A comparison between different patient groups for diabetes management during phases of the COVID-19 pandemic: a retrospective cohort study in Ontario, Canada

BACKGROUND

With the onset of the COVID-19 pandemic and the large uptake in virtual care in primary care in Canada, the care of patients with type 2 diabetes has been greatly affected. This includes decreased in-person visits, laboratory testing and in-person assessments such as blood pressure (BP). No studies have investigated if these changes persisted with pandemic progression, and it is unclear if shifts impacted patient groups uniformly. The purpose of this paper was to examine changes in diabetes care pre, early, and later pandemic across different patient groups.

METHODS

A repeated cross-sectional design with an open cohort was used to investigate diabetes care in adults with type 2 diabetes for a 6-month interval from March 14 to September 13 over three consecutive years: 2019 (pre-pandemic period), 2020 (early pandemic period), and 2021 (later pandemic period). Data for this study were abstracted from the University of Toronto Practice-Based Research Network (UTOPIAN) Data Safe Haven, a primary care electronic medical records database in Ontario, Canada. Changes in diabetes care, which included primary care total visits, in-person visits, hemoglobin A1c (HbA1c) testing, and BP measurements were evaluated across the phases of the pandemic. Difference in diabetes care across patient groups, including age, sex, income quintile, prior HbA1c levels, and prior BP levels, were assessed.

RESULTS

A total of 39,401 adults with type 2 diabetes were included in the study. Compared to the 6-month pre-pandemic period, having any in-person visits decreased significantly early pandemic (OR = 0.079 (0.076-0.082)), with a partial recovery later pandemic (OR = 0.162 (95% CI: 0.157-0.169). Compared to the pre-pandemic period, there was a significant decrease early pandemic for total visits (OR = 0.486 (95% CI: 0.470-0.503)), HbA1c testing (OR = 0.401 (95% CI: 0.389-0.413)), and BP measurement (OR = 0.121 (95% CI: 0.116-0.125)), with partial recovery later pandemic.

CONCLUSIONS

All measures of diabetes care were substantially decreased early pandemic, with a partial recovery later pandemic across all patient groups. With the increase in virtual care due to the COVID-19 pandemic, diabetes care has been negatively impacted over 1-year after pandemic onset.

Statistical sensitivity estimates for oscillating electric dipole moment measurements in storage rings

In this paper analytical expressions are derived to describe the spin motion of a particle in magnetic and electric fields in the presence of an axion field causing an oscillating electric dipole moment (EDM). These equations are used to estimate statistical sensitivities for axion searches at storage rings. The estimates obtained from the analytic expressions are compared to numerical estimates from simulations in Chang et al. (Phys Rev D 99(8):083002, 2019). A good agreement is found.

Phase Locking the Spin Precession in a Storage Ring

This Letter reports the successful use of feedback from a spin polarization measurement to the revolution frequency of a 0.97  GeV/c bunched and polarized deuteron beam in the Cooler Synchrotron (COSY) storage ring in order to control both the precession rate (≈121  kHz) and the phase of the horizontal polarization component. Real time synchronization with a radio frequency (rf) solenoid made possible the rotation of the polarization out of the horizontal plane, yielding a demonstration of the feedback method to manipulate the polarization. In particular, the rotation rate shows a sinusoidal function of the horizontal polarization phase (relative to the rf solenoid), which was controlled to within a 1 standard deviation range of σ=0.21  rad. The minimum possible adjustment was 3.7 mHz out of a revolution frequency of 753 kHz, which changes the precession rate by 26  mrad/s. Such a capability meets a requirement for the use of storage rings to look for an intrinsic electric dipole moment of charged particles.

T-cell immunity in myocardial inflammation: pathogenic role and therapeutic manipulation

T-cell-mediated immunity has been linked not only to a variety of heart diseases, including classic inflammatory diseases such as myocarditis and post-myocardial infarction (Dressler's) syndrome, but also to conditions without an obvious inflammatory component such as idiopathic dilated cardiomyopathy and hypertensive cardiomyopathy. It has been recently proposed that in all these conditions, the heart becomes the focus of T-cell-mediated autoimmune inflammation following ischaemic or infectious injury. For example, in acute myocarditis, an inflammatory disease of heart muscle, T-cell responses are thought to arise as a consequence of a viral infection. In a number of patients, persistent T-cell-mediated responses in acute viral myocarditis can lead to autoimmunity and chronic cardiac inflammation resulting in dilated cardiomyopathy. In spite of the major progress made in understanding the mechanisms of pathogenic T-cell responses, effective and safe therapeutic targeting of the immune system in chronic inflammatory diseases of the heart has not yet been developed due to the lack of specific diagnostic and prognostic biomarkers at an early stage. This has also prevented the identification of targets for patient-tailored immunomodulatory therapies that are both disease- and organ-selective. In this review, we discuss current knowledge of the development and functional characteristics of pathogenic T-cell-mediated immune responses in the heart, and, in particular, in myocarditis, as well as recent advances in experimental models which have the potential to translate into heart-selective immunomodulation.

LINKED ARTICLES

This article is part of a themed section on Targeting Inflammation to Reduce Cardiovascular Disease Risk. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.22/issuetoc and http://onlinelibrary.wiley.com/doi/10.1111/bcp.v82.4/issuetoc.

How to Reach a Thousand-Second in-Plane Polarization Lifetime with 0.97-GeV/c Deuterons in a Storage Ring

We observe a deuteron beam polarization lifetime near 1000 s in the horizontal plane of a magnetic storage ring (COSY). This long spin coherence time is maintained through a combination of beam bunching, electron cooling, sextupole field corrections, and the suppression of collective effects through beam current limits. This record lifetime is required for a storage ring search for an intrinsic electric dipole moment on the deuteron at a statistical sensitivity level approaching 10^{-29}  e cm.

Closing system-wide yield gaps to increase food production and mitigate GHGs among mixed crop-livestock smallholders in Sub-Saharan Africa

In this study we estimate yield gaps for mixed crop-livestock smallholder farmers in seven Sub-Saharan African sites covering six countries (Kenya, Tanzania, Uganda, Ethiopia, Senegal and Burkina Faso). We also assess their potential to increase food production and reduce the GHG emission intensity of their products, as a result of closing these yield gaps. We use stochastic frontier analysis to construct separate production frontiers for each site, based on 2012 survey data prepared by the International Livestock Research Institute for the Climate Change, Agriculture and Food Security program. Instead of relying on theoretically optimal yields-a common approach in yield gap assessments-our yield gaps are based on observed differences in technical efficiency among farms within each site. Sizeable yield gaps were estimated to be present in all of the sites. Expressed as potential percentage increases in outputs, the average site-based yield gaps ranged from 28 to 167% for livestock products and from 16 to 209% for crop products. The emission intensities of both livestock and crop products registered substantial falls as a consequence of closing yield gaps. The relationships between farm attributes and technical efficiency were also assessed to help inform policy makers about where best to target capacity building efforts. We found a strong and statistically significant relationship between market participation and performance across most sites. We also identified an efficiency dividend associated with the closer integration of crop and livestock enterprises. Overall, this study reveals that there are large yield gaps and that substantial benefits for food production and environmental performance are possible through closing these gaps, without the need for new technology.

Community-based adaptation research in the Canadian Arctic

Community-based adaptation (CBA) has emerged over the last decade as an approach to empowering communities to plan for and cope with the impacts of climate change. While such approaches have been widely advocated, few have critically examined the tensions and challenges that CBA brings. Responding to this gap, this article critically examines the use of CBA approaches with Inuit communities in Canada. We suggest that CBA holds significant promise to make adaptation research more democratic and responsive to local needs, providing a basis for developing locally appropriate adaptations based on local/indigenous and Western knowledge. Yet, we argue that CBA is not a panacea, and its common portrayal as such obscures its limitations, nuances, and challenges. Indeed, if uncritically adopted, CBA can potentially lead to maladaptation, may be inappropriate in some instances, can legitimize outside intervention and control, and may further marginalize communities. We identify responsibilities for researchers engaging in CBA work to manage these challenges, emphasizing the centrality of how knowledge is generated, the need for project flexibility and openness to change, and the importance of ensuring partnerships between researchers and communities are transparent. Researchers also need to be realistic about what CBA can achieve, and should not assume that research has a positive role to play in community adaptation just because it utilizes participatory approaches. WIREs Clim Change 2016, 7:175-191. doi: 10.1002/wcc.376 For further resources related to this article, please visit the WIREs website.

New Method for a Continuous Determination of the Spin Tune in Storage Rings and Implications for Precision Experiments

A new method to determine the spin tune is described and tested. In an ideal planar magnetic ring, the spin tune-defined as the number of spin precessions per turn-is given by ν(s)=γG (γ is the Lorentz factor, G the gyromagnetic anomaly). At 970  MeV/c, the deuteron spins coherently precess at a frequency of ≈120  kHz in the Cooler Synchrotron COSY. The spin tune is deduced from the up-down asymmetry of deuteron-carbon scattering. In a time interval of 2.6 s, the spin tune was determined with a precision of the order 10^{-8}, and to 1×10^{-10} for a continuous 100 s accelerator cycle. This renders the presented method a new precision tool for accelerator physics; controlling the spin motion of particles to high precision is mandatory, in particular, for the measurement of electric dipole moments of charged particles in a storage ring.

HPV vaccine education: enhancing knowledge and attitudes of community counselors and educators

Educational efforts targeting parents of preadolescents may help them make informed decisions about having their children vaccinated against the human papillomavirus (HPV). We conducted a pilot study examining knowledge, attitudes, and beliefs of community-based health educators and counselors who routinely disseminate sexual health and prevention information through counseling and supporting these parents. We evaluated the impact of a single, brief workshop by administering questionnaires before and after the session. The workshop consisted of an educational intervention that was presented orally by an expert in gynecological oncology and was followed by an open discussion period. Following the information and discussion session, improvements were seen in knowledge accuracy, confidence in being able to discuss HPV vaccine issues with parents, greater willingness to recommend the vaccine, and a better understanding of potential barriers to vaccine uptake. These results suggest that health educators and counselors may be better prepared to encourage their clients to make well-informed decisions regarding HPV vaccination.

Creation of a gilded trap by the high economic value of the Maine lobster fishery

Unsustainable fishing simplifies food chains and, as with aquaculture, can result in reliance on a few economically valuable species. This lack of diversity may increase risks of ecological and economic disruptions. Centuries of intense fishing have extirpated most apex predators in the Gulf of Maine (United States and Canada), effectively creating an American lobster (Homarus americanus) monoculture. Over the past 20 years, the economic diversity of marine resources harvested in Maine has declined by almost 70%. Today, over 80% of the value of Maine's fish and seafood landings is from highly abundant lobsters. Inflation-corrected income from lobsters in Maine has steadily increased by nearly 400% since 1985. Fisheries managers, policy makers, and fishers view this as a success. However, such lucrative monocultures increase the social and ecological consequences of future declines in lobsters. In southern New England, disease and stresses related to increases in ocean temperature resulted in more than a 70% decline in lobster abundance, prompting managers to propose closing that fishery. A similar collapse in Maine could fundamentally disrupt the social and economic foundation of its coast. We suggest the current success of Maine's lobster fishery is a gilded trap. Gilded traps are a type of social trap in which collective actions resulting from economically attractive opportunities outweigh concerns over associated social and ecological risks or consequences. Large financial gain creates a strong reinforcing feedback that deepens the trap. Avoiding or escaping gilded traps requires managing for increased biological and economic diversity. This is difficult to do prior to a crisis while financial incentives for maintaining the status quo are large. The long-term challenge is to shift fisheries management away from single species toward integrated social-ecological approaches that diversify local ecosystems, societies, and economies.

Successful treatment of peripartum cardiomyopathy with extracorporeal membrane oxygenation

A 24-year-old female developed heart failure within four months of delivering her first child. Echocardiogram revealed a moderately dilated left ventricle with severely reduced systolic function. She continued to decompensate, requiring intubation and inotropic support. When the use of an intra-aortic balloon pump failed to stabilize the patient, the decision was made to place her on ECMO. The circuit consisted of a Quadrox D membrane oxygenator and a CentriMag® centrifugal pump. After 11 days of support, the patient met the weaning criteria and was successfully removed from ECMO. She was discharged one month after her admission. The new technology available allows for ECMO to be considered as an earlier option for the treatment and management of these patients as a bridge to recovery.

Polarized proton collisions at 205 GeV at RHIC

The Brookhaven Relativistic Heavy Ion Collider (RHIC) has been providing collisions of polarized protons at a beam energy of 100 GeV since 2001. Equipped with two full Siberian snakes in each ring, polarization is preserved during acceleration from injection to 100 GeV. However, the intrinsic spin resonances beyond 100 GeV are about a factor of 2 stronger than those below 100 GeV making it important to examine the impact of these strong intrinsic spin resonances on polarization survival and the tolerance for vertical orbit distortions. Polarized protons were first accelerated to the record energy of 205 GeV in RHIC with a significant polarization measured at top energy in 2005. This Letter presents the results and discusses the sensitivity of the polarization survival to orbit distortions.

Cost-effective use of helicopters for the transportation of patients with burn injuries

We performed a retrospective review to analyze the use of helicopters for the transportation of patients with burn injuries to determine whether a more cost-effective approach could be developed without impairing the quality or delivery of health care. Charts were reviewed for all patients with burn injuries who were transported by helicopter to our hospitals during a 2-year period. Patients with inhalation injuries, with burn injuries received more than 24 hours before admission or more than 200 miles from our burn center, with more than 30% total body surface area (TBSA) burned, or with associated trauma injuries were excluded. Control patients with burn injuries who were transported by ambulance were identified and matched to the patients with burn injuries transported by helicopter for the percentage of TBSA burned, the percentage of third-degree burns, transport mileage, and age. The outcome was evaluated by comparison of length of stay, days on ventilator, and mortality rate. Comparisons were performed with Student t test. The transportation charge was determined for the patients transported by helicopter who we believed were eligible for transport by ambulance. Forty-seven of 85 patients transported by helicopter matched the inclusion criteria and had survived. There was no statistically significant difference between the percentage of TBSA burned, the percentage of third-degree burns, length of stay, days on ventilator, age, or transport mileage. There was, however, a significant difference in the time from the injury to admission to the hospital, as well as in the charge for transportation. Patients who had less than 30% TBSA thermal cutaneous injuries without evidence of inhalation injury, and who are less than 200 miles from a burn center may be safely transported by ambulance. Ambulance transportation may take additional time; however, stricter protocols for helicopter transportation of patients with burn injuries will result in potentially substantial savings without affecting outcomes for patients.

Postoperative pulmonary complications in calves after implantation of an electric total artificial heart

In long-term studies testing the Penn State Total Artificial Heart involving 30 calves, seven calves died of pulmonary complications within 2 weeks after receiving the implant (Group 1 [G1]) and seven calves survived from 2 weeks to 3 months without infection (Group 2 [G2]). Comparative studies were performed using multiple variables: cardiopulmonary bypass (CPB) time, cardiac index, central venous pressure, leukocyte count, hematocrit, total protein, albumin, serum glutamic oxaloacetic transaminase (GOT), creatinine, water balance, and transfused blood volume. In G1, CPB time was longer than in G2 (182 +/- 19 vs 156 +/- 17 minutes, respectively, p = 0.018). Postoperative minimum total protein and albumin in G1 were lower than those in G2 (56.5% +/- 6.0% and 59.0% +/- 5.5% of preoperative values vs 68.4% +/- 8.5% and 67.8% +/- 6.1%, respectively, p = 0.011 and 0.015). Water balance in G2 was more positive than in G1 (11.7 +/- 6.8 vs 1.4 +/- 8.3 L, respectively, p = 0.020). Other variables showed no significant differences. Microscopic findings of the lung in G1 were congestion, hemorrhage, aggregation of neutrophils, and proteinaceous material within the interstitial tissues and alveoli.

Percutaneous feeding tube changes in long-term-care facility patients

OBJECTIVE

To compare patient outcomes when percutaneous feeding tubes were changed routinely each month or only when necessary (prn).

DESIGN

Prospective, randomized, nonblinded crossover study of 6 months of routine monthly changes compared with 6 months of prn changes.

SETTING

416-bed long-term-care facility.

PATIENTS

26 permanent residents with nutrition managed through percutaneous gastrostomy or jejunostomy feeding tubes. The median age was 61.5 years; 8 (31%) also had tracheostomies, and 3 (12%) had indwelling urinary catheters.

RESULTS

The frequency of feeding tube changes was 40 per 1,000 patient-days during the 6 months of routine tube changes and 14 per 1,000 when tubes were changed prn (P < .001). There were no differences between the two study periods in frequency of stoma site infections, fever, episodes of emesis, and total antibiotic courses. The median duration in situ of feeding tubes with prn changes was 104 days. For both periods, feeding tubes were significantly more likely to fall out and require replacement with-in 24 hours of previous tube replacement.

CONCLUSION

There were no observed differences in clinical outcomes in long-term-care facility patients when feeding tubes were changed only as necessary as compared to routine monthly changes.

The identification and treatment of motor/learning difficulties: parents' perceptions and the role of the therapist

The diagnostic experience of 31 children, assessed as having motor/learning difficulties, attending an occupational therapy department within a children's hospital, was investigated. The study demonstrates the difficulty of specific identification of perceptuomotor problems. Close examination of the children's individual diagnostic pathways revealed a high number of health-care professional contacts and the fact that frequently there were lengthy gaps between parental (and sometimes professional) suspicions and final confirmation. The children's diagnostic experiences prior to starting treatment were varied and involved, and no one single route was predominant. The rationale for occupational-therapy assessment and treatment of this disorder is described, and parental perceptions of its effect are discussed. The findings suggest that an important part of therapeutic intervention may be increasing children's self-confidence and reducing intra and extra family tensions. Fewer behavioural problems were reported once treatment had commenced. It was concluded that an important part of the therapist's role was to provide information and support for parents and to liaise with school teachers, in addition to treating the children themselves.

Motor/learning difficulties and the family

The work reported here, which has as its central concern family dynamics and relationships, is part of a wider study of 31 children with motor/learning difficulties. All the children were attending an Occupational Therapy Department and had been assessed as having motor/learning difficulties. Descriptions of family background, structure and composition are provided and findings on conjugal, parent/child, sibling and extended family relationships presented. Characteristic patterns of family interaction are identified and factors affecting family cohesion discussed.

Vegetarian diet and cobalamin deficiency: their association with tuberculosis

To determine whether the high incidence of tuberculosis among Asiatic Indians in the United Kingdom was due to impaired killing of Mycobacterium tuberculosis by macrophages from patients deficient in cobalamin, a nutritional survey was carried out among 1187 Indians and the incidence of tuberculosis determined from medical records. The question asked was whether tuberculosis was significantly more common among life-long vegetarians compared with omnivores. The incidence of tuberculosis in vegetarians was 133 in 1000 and that in subjects on mixed diets 48 in 1000. These findings lend support to the hypothesis that dietary factors are of major importance in determining the susceptibility of Asiatic Indians to tuberculosis.

Education and care of the diabetic patient on CAPD

Because continuous ambulatory peritoneal dialysis (CAPD) is becom ing widely used nurses should be aware of the indications and contrain dications for this mode of therapy. Ed ucation of these patients is extensive and involves not only the patient and family, but staff nurses, dietitians, house staff, and the diabetes nurse specialist. A case study demonstrates some of the problems.

Bile acids. LXVII. The major bile acids of Varanus monitor

The major bile acids of gall bladder bile of Varanus monitor have been separated by thin-layer chromatography and shown to be derivatives of taurine. After alkaline hydrolysis, the free acids were separated by thin-layer and partition chromatography. Identification or characterization of the free acids was facilitated by gas-liquid chromatography and gas-liquid chromatography-mass spectometry of the methyl esters or methyl ester-trimethylsilyl ethers. About 13% of the total bile acids was represented by the C24 acids cholic, deoxycholic, allocholic, chenodeoxycholic, and 12-oxo-3 alpha-hydroxy-5 beta-cholanic acids, of which cholic acid constituted about 50%. The remainder of the bile acids consisted of eight C27 acids of which varanic acid was the major constituent; an isomer of varanic acid and 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-cholestanoic acid were also identified. By chromatographic behavior and mass spectral fragmentation, the structures of four C27 acids with unsaturated side chains were elucidated as follows: 3 alpha, 7 alpha-dihydroxy-5 beta-cholest-23-enoic, 3 alpha, 7 alpha-dihydroxy-5 beta-cholest-24-enoic, 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-cholest-23-enoic, and 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-cholest-24-enoic acids. Similarly, the structure of the 12-deoxy analog of varanic acid, 3 alpha, 7 alpha, 24 xi-trihydroxy-5 beta-cholestanoic acid, was suggested for the component that constituted 7% of the total.

Further Observations on Experimental Bone Formation with Special Reference to the Bone-Forming Properties of the Epithelial Lining of the Trigone in the Dog

Images

RENAL SYMPATHECTOMY

Images

A CASE OF VOLVULUS OF THE STOMACH

Images