation meetings with participating patients and clinicians.

CONCLUSIONS

A decision aid can provide information, facilitate clinician-patient dialog and strengthen the therapeutic relationship. Implementation of the decision aid can fit into a model of team care that respects and exemplifies professional identity, and can facilitate intra-team communication.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.

[Research progress in saliva collection, analysis and its relationship with oral diseases]

As one of the major body fluid, saliva has various components that can shift according to the systemic health state. With the atraumatic way of collection, saliva can be a promising media to help the detection of oral diseases. With the development of salivaomics and the application of unbiased, highly sensitive, and high throughout separation techniques for salivary components, there's now more possibilities for effective identification of biomarkers correlated with oral diseases. This review aimed to introduce the current state of saliva collection and detection techniques as well as their correlation with oral diseases, hoping to provide evidence for further research.

[One case of severe subcutaneous soft tissue infection caused by nonstandard insulin injection]

On January 1st 2018, a male 44 years old diabetic patient with subcutaneous soft tissue infection in right thigh was admitted to our hospital. The patient repeatedly used the same needle to inject insulin subcutaneously in the unsterilized right thigh, and his blood glucose was badly controlled in the long term. Severe subcutaneous soft tissue infection of the right thigh occurred after his fatigue, accompanied with ketoacidosis. Then he received conservative treatment in the local hospital for one month, but the infection persisted. After being transferred to our hospital, we highly suspected the diagnosis of necrotizing fasciitis according to previous test indicators and local B-ultrasound results, but suggestion of aggressive surgery was refused. So we treated him with conservative therapies using sensitive antibiotics and supportive remedies. The patient was basically healed after treatment of 1 month and he was recovered well during the follow-up 2 months after discharged from our hospital. This case emphasizes the importance of standard injection of insulin and early diagnosis of severe subcutaneous soft tissue infection.

Relationship Among Diabetes Distress, Decisional Conflict, Quality of Life, and Patient Perception of Chronic Illness Care in a Cohort of Patients With Type 2 Diabetes and Other Comorbidities

OBJECTIVE

The primary outcome is to evaluate the relationship between diabetes distress and decisional conflict regarding diabetes care in patients with diabetes and two or more comorbidities. Secondary outcomes include the relationships between diabetes distress and quality of life and patient perception of chronic illness care and decisional conflict.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of 192 patients, ≥18 years of age, with type 2 diabetes and two or more comorbidities, recruited from primary care practices in the Greater Toronto Area. Baseline questionnaires were completed using validated scales: Diabetes Distress Scale (DDS), Decisional Conflict Scale (DCS), Short-Form Survey 12 (SF-12), and Patient Assessment of Chronic Illness Care (PACIC). Multiple linear regression models evaluated associations between summary scores and subscores, adjusting for age, education, income, employment, duration of diabetes, and social support.

RESULTS

Most participants were >65 years old (65%). DCS was significantly and positively associated with DDS (β = 0.0139; CI 0.00374-0.0246; P = 0.00780). DDS-emotional burden subscore was significantly and negatively associated with SF-12-mental subscore (β =-3.34; CI -4.91 to -1.77; P < 0.0001). Lastly, DCS was significantly and negatively associated with PACIC (β = -6.70; CI -9.10 to -4.32; P < 0.0001).

CONCLUSIONS

We identified a new positive relationship between diabetes distress and decisional conflict. Moreover, we identified negative associations between emotional burden and mental quality of life and patient perception of chronic illness care and decisional conflict. Understanding these associations will provide valuable insights in the development of targeted interventions to improve quality of life in patients with diabetes.

Diabetes Canada 2018 clinical practice guidelines: Key messages for family physicians caring for patients living with type 2 diabetes

OBJECTIVE

To summarize the 2018 Diabetes Canada clinical practice guidelines, focusing on high-priority recommendations for FPs managing people who live with type 2 diabetes.

QUALITY OF EVIDENCE

A prioritization process was conducted to focus the efforts of Diabetes Canada's guideline dissemination and implementation efforts. The resulting identified key messages for FPs to consider when managing patients with type 2 diabetes are described. Evidence supporting the guideline recommendations ranges from levels I to IV and grades A to D.

MAIN MESSAGE

Three key messages were identified from the 2018 guidelines as priorities for FPs: discussing opportunities to reduce the risk of diabetes complications, discussing opportunities to ensure safety and prevent hypoglycemia, and discussing progress on self-management goals and addressing barriers. A theme cutting across these key messages was the need to tailor discussions to the needs and preferences of each person. These important guideline recommendations are highlighted, along with information about relevant tools for implementing the recommendations in real-world practice.

CONCLUSION

High-quality diabetes care involves a series of periodic conversations about self-management and about pharmacologic and nonpharmacologic treatments that fit with each patient's goals (ie, shared decision making). Incorporating these conversations into regular practice provides FPs with opportunities to maximize likely benefits of treatments and decrease the risk of harms, to support patients in initiating and sustaining desired lifestyle changes, and to help patients cope with the burdens of diabetes and comorbid conditions.

[Not Available]

Objectif

Résumer les lignes directrices de pratique clinique 2018 de Diabète Canada en s’attardant aux recommandations prioritaires pour les médecins de famille qui traitent des personnes vivant avec le diabète de type 2.

Qualité des données

Un processus de priorisation a été réalisé dans le but de canaliser les efforts de dissémination et de mise en oeuvre des lignes directrices de Diabète Canada. Il en a résulté une description des principaux messages à l’intention des médecins de famille qui soignent des patients de diabète de type 2. Les données étayant les recommandations des lignes directrices varient des niveaux I à IV, et des catégories A à D.

Message principal

Trois principaux messages prioritaires pour les médecins de famille ont été relevés dans les lignes directrices 2018 : parler des occasions de réduire le risque de complications du diabète, parler des occasions d’assurer la sécurité et de prévenir l’hypoglycémie, et parler des progrès vers l’atteinte des objectifs d’autoprise en charge et de l’élimination des obstacles. Ces principaux messages ont fait ressortir un thème : celui d’adapter les conversations aux besoins et aux préférences de chacun. Ces importantes recommandations sont mises en lumière, de même que l’information sur les outils pertinents pour mettre en oeuvre les recommandations en pratique réelle.

Conclusion

Les soins du diabète de grande qualité comprennent une série de conversations périodiques sur l’autoprise en charge, et sur les traitements pharmacologiques et non pharmacologiques adaptés aux objectifs de chaque patient (c.-à-d. prise de décision partagée). Lorsque les médecins de famille incorporent ces conversations dans la pratique régulière, ils ont la chance d’optimiser les bienfaits possibles du traitement et de réduire le risque d’effets nuisibles, d’encourager les patients à instaurer et à maintenir les modifications désirées du mode de vie, et de les aider à composer avec le fardeau du diabète et des comorbidités.

Level Attraction Due to Dissipative Magnon-Photon Coupling

We report dissipative magnon-photon coupling caused by the cavity Lenz effect, where the magnons in a magnet induce a rf current in the cavity, leading to a cavity backaction that impedes the magnetization dynamics. This effect is revealed in our experiment as level attraction with a coalescence of hybridized magnon-photon modes, which is distinctly different from level repulsion with mode anticrossing caused by coherent magnon-photon coupling. We develop a method to control the interpolation of coherent and dissipative magnon-photon coupling, and observe a matching condition where the two effects cancel. Our work sheds light on the so-far hidden side of magnon-photon coupling, opening a new avenue for controlling and utilizing light-matter interactions.

Impact of the Canadian Diabetes Association guideline dissemination strategy on clinician knowledge and behaviour change outcomes

AIM

Implementation of clinical practice guideline (CPG) into clinical practice remains limited. Using the Knowledge-To-Action framework, a guideline dissemination and implementation strategy for the Canadian Diabetes Association's 2013 CPG was developed and launched to clinicians and people with diabetes.

METHODS

The RE-AIM framework guided evaluation of this strategy clinician; we report here one aspect of the effectiveness dimension using mixed methods. We measured impact of the strategy on clinican knowledge and behaviour change constructs using evaluation forms, national online survey and individual interviews.

RESULTS

After attending a lecture, clinician confidence (n = 915) increased (3.7(SD 0.7) to 4.5 (SD 0.6) on a 5-point scale (p < 0.001)), with 55% (n = 505) intending to make a practice change (e.g. clinical management regarding glycemic control). Ninety-four percent of survey respondents (n = 907) were aware of the guidelines, attributed to communications from professional associations, continuing professional development events, and colleagues. Forty to 98% of respondents (total n 462-485) were correct in their interpretation of CPG messages, and 33-65%(total n 351-651) reported that they had made changes to their practice. Interviews with 28 clinicians revealed that organizational credibility, online access to tools, clarity of tool content, and education sessions facilitated uptake; lack of time, team-based consensus, and seamless integration into care and patient complexity were barriers.

CONCLUSION

The complexity of diabetes care requires systemic adoption of organization of care interventions, including interprofessional collaboration and consensus. Augmenting our strategy to include scalable models for professional development, integration of guidelines into electronic medical records, and expansion of our target audience to include health care teams and patients, may optimize guideline uptake.

A rare oesophageal inflammatory myofibroblastic tumour treated by endoscopy

An inflammatory myofibroblastic tumour is a mesenchymal neoplasm that mostly involves the lung and rarely involves the oesophagus. Surgery has been most commonly used for the treatment of oesophageal inflammatory myofibroblastic tumours but there are no definite guidelines for their diagnosis and treatment. We describe the case of a 60-year-old woman presenting with dysphagia and poor appetite who was diagnosed with a submucosal oesophageal tumour by contrast enhanced computed tomography and ultrasonography endoscopy. She was treated successfully by endoscopic submucosal dissection with no complications. The final diagnosis was confirmed by pathological examination.

[Impact of daily mean temperature, cold spells, and heat waves on stroke mortality a multivariable Meta-analysis from 12 counties of Hubei province, China]

Objective: To assess the acute effects of daily mean temperature, cold spells, and heat waves on stroke mortality in 12 counties across Hubei province, China. Methods: Data related to daily mortality from stroke and meteorology in 12 counties across Hubei province during 2009-2012, were gathered. Distributed lag nonlinear model (DLNM) was first used, to estimate the county-specific associations between daily mean temperature, cold spells, heat waves and stroke mortality. Multivariate Meta-analysis was then applied to pool the community-specific relationships between temperature and stroke mortality (exposure-response relationship) as well as both cold- and- heat-associated risks on mortality at different lag days (lag-response relationship). Results: During 2009-2012, a total population of 6.7 million was included in this study with 42 739 persons died of stroke. An average of 2.7 (from 0.5 to 6.0) stroke deaths occurred daily in each county, with annual average mean temperature as 16.6 ℃ (from 14.7 ℃ to 17.4 ℃) during the study period. An inverse J-shaped association between temperature and stroke mortality was observed at the provincial level. Pooled mortality effect of cold spells showed a 2-3-day delay and lasted about 10 days, while effect of heat waves appeared acute but attenuated within a few days. The mortality risks on cold-spell days ranged from 0.968 to 1.523 in 12 counties at lag 3-14, with pooled effect as 1.180 (95%CI:1.043-1.336). The pooled mortality risk (ranged from 0.675 to 2.066) on heat-wave days at lag 0-2 was 1.114 (95%CI: 1.012-1.227). Conclusions: An inverse J-shaped association between temperature and stroke mortality was observed in Hubei province, China. Both cold spells and heat waves were associated with increased stroke mortality, while different lag patterns were observed in the mortality effects of heat waves and cold spells.

Computerized Insulin Order Sets and Glycemic Control in Hospitalized Patients

BACKGROUND

The purpose of this study was to evaluate the impact of computerized provider order entry subcutaneous insulin order sets on inpatient glycemic control and ordering behavior.

METHODS

This was an interrupted time series study of non-intensive care patients at an urban teaching hospital. The primary outcome was proportion of capillary blood glucose in optimal range (4.0-10.0 mmol/L [72-180 mg/dL]) during the 6 months before and after a change to a computerized provider order entry-integrated insulin order set. Secondary outcomes included other measures of glycemia (hyperglycemia [>13.9mmol/L (250 mg/dL)], hypoglycemia [<4.0 mmol/L (72 mg/dL)], severe hypoglycemia [<2.2 mmol/L (40 mg/dL)]) and ordering behavior (use of basal-bolus-correctional insulin regimens). Comparisons of sensitivity-based versus generic correctional scale were also conducted.

RESULTS

A total of 63,393 measurements were obtained from June 2011 to June 2012. Order set usage was limited (51.5%). The weekly proportion of capillary blood glucose within the optimal range was not significantly different after the switch to computerized provider order entry order sets (pre-period: 64.9% vs post-period: 65.3%, P = .996). There were no differences in the proportions of moderate or severe hyperglycemia (pre-period: 10.9% vs post-period: 12.0%, P = .061) and hypoglycemia (pre-period: 1.9% vs post-period: 1.6%, P = .144). However, an increased proportion within the optimal range was seen in those with an order set featuring a sensitivity-based correctional scale versus orders without (65.3% vs 55.0%, P <.001). Increased basal-bolus-correctional ordering was observed after protocol implementation (20.3% vs 23.6%, P <.0001).

CONCLUSIONS

With low institutional uptake, computerized insulin order sets did not improve inpatient glycemic control.

[Research advances in diagnosis of non-alcoholic fatty liver disease]

Non-alcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases in clinical practice, and the spectrum of NAFLD includes nonalcoholic simple fatty liver, nonalcoholic steatohepatitis, and liver cirrhosis. Some patients may even progress to hepatocellular carcinoma. At present, the gold standard for the diagnosis of NAFLD is liver biopsy, but since this is an invasive examination and has high costs, its application is limited in clinical practice. More and more studies have focused on noninvasive diagnostic methods for NAFLD, including serological markers, fatty liver predictive model, and imaging examinations. Emerging diagnostic techniques, including genomics, proteomics, glycomics, and metabolomics, also play an important role in the diagnosis of NAFLD.

Is glycemia control in Canadians with diabetes individualized? A cross-sectional observational study

OBJECTIVE

Diabetes guidelines recommend individualized glycemic targets: tighter control in younger, healthier patients and consideration of more moderate control in the elderly and those with coexisting illnesses. Our objective was to examine whether glycemic control varied by age and comorbidities in Canadian primary care.

RESEARCH DESIGN AND METHODS

Cross-sectional study using data from the electronic medical records of 537 primary care providers across Canada; 30 416 patients with diabetes, aged 40 or above, with at least one encounter and one hemoglobin A1c (HbA1c) measurement between 1 January 2012 and 31 December 2013. The outcome was the most recent HbA1c, categorized into three levels of control: tight (<7.0% or <53 mmol/mol), moderate (7.0%-8.5%, 53 mmol/mol-69.5 mmol/mol) and uncontrolled (>8.5% or >69.5 mmol/mol). We adjusted for several factors associated with glycemic control including treatment intensity.

RESULTS

Younger patients (aged 40-49) were more likely to have moderate as opposed to tight control than the older patients (aged 80+) (OR 1.28; 95% CI 1.11 to 1.49, p=0.001). The youngest were also more likely to have uncontrolled as opposed to moderately controlled glycemia (OR 3.39; 95% CI 2.75 to 4.17, p<0.0001). Patients with no or only one comorbidity were more likely to have moderate as opposed to tight control than those with three or more comorbidities (OR 1.66;95% CI 1.46 to 1.90, p<0.0001).

CONCLUSIONS

Levels of glycemic control, given age and comorbidities appear to differ from guideline recommendations. Research is needed to understand these discrepancies and develop methods to assist providers in personalizing glycemic targets.

[Acute effect of daily mean temperature on ischemic heart disease mortality: a multivariable meta-analysis from 12 counties across Hubei Province, China]

Objective: To evaluate the acute effects of daily mean temperature on ischemic heart disease (IHD) mortality in 12 counties across Hubei Province, China. Methods: We obtained the daily IHD mortality data and meteorological data of the 12 counties for 2009-2012. The distributed lag nonlinear model (DLNM) was used to estimate the community-specific association between mean temperature and IHD mortality. A multivariate meta-analysis was then applied to pool the community-specific relationship between temperature and IHD mortality, and the effects of cold and heat on mortality risk. Results: In 2009-2012, of the 6 702 012 people included in this study, 19 688 died of IHD. A daily average of 1.2 IHD deaths occurred in each community. The annual average mean temperature was 16.6 ℃ during the study period. A nonlinear temperature-IHD mortality relationship was observed for different cumulative lag days at the provincial level. The pooled heat effect was acute but attenuated within 2 days. In contrast, the cold effect was delayed and persisted for more than 2 weeks. Compared with a reference temperature (25^th percentile of mean temperature during the study period, P₂₅), the cold effect for P₁₀ of mean temperature was associated with IHD mortality, the RR(95% CI) was 1.084 (1.008-1.167) at lag 0-14, and 1.149 (1.053-1.253) at lag 0-21. For the P₁ cold temperature, the mortality RR (95% CI) values were 1.116 (0.975-1.276) and 1.220 (1.04-1.428), respectively. We found no significant association between high temperatures and IHD mortality in the present study at different lag days. Conclusion: In Hubei Province, low temperature was associated with increased IHD mortality risk, and cold effects lasted for several days; no significant effect of high temperature was observed.

LECT2 association with macrophage-mediated killing of Helicobacter pylori by activating NF-κB and nitric oxide production

Helicobacter pylori employs unique methods to colonize the stomach, which induces chronic inflammation. It is also able to avoid eradication by macrophages and other immune cells. Leukocyte cell-derived chemotaxin 2 (LECT2), a multi-functional cytokine involved in many pathological conditions, has recently been shown to activate macrophages via the CD209a receptor. Therefore, we aimed to investigate the effects of LECT2 on H. pylori-infected macrophages. Macrophages were treated with recombinant LECT2, and both their ability to kill H. pylori and produce nitric oxide were analyzed. Western blot was performed to determine nuclear translocation and protein phosphorylation of p65, a subunit of nuclear factor (NF)-κB. Transfection experiments were performed to analyze the signaling pathway of LECT2 in macrophages. We found that treatment with LECT2 enhanced H. pylori killing and nitric oxide production in macrophages. In addition, DNA-binding activity and nuclear translocation of p65 were up-regulated by LECT2 treatment. Furthermore, we found that NF-κB activation by LECT2 was mediated by Raf-1 in macrophages, and Raf-1 phosphorylation was specifically altered in response to LECT2. Moreover, LECT2 induced Ser28 phosphorylation in the intracellular domain of CD209a. CD209a Ser28 phosphorylation was required for LECT2-induced Raf-1 and NF-κB activation in RAW264.7 macrophages. Our study showed that the effects of LECT2 on H. pylori killing and nitric oxide production were dependent on CD209a phosphorylation, Raf-1, and NF-κB activation. Together, these results demonstrate for the first time that exposure to LECT2 can modulate specific intracellular mechanisms downstream of CD209a to enhance H. pylori killing and nitric oxide production in macrophages.

High-Brightness High-Energy Electron Beams from a Laser Wakefield Accelerator via Energy Chirp Control

By designing a structured gas density profile between the dual-stage gas jets to manipulate electron seeding and energy chirp reversal for compressing the energy spread, we have experimentally produced high-brightness high-energy electron beams from a cascaded laser wakefield accelerator with peak energies in the range of 200-600 MeV, 0.4%-1.2% rms energy spread, 10-80 pC charge, and ∼0.2  mrad rms divergence. The maximum six-dimensional brightness B_{6D,n} is estimated as ∼6.5×10^{15}  A/m^{2}/0.1%, which is very close to the typical brightness of e beams from state-of-the-art linac drivers. These high-brightness high-energy e beams may lead to the realization of compact monoenergetic gamma-ray and intense coherent x-ray radiation sources.

Long-term exposure of K562 cells to benzene metabolites inhibited erythroid differentiation and elevated methylation in erythroid specific genes

Benzene is a common occupational hazard and a widespread environmental pollutant. Previous studies have revealed that 72 h exposure to benzene metabolites inhibited hemin-induced erythroid differentiation of K562 cells accompanied with elevated methylation in erythroid specific genes. However, little is known about the effects of long-term and low-dose benzene metabolite exposure. In this study, to elucidate the effects of long-term benzene metabolite exposure on erythroid differentiation, K562 cells were treated with low-concentration phenol, hydroquinone and 1,2,4-benzenetriol for at least 3 weeks. After exposure of K562 cells to benzene metabolites, hemin-induced hemoglobin synthesis declined in a concentration- and time-dependent manner, and the hemin-induced expressions of α-, β- and γ-globin genes and heme synthesis enzyme porphobilinogen deaminase were significantly suppressed. Furthermore, when K562 cells were continuously cultured without benzene metabolites for another 20 days after exposure to benzene metabolites for 4 weeks, the decreased erythroid differentiation capabilities still remained stable in hydroquinone- and 1,2,4-benzenetriol-exposed cells, but showed a slow increase in phenol-exposed K562 cells. In addition, methyltransferase inhibitor 5-aza-2'-deoxycytidine significantly blocked benzene metabolites inhibiting hemoglobin synthesis and expression of erythroid genes. Quantitative MassARRAY methylation analysis also confirmed that the exposure to benzene metabolites increased DNA methylation levels at several CpG sites in several erythroid-specific genes and their far-upstream regulatory elements. These results demonstrated that long-term and low-dose exposure to benzene metabolites inhibited the hemin-induced erythroid differentiation of K562 cells, in which DNA methylation played a role through the suppression of erythroid specific genes.

"There's no billing code for empathy" - Animated comics remind medical students of empathy: a qualitative study

BACKGROUND

Physician empathy is associated with improved diabetes outcomes. However, empathy declines throughout medical school training. This study seeks to describe how comics on diabetes affect learning processes for empathy in medical students.

METHODS

All first- or second-year students at a Canadian medical school were invited to provide written reflections on two comics regarding diabetes and participate in a focus group. Responses were analyzed qualitatively for emergent themes. Students completed the Jefferson Scale of Physician Empathy (JSPE) at baseline, after the comic, and after the focus group. Linear mixed model statistical analyses were performed.

RESULTS

Thirteen first-year and 12 second-year students participated. Qualitative analysis revealed four themes: 1) Empathy decline and its barriers; 2) Impact of the comic and focus group on knowledge, attitudes and skills; 3) Role of the comic in the curriculum as a reminder tool of the importance of empathy; 4) Comics as an effective medium. Baseline mean JSPE scores were 116.4 (SD 10.5) and trended up to 117.2 (SD 12.5) and 119.6 (SD 15.2) after viewing the comics and participating in the focus groups, respectively (p = 0.08).

CONCLUSIONS

Animated comics on diabetes are novel methods of reminding students about empathy by highlighting the patient perspective.

[Investigation and analysis for impact factors of distress in patients with first diagnosed lung cancer]

OBJECTIVE

To study the impact factors of psychological distress in patients with first diagnosed lung cancer.

METHODS

The cross-sectional study was applied to newly diagnosed lung cancer patients who received treatments in Cancer Center of West China Hospital of Sichuan University in Chengdu from June 2013 to March 2015 by distributed questionnaires. The general information of the patients, the hospital anxiety and depression scale (HADS) and distress management screening measure (DMSM) were included in the questionnaire to evaluate the states of distress, pain and the factors related to the distress of the patients.

RESULTS

The survey investigated a total of 390 patients with first diagnosed lung cancer, including 291 male patients and 99 female patients. The proportion of the patients with positive anxiety symptom was 26.7% (104/390), with positive depression symptom was 27.7% (108/390), and with positive distress symptom was 30.0% (117/390). On the top five problem list of DMSM were worry, disease treatment, breathing, pain and sleep. The Spearman correlation analysis showed that anxiety score, depression score, and the pain intensity were positively correlated with the distress. Multiple linear regression analysis showed that gender (β=-0.209, P=0.003), age (β=-0.098, P=0.042), chronic disease (β=0.378, P<0.001), and pain score (β=0.100, P=0.029) could affect the distress of the patients. Smoking (β=0.111, P=0.041) could affect the anxiety of newly diagnosed lung cancer patients.

CONCLUSION

The gender, age, chronic disease and pain score of the patients are the independent factors of the psychological distress of first diagnosed lung cancer patients. Smoking is the predictive factors of the patients with anxiety. Controlling the pain intensity and the clinical process of chronic disease of the patients actively, solving the sleep and breathing problem and helping the patients to quit smoking progressively could alleviate the psychological distress of the patients.

Meta-Prediction of MTHFR Gene Polymorphism Mutations and Associated Risk for Colorectal Cancer

The methylenetetrahydrofolate reductase (MTHFR) gene is one of the most investigated of the genes associated with chronic human diseases because of its associations with hyperhomocysteinemia and toxicity. It has been proposed as a prototype gene for the prevention of colorectal cancer (CRC). The major objectives of this meta-analysis were to examine the polymorphism-mutation patterns of MTHFR and their associations with risk for CRC as well as potential contributing factors for mutations and disease risks. This analysis included 33,626 CRC cases and 48,688 controls across 92 studies for MTHFR 677 and 16,367 cases and 24,874 controls across 54 studies for MTHFR 1298, comprising data for various racial and ethnic groups, both genders, and multiple cancer sites. MTHFR 677 homozygous TT genotype was protective (p < .05) for CRC for all included populations; however, with heterogeneity across various racial–ethnic groups and opposing findings, it was a risk genotype for the subgroup of Hispanics (p < .01). Additional countries for which subgroup analyses resulted in 677 TT as a risk genotype included Turkey, Romania, Croatia, Hungary, Portugal, Mexico, Brazil, U.S. Hawai’i, Taiwan, India, and Egypt. Countries with the highest mutation rates and risks for both MTHFR 677 and 1298 genotypes are presented using global maps to visualize the grouping patterns. Meta-predictive analyses revealed that air pollution levels were associated with gene polymorphisms for both genotypes. Future nursing research should be conducted to develop proactive measures to protect populations in cities where air pollution causes more deaths.

Incentivizing health care behaviors in emerging adults: a systematic review

PURPOSE

For emerging adults with chronic medical diseases, the transition from pediatric to adult health care is often a time of great upheaval, commonly associated with unhealthy self-management choices, loss to follow-up, and adverse outcomes. We conducted a systematic review to examine the use of incentive strategies to promote positive health-related behaviors in young adults with chronic medical diseases.

METHODS

The Medline, CINAHL, Embase, PsycInfo, and Cochrane databases were searched through June 2014. Studies of any design where an incentive was used to achieve a target behavior or outcome in a pediatric or emerging adult population (age <30 years) with chronic medical conditions including addictions, were included.

RESULTS

A total of 26 studies comprising 10,880 patients met our inclusion criteria after screening 10,305 abstracts and 301 full-text articles. Of these studies, 20 examined the effects of behavioral incentives on cigarette smoking or substance abuse, including alcohol; four studies explored behavioral incentives in the setting of HIV or sexual health; and two articles studied individuals with other chronic medical conditions. Seventeen articles reported a statistically significant benefit of the behavioral incentive on one or more outcomes, although only half reported follow-up after the incentive period was terminated.

CONCLUSION

While the majority of studies reported positive outcomes, these studies focused on promoting the cessation of adverse behaviors rather than promoting positive behaviors. In addition, conclusions were limited by the high risk of bias present in the majority of studies, as well as lack of follow-up after the incentive period. Whether behavioral incentives facilitate the adoption of positive health choices in this population remains to be determined.

Impact of an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes on decisional conflict--study protocol for a randomized controlled trial

BACKGROUND

Competing health concerns present real obstacles to people living with diabetes and other chronic diseases as well as to their primary care providers. Guideline implementation interventions rarely acknowledge this, leaving both patients and providers feeling overwhelmed by the volume of recommended actions. Interprofessional (IP) shared decision-making (SDM) with the use of decision aids may help to set treatment priorities. We developed an evidence-based SDM intervention for patients with diabetes and other conditions that was framed by the IP-SDM model and followed a user-centered approach. Our objective in the present study is to pilot an IP-SDM and goal-setting toolkit following the Knowledge-to-Action Framework to assess (1) intervention fidelity and the feasibility of conducting a larger trial and (2) impact on decisional conflict, diabetes distress, health-related quality of life and patient assessment of chronic illness care.

METHODS/DESIGN

A two-step, parallel-group, clustered randomized controlled trial (RCT) will be conducted, with the primary goal being to assess intervention fidelity and the feasibility of conducting a larger RCT. The first step is a provider-directed implementation only; the second (after a 6-month delay) involves both provider- and patient-directed implementation. Half of the clusters will be assigned to receive the IP-SDM toolkit, and the other will be assigned to be mailed a diabetes guidelines summary. Individual interviews with patients, their family members and health care providers will be conducted upon trial completion to explore toolkit use. A secondary purpose of this trial is to gather estimates of the toolkit's impact on decisional conflict. Secondary outcomes include diabetes distress, quality of life and chronic illness care, which will be assessed on the basis of patient-completed questionnaires of validated scales at baseline and at 6 and 12 months. Multilevel hierarchical regression models will be used to account for the clustered nature of the data.

DISCUSSION

An individualized approach to patients with multiple chronic conditions using SDM and goal setting is a desirable strategy for achieving guideline-concordant treatment in a patient-centered fashion. Our pilot trial will provide insights regarding strategies for the routine implementation of such interventions in clinical practice, and it will offer an assessment of the impact of this approach.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.