Behavioral outcomes of online interprofessional education for graduate physical therapy and nurse practitioner students

Authors assessed changes in behavioral outcomes and observed student reflections regarding interprofessional collaboration (IPC) for current, practicing nurses enrolled in a nurse practitioner program and doctor of physical therapy students (DPT) post- interprofessional education (IPE) training

The effect of hypoglycaemia during hospital admission on health-related outcomes for people with diabetes: a systematic review and meta-analysis

Aims: To assess the health-related outcomes of hypoglycaemia for people with diabetes admitted to hospital; specifically, hospital length of stay and mortality.Methods: We conducted a systematic review and meta-analysis of studies relating to inpatient hypoglycaemia (<4 mmol/L) for hospitalised adults (≥16 years) with diabetes reporting the primary outcomes of interest, hospital length of stay or mortality. Final papers for inclusion were reviewed in duplicate and the adjusted results of each were pooled, using a random effects model then undergoing further prespecified subgroup analysis.Results: 15 studies were included in the meta-analysis. The pooled mean difference in length of stay for ward-based inpatients exposed to hypoglycaemia was 4.1 days longer (95% confidence interval [CI], 2.36-5.79; IÇ = 99%) compared to inpatients without hypoglycaemia. This association remained robust across the pre-specified subgroup analyses. The pooled relative risk (RR) of in-hospital mortality was greater for inpatients exposed to hypoglycaemia 2.09 (95% CI, 1.64 to 2.67; IÇ = 94%, n=7 studies) but not in intensive care unit mortality RR 0.75 (0.49 to 1.16; IÇ =0%, n=2 studies).Conclusion: There is an association between inpatient hypoglycaemia and longer length of stay and greater in-hospital mortality. Studies examining this association were heterogenous in terms of both clinical populations and effect size, but the overall direction of the association was consistent. Therefore, glucose concentration should be considered a potential tool to aid the identification of patients at risk of poor health-related outcomes

Effects of Endolithic Parasitism on Invasive and Indigenous Mussels in a Variable Physical Environment

Biotic stress may operate in concert with physical environmental conditions to limit or facilitate invasion processes while altering competitive interactions between invaders and native species. Here, we examine how endolithic parasitism of an invasive and an indigenous mussel species acts in synergy with abiotic conditions of the habitat. Our results show that the invasive Mytilus galloprovincialis is more infested than the native Perna perna and this difference is probably due to the greater thickness of the protective outer-layer of the shell of the indigenous species. Higher abrasion due to waves on the open coast could account for dissimilarities in degree of infestation between bays and the more wave-exposed open coast. Also micro-scale variations of light affected the level of endolithic parasitism, which was more intense at non-shaded sites. The higher levels of endolithic parasitism in Mytilus mirrored greater mortality rates attributed to parasitism in this species. Condition index, attachment strength and shell strength of both species were negatively affected by the parasites suggesting an energy trade-off between the need to repair the damaged shell and the other physiological parameters. We suggest that, because it has a lower attachment strength and a thinner shell, the invasiveness of M. galloprovincialis will be limited at sun and wave exposed locations where endolithic activity, shell scouring and risk of dislodgement are high. These results underline the crucial role of physical environment in regulating biotic stress, and how these physical-biological interactions may explain site-to-site variability of competitive balances between invasive and indigenous species

Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial.

BACKGROUND: Pregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes. METHODS: In this multicentre, open-label, randomised controlled trial, we recruited women aged 18-40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA1c). The primary outcome was change in HbA1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527. FINDINGS: Between March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA1c in pregnant women using CGM (mean difference -0·19%; 95% CI -0·34 to -0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most common adverse events were skin reactions occurring in 49 (48%) of 103 CGM participants and eight (8%) of 104 control participants during pregnancy and in 23 (44%) of 52 CGM participants and five (9%) of 57 control participants in the planning pregnancy trial. The most common serious adverse events were gastrointestinal (nausea and vomiting in four participants during pregnancy and three participants planning pregnancy). INTERPRETATION: Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use. FUNDING: Juvenile Diabetes Research Foundation, Canadian Clinical Trials Network, and National Institute for Health Research

Risk factors for recurrent admissions with diabetic ketoacidosis : importance of mental health

Letter to the editor

Successful use of acarbose to manage post-prandial glycaemia in two patients with type 1 diabetes on continuous subcutaneous insulin infusion

Post-prandial hyperglycaemia is a particular problem for some patients with diabetes despite administering continuous subcutaneous insulin infusion (CSII) to deliver insulin flexibly. We describe two cases of patients on CSII with persistent post-prandial hyperglycaemia despite varying insulin doses and timing. Treatment with acarbose improved their glycaemic control

Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events

Aims: To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes. Methods: Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods. Results: Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)]. Conclusions: The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach

Implementation of fully closed-loop insulin delivery for inpatients with diabetes: Real-world outcomes.

Funder: Addenbrooke's Charitable TrustAIMS: Fully closed-loop insulin delivery has been shown in clinical trials to be safe and improve glucose control compared with standard insulin therapy in the inpatient setting. We investigated the feasibility of implementing the approved CamAPS HX fully closed-loop system in a hospital setting. METHODS: This implementation project was conducted in a large teaching hospital in Cambridge, UK. Healthcare professional training was multimodal including face-to-face workshops, online learning modules and supported by standard operating procedures. Set-up and maintenance of closed-loop devices were undertaken by the inpatient diabetes team. Selection of suitable patients was multidisciplinary and prioritised those with more challenging diabetes management. Demographic and clinical data were collected from electronic health records and diabetes data management platforms. RESULTS: In the 12 months since the closed-loop system was implemented, 32 inpatients (mean ± SD age 61 ± 16 years, 8 females, 24 males) used closed-loop insulin delivery during their admission, across medical and surgical wards in the hospital with a total of 555 days of closed-loop glucose control (median [IQR]: 14 [6, 22] days per inpatient). The time spent in target glucose range 3.9-10.0 mmol/L was 53.3 ± 18.3%. Mean glucose was 10.7 ± 1.9 mmol/L with 46.0 ± 18.2% of time spent with glucose >10.0 mmol/L. Time spent with sensor glucose below 3.9 mmol/L was low (median [IQR]: 0.38 [0.00, 0.85]). There were no episodes of severe hypoglycaemia or diabetic ketoacidosis during closed-loop use. CONCLUSIONS: We have demonstrated that the fully closed-loop system can be safely and effectively implemented by a diabetes outreach team in complex medical and surgical inpatients with challenging glycaemic control