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

Closed-loop insulin delivery in inpatients with type 2 diabetes: a randomised, parallel-group trial.

BACKGROUND: We assessed whether fully closed-loop insulin delivery (the so-called artificial pancreas) is safe and effective compared with standard subcutaneous insulin therapy in patients with type 2 diabetes in the general ward. METHODS: For this single-centre, open-label, parallel-group, randomised controlled trial, we enrolled patients aged 18 years or older with type 2 diabetes who were receiving insulin therapy. Patients were recruited from general wards at Addenbrooke's Hospital, Cambridge, UK. Participants were randomly assigned (1:1) by a computer-generated minimisation method to receive closed-loop insulin delivery (using a model-predictive control algorithm to direct subcutaneous delivery of rapid-acting insulin analogue without meal-time insulin boluses) or conventional subcutaneous insulin delivery according to local clinical guidelines. The primary outcome was time spent in the target glucose concentration range of 5·6-10·0 mmol/L during the 72 h study period. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01774565. FINDINGS: Between Feb 20, 2015, and March 24, 2016, we enrolled 40 participants, of whom 20 were randomly assigned to the closed-loop intervention group and 20 to the control group. The proportion of time spent in the target glucose range was 59·8% (SD 18·7) in the closed-loop group and 38·1% (16·7) in the control group (difference 21·8% [95% CI 10·4-33·1]; p=0·0004). No episodes of severe hypoglycaemia or hyperglycaemia with ketonaemia occurred in either group. One adverse event unrelated to study devices occurred during the study (gastrointestinal bleed). INTERPRETATION: Closed-loop insulin delivery without meal-time boluses is effective and safe in insulin-treated adults with type 2 diabetes in the general ward. FUNDING: Diabetes UK; European Foundation for the Study of Diabetes; JDRF; National Institute for Health Research Cambridge Biomedical Research Centre; Wellcome Trust.This study was supported by Diabetes UK (#14/0004878) and the European Foundation for the Study of Diabetes. Additional support for research on the artificial pancreas was received from the Juvenile Diabetes Research Foundation, National Institute for Health Research Cambridge Biomedical Research Centre, and Wellcome Strategic Award (100574/Z/12/Z).This is the final version of the article. It first appeared from Elsevier via https://doi.org/10.1016/S2213-8587(16)30280-

Association between Patient Characteristics and HPV Vaccination Recommendation for Postpartum Patients: A National Survey of Obstetrician/Gynecologists

Human papillomavirus (HPV) vaccination rates in the U.S. are relatively low. Provider recommendation rates for HPV vaccination often vary by patient age and relationship status. Obstetrician/gynecologists (OB/GYNs) represent a key provider group that can recommend the HPV vaccine. This study examined differences in OB/ GYN recommendation of HPV vaccination for inpatient postpartum patients by age, parity, and marital status. Data were collected from OB/GYNs nationally via a cross-sectional survey. Participants were randomized to two vignette groups (23-year-old patient or 33-year-old patient). Within each group, participants received 4 vignettes that were identical except for patient marital status (married/not in a committed relationship) and number of children (first/third child), and were asked to indicate HPV vaccination recommendation likelihood on a scale of 0 (definitely would not) to 100 (definitely would). A 2 × 2 × 2 general linear model with repeated measures was used to examine main and interaction effects of patient age, relationship status, and parity. 207 OB/GYNs were included in the final analyses. Recommendation was high for 23-year-old patients (range: 64.5–84.6 out of 100). When marital status and parity were held constant, recommendation likelihood was higher for the younger vs. older patient and was also higher for patients not in a committed relationship, compared to married patients (all p-values \u3c 0.001). Differences in recommendation exist when considering age and relationship status, which provides insight into OB/GYN clinical decision-making. Findings highlight the need to address barriers to HPV vaccination recommendation, including awareness of risk factors to consider when recommending the vaccine

A likelihood-based approach to mixed modeling with ambiguity in cluster identifiers

This manuscript describes a novel, linear mixed-effects model–fitting technique for the setting in which correlated data indicators are not completely observed. Mixed modeling is a useful analytical tool for characterizing genotype–phenotype associations among multiple potentially informative genetic loci. This approach involves grouping individuals into genetic clusters, where individuals in the same cluster have similar or identical multilocus genotypes. In haplotype-based investigations of unrelated individuals, corresponding cluster assignments are unobservable since the alignment of alleles within chromosomal copies is not generally observed. We derive an expectation conditional maximization approach to estimation in the mixed modeling setting, where cluster assignments are ambiguous. The approach has broad relevance to the analysis of data with missing correlated data identifiers. An example is provided based on data arising from a cohort of human immunodeficiency virus type-1–infected individuals at risk for antiretroviral therapy–associated dyslipidemia

Meeting Report: The Dallas Consensus Conference on Liver Transplantation for Alcohol Associated Hepatitis

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/153137/1/lt25681.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/153137/2/lt25681_am.pd

Digital technologies for bowel management: A scoping review

The use of digital technologies in managing bowel conditions has been a topic of interest among healthcare practitioners. The objectives of this paper were to provide information about the types of digital technologies that have been used for bowel management and the context of the studies; identify the gaps and challenges in digital technologies for bowel management and propose new methods and techniques for the application of digital technologies in bowel management. A scoping review was conducted following the principles of Preferred Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was conducted on six academic databases. 1891 papers were retrieved from the initial search; however, 6 papers were included based on the inclusion and exclusion criteria. The findings suggest that published work focused mainly on a research context and with a narrow focus targeting sub-categories of bowel conditions and not implemented in the context of everyday use. The findings also illustrate the variety of early-stage developments focused on increasing support for severe bowel dysfunction, for example, through biofeedback to aid muscle control training, or the placement of artificial anal sphincters to increase rectal perception. However, technology to support bowel management for broader populations with less severe or variable symptoms appears limited. Future work would be to conduct empirical research in the application of advanced technologies such as on-organ sensors in managing bowel conditions.Output status: forthcomin

Digital technologies for bowel management: A scoping review

The use of digital technologies in managing bowel conditions has been a topic of interest among healthcare practitioners. The objectives of this paper were to provide information about the types of digital technologies that have been used for bowel management and the context of the studies; identify the gaps and challenges in digital technologies for bowel management and propose new methods and techniques for the application of digital technologies in bowel management. A scoping review was conducted following the principles of Preferred Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A search was conducted on six academic databases. 1891 papers were retrieved from the initial search; however, 6 papers were included based on the inclusion and exclusion criteria. The findings suggest that published work focused mainly on a research context and with a narrow focus targeting sub-categories of bowel conditions and not implemented in the context of everyday use. The findings also illustrate the variety of early-stage developments focused on increasing support for severe bowel dysfunction, for example, through biofeedback to aid muscle control training, or the placement of artificial anal sphincters to increase rectal perception. However, technology to support bowel management for broader populations with less severe or variable symptoms appears limited. Future work would be to conduct empirical research in the application of advanced technologies such as on-organ sensors in managing bowel conditions

Born to learn: The inspiration, progress, and future of evolved plastic artificial neural networks

Biological plastic neural networks are systems of extraordinary computational capabilities shaped by evolution, development, and lifetime learning. The interplay of these elements leads to the emergence of adaptive behavior and intelligence. Inspired by such intricate natural phenomena, Evolved Plastic Artificial Neural Networks (EPANNs) use simulated evolution in-silico to breed plastic neural networks with a large variety of dynamics, architectures, and plasticity rules: these artificial systems are composed of inputs, outputs, and plastic components that change in response to experiences in an environment. These systems may autonomously discover novel adaptive algorithms, and lead to hypotheses on the emergence of biological adaptation. EPANNs have seen considerable progress over the last two decades. Current scientific and technological advances in artificial neural networks are now setting the conditions for radically new approaches and results. In particular, the limitations of hand-designed networks could be overcome by more flexible and innovative solutions. This paper brings together a variety of inspiring ideas that define the field of EPANNs. The main methods and results are reviewed. Finally, new opportunities and developments are presented

Fire and biodiversity in the Anthropocene

The workshop leading to this paper was funded by the Centre Tecnològic Forestal de Catalunya and the ARC Centre of Excellence for Environmental Decisions. L.T.K. was supported by a Victorian Postdoctoral Research Fellowship (Victorian Government), a Centenary Fellowship (University of Melbourne), and an Australian Research Council Linkage Project Grant (LP150100765). A.R. was supported by the Xunta de Galicia (Postdoctoral Fellowship ED481B2016/084-0) and the Foundation for Science and Technology under the FirESmart project (PCIF/MOG/0083/2017). A.L.S. was supported by a Marie Skłodowska-Curie Individual Fellowship (746191) under the European Union Horizon 2020 Programme for Research and Innovation. L.R. was supported by the Australian Government’s National Environmental Science Program through the Threatened Species Recovery Hub. L.B. was partially supported by the Spanish Government through the INMODES (CGL2014-59742-C2-2-R) and the ERANET-SUMFORESTS project FutureBioEcon (PCIN-2017-052). This research was supported in part by the U.S. Department of Agriculture, Forest Service, Pacific Southwest Research Station.BACKGROUND Fire has shaped the diversity of life on Earth for millions of years. Variation in fire regimes continues to be a source of biodiversity across the globe, and many plants, animals, and ecosystems depend on particular temporal and spatial patterns of fire. Although people have been using fire to modify environments for millennia, the combined effects of human activities are now changing patterns of fire at a global scale—to the detriment of human society, biodiversity, and ecosystems. These changes pose a global challenge for understanding how to sustain biodiversity in a new era of fire. We synthesize how changes in fire activity are threatening species with extinction across the globe, highlight forward-looking methods for predicting the combined effects of human drivers and fire on biodiversity, and foreshadow emerging actions and strategies that could revolutionize how society manages fire for biodiversity in the Anthropocene. ADVANCES Our synthesis shows that interactions with anthropogenic drivers such as global climate change, land use, and biotic invasions are transforming fire activity and its impacts on biodiversity. More than 4400 terrestrial and freshwater species from a wide range of taxa and habitats face threats associated with modified fire regimes. Many species are threatened by an increase in fire frequency or intensity, but exclusion of fire in ecosystems that need it can also be harmful. The prominent role of human activity in shaping global ecosystems is the hallmark of the Anthropocene and sets the context in which models and actions must be developed. Advances in predictive modeling deliver new opportunities to couple fire and biodiversity data and to link them with forecasts of multiple drivers including drought, invasive plants, and urban growth. Making these connections also provides an opportunity for new actions that could revolutionize how society manages fire. Emerging actions include reintroduction of mammals that reduce fuels, green fire breaks comprising low-flammability plants, strategically letting wildfires burn under the right conditions, managed evolution of populations aided by new genomics tools, and deployment of rapid response teams to protect biodiversity assets. Indigenous fire stewardship and reinstatement of cultural burning in a modern context will enhance biodiversity and human well-being in many regions of the world. At the same time, international efforts to reduce greenhouse gas emissions are crucial to reduce the risk of extreme fire events that contribute to declines in biodiversity. OUTLOOK Conservation of Earth’s biological diversity will be achieved only by recognition of and response to the critical role of fire in shaping ecosystems. Global changes in fire regimes will continue to amplify interactions between anthropogenic drivers and create difficult trade-offs between environmental and social objectives. Scientific input will be crucial for navigating major decisions about novel and changing ecosystems. Strategic collection of data on fire, biodiversity, and socioeconomic variables will be essential for developing models to capture the feedbacks, tipping points, and regime shifts characteristic of the Anthropocene. New partnerships are also needed to meet the challenges ahead. At the local and regional scale, getting more of the “right” type of fire in landscapes that need it requires new alliances and networks to build and apply knowledge. At the national and global scale, biodiversity conservation will benefit from greater integration of fire into national biodiversity strategies and action plans and in the implementation of international agreements and initiatives such as the UN Convention on Biological Diversity. Placing the increasingly important role of people at the forefront of efforts to understand and adapt to changes in fire regimes is central to these endeavors.PostprintPeer reviewe