Is all hypoglycaemia treated as equal? An observational study of how the type of diabetes and treatment prescribed prior to admission influences quality of treatment of inpatient hypoglycaemia

Aims: Inpatient hypoglycaemia is common and associated with adverse outcomes. There is often increased vigilance of hypoglycaemia in inpatients with type 1 diabetes (T1DM) compared to type 2 diabetes (T2DM). We aimed to investigate this apparent discrepancy, utilising the time to repeat (TTR) capillary blood glucose (CBG) measurement as a surrogate for engagement with guidelines stating that CBG should be rechecked following intervention within 15 min of an initial CBG of <4 mmol/L. Methods: This is an observational study of inpatient CBG data from 8 hospitals over a 7-year period. A national diabetes registry allowed identification of individual’s diagnosis and diabetes therapy. For each initial (index) CBG, the TTR for individuals with T2DM—on insulin or sulphonylurea—was compared with the TTR for individuals with T1DM, using a t test for significance performed on log(TTR). The median TTR was plotted for each group per index CBG. Results: In total, 1480,335 CBG measurements were obtained. A total of 26,664 were <4 mmol/L. The TTR in T2DM individuals on sulphonylurea was significantly greater than in T1DM individuals where index CBG was ≥2.3 mmol/L (except index CBG 2.6 mmol/L). For T2DM patients receiving insulin significance exists for index CBGs of ≥3.2 mmol/L. Conclusions: This analysis suggests that quality of care of hypoglycaemia varies according to diagnosis and medication. The group with the highest TTR (T2DM sulphonylurea treated) are possibly the clinical group in whom hypoglycaemia is most concerning. These data therefore suggest a need for education and raising awareness within the inpatient nursing staff

Civic Melancholy, Brackish Songs

Civic Melancholy, Brackish Songs is an inter-regional and inter-disciplinary project, which was funded by a $15,000 grant through the NSW Art Central Regional Creative Industry Program, between fine-art photographer Jamie Holcombe and contemporary composer Chris Sainsbury. Sainsbury wrote a musical composition based on Holcombe's Civic Melancholy photographic project, and Holcombe responded with photographic images inspired by Sainsbury's Brackish Songs song cycle (a series of songs based on a theme). The project culminated in a combined performance and exhibition celebrating a dialogue of cultures between non-traditional collaborators.Jamie and Chris came together through a common interest in mediating the experience of place through their respective creative disciplines. In relation to regional arts practice, and through this project, together they challenge the rhetoric of the parochial, which is so often aimed at the people of regional Australia, and challenge tired 'local colourists' (those who advocate and express romantic notions of regional life, usually and ironically from our cities). They replace it with a creative dialogue between their respective inland and coastal regions.Photo/music project - 2 artists responding to each other's wor

Inpatient glycemic variability and long-term mortality in hospitalized patients with type 2 diabetes

Aims/Hypothesis: To determine the association between inpatient glycemic variability and long-term mortality in patients with type 2 diabetes mellitus. Methods: Capillary blood glucose (CBG) of inpatients from 8 hospitals was analysed. 28,353 admissions identified were matched for age, duration of diabetes and admission and median and interquartile range of CBG. 6 year mortality was investigated for (i) those with CBG IQR in the top half of all IQR measurements (matched for all except IQR), vs those in the lower half and (ii) those with the lowest quartile median glucose (matched for all except median). Results: 1. Glycemic variability 3165 matched pairs were analysed. Mortality was greater in those with IQR in upper 50% (≥ 50.9 mg/dl) over follow-up from day 90 post-discharge to a maximum of 6 years (p<0.01, HR 1.17). 2. Median glucose 2.3755 matched pairs were analysed. Mortality was lower in those with a median glucose in upper 50% (≥ 148.5 mg/dl) over follow-up from day 90 post-discharge to a maximum of 6 years (p < 0.01, HR 0.87). Conclusion: Higher inpatient glycemic variability is associated with increased mortality on long-term follow up. When matched by IQR, we have demonstrated higher median CBG is associated with lower long-term mortality. CBG variability may increase cardiovascular morbidity by increasing exposure to hypoglycaemia or to variability per se. In hospitalized patients with diabetes, glycemic variability should be minimised and when greater CBG variability is unavoidable, a less stringent CBG target considered

Patterns and impact of hypoglycemia, hyperglycemia, and glucose variability on inpatients with insulin-treated cystic fibrosis-related diabetes

Introduction: Mortality in patients with cystic fibrosis-related diabetes (CFRD) is higher than that in patients with cystic fibrosis without diabetes. Hypoglycemia, hyperglycemia, and glucose variability confer excess mortality and morbidity in the general inpatient population with diabetes. Methods: We investigated patterns of hypoglycemia and the association of hypoglycemia, hyperglycemia, and glucose variability with mortality and readmission rate in inpatients with CFRD. All capillary blood glucose (CBG) readings (measured using the Abbott Precision web system) of patients with insulin-treated CFRD measured within our health board between January 2009 and January 2015 were. Frequency and timing of hypoglycemia (<4 mmol/L) and was recorded. The effect of dysglycemia on readmission and mortality was investigated with survival analysis. Results: Sixty-six patients were included. A total of 22,711 CBG results were included in the initial analysis. Hypoglycemia was common with 1433 episodes (6.3%). Hypoglycemia ascertainment was highest between 2400 and 0600 h. Hypoglycemia was associated with a significantly higher rate of readmission or death over the 3.5-year follow-up period (P = 0.03). There was no significant association between hyperglycemia or glucose variability and the rate of readmission and mortality. Conclusion: Among inpatients with CFRD hypoglycemia is common and is associated with an increased composite endpoint of readmission and death. As with previously reported trends in general inpatient population this group shows a peak incidence of hypoglycemic during the night

Predicting clinical events based on raw text : from bag-of-words to attention-based transformers

Identifying which patients are at higher risks of dying or being re-admitted often happens to be resource- and life- saving, thus is a very important and challenging task for healthcare text analytics. While many successful approaches exist to predict such clinical events based on categorical and numerical variables, a large amount of health records exists in the format of raw text such as clinical notes or discharge summaries. However, the text-analytics models applied to free-form natural language found in those notes are lagging behind the break-throughs happening in the other domains and remain to be primarily based on older bag-of-words technologies. As a result, they rarely reach the accuracy level acceptable for the clinicians. In spite of their success in other domains, the superiority of deep neural approaches over classical bags of words for this task has not yet been convincingly demonstrated. Also, while some successful experiments have been reported, the most recent break-throughs due to the pre-trained language models have not yet made their ways into the medical domain. Using a publicly available healthcare dataset, we have explored several classification models to predict patients' re-admission or a fatality based on their discharge summaries and established that 1) The performance of the neural models used in our experiments convincingly exceeds those based on bag-of-words by several percentage points as measured by the standard metrics. 2) This allows us to achieve the accuracy typically acceptable by the clinicians as of practical use (area under the ROC curve above 0.70) for the majority of our prediction targets. 3) While the pre-trained attention-based transformer performed only on par with the model that averages word embeddings when applied to full length discharge summaries, the transformer still handles shorter text segments substantially better, at times with the margin of 0.04 in the area under the ROC curve. Thus, our findings extend the success of pre-trained language models reported in other domains to the task of clinical event prediction, and likely to other text-classification tasks in the healthcare analytics domain. 4) We suggest several models to overcome the transformers' major drawback (their input size limitation), and confirm that this is crucial to achieve their top performance. Our modifications are domain agnostic, and thus can be applied in other applications where the text inputs exceed 200 words. 5) We have successfully demonstrated how non-text attributes (such as patient age, demographics, type of admission etc.) can be combined with text to gain additional improvements for several prediction targets. We include extensive ablation studies showing the impact of the training size, and highlighting the tradeoffs between the performance and the resources needed

Squirrelpox virus: assessing prevalence, transmission and environmental degradation

Red squirrels (Sciurus vulgaris) declined in Great Britain and Ireland during the last century, due to habitat loss and the introduction of grey squirrels (Sciurus carolinensis), which competitively exclude the red squirrel and act as a reservoir for squirrelpox virus (SQPV). The disease is generally fatal to red squirrels and their ecological replacement by grey squirrels is up to 25 times faster where the virus is present. We aimed to determine: (1) the seropositivity and prevalence of SQPV DNA in the invasive and native species at a regional scale; (2) possible SQPV transmission routes; and, (3) virus degradation rates under differing environmental conditions. Grey (n = 208) and red (n = 40) squirrel blood and tissues were sampled. Enzyme-linked immunosorbent assay (ELISA) and quantitative real-time polymerase chain reaction (qPCR) techniques established seropositivity and viral DNA presence, respectively. Overall 8% of squirrels sampled (both species combined) had evidence of SQPV DNA in their tissues and 22% were in possession of antibodies. SQPV prevalence in sampled red squirrels was 2.5%. Viral loads were typically low in grey squirrels by comparison to red squirrels. There was a trend for a greater number of positive samples in spring and summer than in winter. Possible transmission routes were identified through the presence of viral DNA in faeces (red squirrels only), urine and ectoparasites (both species). Virus degradation analyses suggested that, after 30 days of exposure to six combinations of environments, there were more intact virus particles in scabs kept in warm (25°C) and dry conditions than in cooler (5 and 15°C) or wet conditions. We conclude that SQPV is present at low prevalence in invasive grey squirrel populations with a lower prevalence in native red squirrels. Virus transmission could occur through urine especially during warm dry summer conditions but, more notably, via ectoparasites, which are shared by both species

Body of evidence: forensic use of baseline health assessments to convict wildlife poachers

CONTEXT. Given the immense impact of wildlife trade, disease and repatriations on populations, health assessments can" "provide powerful forensic material to help convict wildlife poachers and minimise risks of releasing unhealthy wildlife." AIMS. We aimed to use reference ranges to assess the health of confiscated tortoises, to illustrate forensic application of these ranges, and to advance analyses for future applications." METHODS. We used analyses of variance (ANOVA) and covariance (ANCOVA), and composite indices, to compare wild and confiscate tortoise body condition, haematocrit and haemoglobin concentration of males and females of three tortoise species. Subsequently, we used multivariate statistics (e.g. discriminant analyses) to evaluate the relative importance of species, sex and group (wild or confiscate) on tortoise condition and haematology." KEY RESULTS. Our initial statistical tests demonstrated, at P < 0.05 to P < 0.0005, that confiscate body condition and haematology were compromised compared with that of wild tortoises. Subsequently, discriminant analyses strongly discriminated between most wild and confiscate groups (P < 0.0001), correctly classified individual health as wild or confiscate 80–90% of the time, indicated that species and sex effects were stronger than was the wild-confiscate category, and provided discriminant functions for use on other taxa and studies." CONCLUSIONS. The health assessments discriminated well between wild and confiscate tortoises. The results had considerable forensic value, being relevant, quickly generated using portable field equipment, reliable, accurate, easy to explain and convey in terms of likelihood in a court of law, synergistically consistent among variables and groups, a strong rebuttal to the poachers’ specific statements, and consistent with other types of evidence. Multivariate analyses were consistent with, and more prudent and powerful than, the original statistical analyses. Discriminant functions can be applied in future studies and on other chelonian species, and should be developed for other wildlife species." IMPLICATIONS. Reference ranges provide considerable value for forensics, diagnostics and treatment. Given the disease risks resulting from the massive scale of wildlife trade and release, reference ranges should be developed for more species."Web of Scienc

Patterns of initial and first-intensifying antidiabetic drug utilization among patients with type 2 diabetes mellitus in Scotland, 2010-2020: A retrospective population-based cohort study : a retrospective population-based cohort study

To evaluate the utilization and prescribing patterns of antidiabetic drugs (ADDs) for patients with type 2 diabetes mellitus (T2DM) at treatment initiation and first intensification. A retrospective cohort study was performed using linked routinely collected data of patients with T2DM who received ADDs between January 2010 and December 2020 in Scotland. The prescribing patterns were quantified using frequency/percentages, absolute/relative change, and trend tests. Overall, 145 909 new ADD users were identified, with approximately 91% (N = 132 382) of patients receiving a single ADD at first treatment initiation. Metformin was the most often prescribed monotherapy (N = 118 737, 89.69%). A total of 50 731 patients (39.40%) who were started on metformin (N = 46 730/118 737, 39.36%) or sulphonylurea (SU; N = 4001/10 029, 39.89%) monotherapy had their treatment intensified with one or more additional ADD. Most initial-metformin (45 963/46 730; 98.36%) and initial-SU users (3894/4001; 97.33%) who added further drugs were intensified with single ADDs. SUs (22 197/45 963; 48.29%) were the most common first-intensifying monotherapy after initial metformin use, but these were replaced by sodium-glucose cotransporter-2 (SGLT2) inhibitors in 2019 (SGLT2 inhibitors: 2039/6065, 33.62% vs. SUs: 1924/6065, 31.72%). Metformin was the most frequently added monotherapy to initial SU use (2924/3894, 75.09%). Although the majority of patients received a single ADD, the use of combination therapy significantly increased over time. Nevertheless, there was a significant increasing trend towards prescribing the newer ADD classes (SGLT2 inhibitors, dipeptidyl peptidase-4 inhibitors) as monotherapy or in combination compared with the older ones (SUs, insulin, thiazolidinediones) at both drug initiation and first intensification. An overall increasing trend in prescribing the newer ADD classes compared to older ADDs was observed. However, metformin remained the most commonly prescribed first-line ADD, while SGLT2 inhibitors replaced SUs as the most common add-on therapy to initial metformin use in 2019. [Abstract copyright: © 2024 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.

The optimal second-line therapy for older adults with type 2 diabetes mellitus: protocol for a systematic review and network meta-analysis using individual participant data (IPD)

Background: Due to increasing life expectancy, almost half of people with type 2 diabetes are aged 65 years or over worldwide. When metformin alone does not control blood sugar, the choice of which second-line therapy to prescribe next is not clear from currently available evidence. The existence of frailty and comorbidities in older adults further increases the complexity of medical decision-making. As only a relatively small proportion of trials report results separately for older adults, the relative efficacy and safety of second-line therapies in older adults with type 2 diabetes mellitus are unknown and require further investigation. This individual participant data (IPD) network meta-analysis evaluates the relative efficacy and safety of second-line therapies on their own or in combination in older adults with type 2 diabetes mellitus. Methods: All relevant published and unpublished trials will be identified. Studies published prior to 2015 will be identified from two previous comprehensive aggregate data network meta-analyses. Searches will be conducted in CENTRAL, MEDLINE, and EMBASE from 1st January 2015 onwards, and in clinicaltrials.gov from inception. Randomised controlled trials with at least 100 estimated older adults (≥ 65 years) receiving at least 24 weeks of intervention that assess the effects of glucose-lowering drugs on mortality, glycemia, vascular and other comorbidities outcomes, and quality of life will be eligible. The screening and data extraction process will be conducted independently by two researchers. The quality of studies will be assessed using the Cochrane risk of bias tool 2. Anonymised IPD of all eligible trials will be requested via clinical trial portals or by contacting the principal investigators or sponsors. Received data will be reanalysed where necessary to standardise outcome metrics. Network meta-analyses will be performed to determine the relative effectiveness of therapies. Discussion: With the increasing number of older adults with type 2 diabetes worldwide, an IPD network meta-analysis using data from all eligible trials will provide new insights into the optimal choices of second-line antidiabetic drugs to improve patient management and reduce unnecessary adverse events and the subsequent risk of comorbidities in older adults. Systematic review registration: PROSPERO CRD42021272686

A novel causal mechanism for grey squirrel bark stripping: The Calcium Hypothesis

AbstractGrey squirrels, Sciurus carolinensis, damage trees in the UK by stripping bark and eating the underlying phloem; squirrel motivation for damage is, however, unknown. Damage can result in deterioration of timber quality and a significant economic toll on the forestry industry. Prediction of severe damage followed by targeted killing of squirrels is the current recommended management option. However, the use of warfarin (an anticoagulant poison) is now restricted in the UK and other more humane methods of killing are labour-intensive, so an alternative solution is needed. A better understanding of what motivates grey squirrels to strip bark may enable a preventive approach to be developed. Whilst the bark stripping literature has explored predictive factors affecting the likelihood of damage, causal understanding is lacking. The aim of this review is to introduce the Calcium Hypothesis as a possible explanation for bark stripping, with a view to informing the prevention of damage. The Calcium Hypothesis states that grey squirrels damage trees to ameliorate a calcium deficiency. The main predictive factors of bark stripping behaviour each inform and lend support to the Calcium Hypothesis. Calcium is stored in tree phloem, and damage increases with phloem width, providing squirrels with more calcium per unit area ingested. Calcium levels increase in trees as active growth resumes after winter dormancy, this occurs immediately prior to the main bark stripping season of May–July, and trees growing most vigorously are at increased risk of damage. It is likely grey squirrels also have a requirement for calcium during the bark stripping season. Adult females will be under post-parturition pressures such as lactation, and juveniles will be going through their main period of bone growth, both of which likely represent a requirement for calcium – which supports an observed positive correlation between juvenile abundance and bark stripping. A high autumnal seed crop increases juvenile recruitment the following spring, and could also induce a requirement for calcium to a population due to the high phosphorus to calcium ratio of seeds. To further investigate the hypothesis, the extent to which grey squirrels can utilise calcium oxalate, as calcium occurs in bark, should be determined, and also the extent to which grey squirrels undergo seasonal periods of calcium deficiency. Increasing our causal understanding of bark stripping could inform the future development of preventive measures to aid forest management