Digitally enabled flash glucose monitoring for inpatients with COVID-19: Feasibility and pilot implementation in a teaching NHS Hospital in the UK

BACKGROUND

COVID-19 placed significant challenges on healthcare systems. People with diabetes are at high risk of severe COVID-19 with poor outcomes. We describe the first reported use of inpatient digital flash glucose monitoring devices in a UK NHS hospital to support management of people with diabetes hospitalized for COVID-19.

METHODS

Inpatients at University Hospitals Coventry & Warwickshire (UHCW) NHS Trust with COVID-19 and diabetes were considered for digitally enabled flash glucose monitoring during their hospitalization. Glucose monitoring data were analysed, and potential associations were explored between relevant parameters, including time in hypoglycaemia, hyperglycaemia, and in range, glycated haemoglobin (HbA1c), average glucose, body mass index (BMI), and length of stay.

RESULTS

During this pilot, digital flash glucose monitoring devices were offered to 25 inpatients, of whom 20 (type 2/type 1: 19/1; mean age: 70.6 years; mean HbA1c: 68.2 mmol/mol; mean BMI: 28.2 kg/m2) accepted and used these (80% uptake). In total, over 2788 h of flash glucose monitoring were recorded for these inpatients with COVID-19 and diabetes. Length of stay was not associated with any of the studied variables (all p-values >0.05). Percentage of time in hyperglycaemia exhibited significant associations with both percentage of time in hypoglycaemia and percentage of time in range, as well as with HbA1c (all p-values <0.05). The average glucose was significantly associated with percentage of time in hypoglycaemia, percentage of time in range, and HbA1c (all p-values <0.05).

DISCUSSION

We report the first pilot inpatient use of digital flash glucose monitors in an NHS hospital to support care of inpatients with diabetes and COVID-19. Overall, there are strong arguments for the inpatient use of these devices in the COVID-19 setting, and the findings of this pilot demonstrate feasibility of this digitally enabled approach and support wider use for inpatients with diabetes and COVID-19.

Impact of the COVID-19 pandemic on neuroendocrine tumour services in England

PURPOSE

During the COVID-19 pandemic, there have been particular concerns regarding the related impact on specialist tumour services. Neuroendocrine tumour (NET) services are delivered in a highly specialised setting, typically delivered in a small number of centres that fulfil specific criteria as defined by the European Neuroendocrine Tumour Society (ENETS). We aimed to address the COVID-19-related impact on specialist NET tumour services in England and other countries.

METHODS

Electronic survey addressing patient access and delivery of care distributed to all ENETS Centres of Excellence (CoE) in England and matching number of ENETS CoE elsewhere. Semi-quantitative and qualitative analyses of survey responses were performed.

RESULTS

Survey response of ENETS CoE in England was 55% (6/11). Responses from six non-UK ENETS CoE elsewhere were received and analysed in a similar manner. Relevant disruption of various NET services was noted across all responding Centres, which included delayed patient appointments and investigations, reduced availability of treatment modalities including delayed surgical treatment and a major negative impact on research activities. The comparison between English and non-UK ENETS CoE suggested that the former had significantly greater concerns related to future research funding (p = 0.014), whilst having less disruption to multidisciplinary meetings (p = 0.01). A trend was also noted towards virtual patient appointments in ENETS CoE in England vs. elsewhere (p = 0.092).

CONCLUSIONS

Restoration of highly specialised NET services following COVID-19 and planning for future service delivery and research funding must take account of the severe challenges encountered during the pandemic.

Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems

Objective

The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions.

Design

Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance—anticipating, monitoring, responding and learning.

Setting

Accident and Emergency Department (ED) and the Older People’s Unit (OPU) of a large teaching hospital in central London.

Participants

ED—observations 104 h, and 14 staff interviews. OPU—observations 60 h, and 15 staff interviews.

Results

Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment.

Conclusions

The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

Use of propranolol for treatment of hemangiomas in PHACE syndrome

We report the case of a 29-week preterm infant with PHACE (posterior fossa malformations, hemangionas, arterial anomalies, cardiac anomalies, eye anomalies) syndrome. PHACE syndrome is a neurocutaneous disorder with large facial segmental hemangionas associated with anomalies of the brain, eye, heart and aorta. The hemangiomas in our patient were problematic, distorting the airway and interfering with respirations to the point of requiring mechanical ventilation. Consultation with several different centers with medical expertize in treatment of congenital hemangiomas revealed different views on the best management strategy. In this infant, the hemangiomas progressed with failure to involute despite currently recommended therapy including corticosteroids and vincristine. Therefore, the infant was treated with propranolol and had significant regression of the hemangiomas. The use of propranolol for the treatment of infantile hemangiomas is reviewed.

The older persons' assessment and liaison team 'OPAL': evaluation of comprehensive geriatric assessment in acute medical inpatients

BACKGROUND

Reducing hospital length of stay (LOS) in older acute medical inpatients is a key productivity measure. Evidence-based predictors of greater LOS may be targeted through Comprehensive Geriatric Assessment (CGA).

OBJECTIVE

Evaluate a novel service model for CGA screening of older acute medical inpatients linked to geriatric intervention.

SETTING

Urban teaching hospital.

SUBJECTS

Acute medical inpatients aged 70+ years.

INTERVENTION

Multidisciplinary CGA screening of all acute medical admissions aged 70+ years leading to (a) rapid transfer to geriatric wards or (b) case-management on general medical wards by Older Persons Assessment and Liaison team (OPAL).

METHODS

Prospective pre-post comparison with statistical adjustment for baseline factors, and use of national benchmarking LOS data. Pre-OPAL (n = 46) and post-OPAL (n = 49) cohorts were similarly identified as high-risk by the CGA screening tool, but only post-OPAL patients received the intervention.

RESULTS

Pre-OPAL, 0% fallers versus 92% post-OPAL were specifically assessed and/or referred to a falls service post-discharge. Management of delirium, chronic pain, constipation, and urinary incontinence similarly improved. Over twice as many patients were transferred to geriatric wards, with mean days from admission to transfer falling from 10 to 3. Mean LOS fell by 4 days post-OPAL. Only the OPAL intervention was associated with LOS (P = 0.023) in multiple linear regression including case-mix variables (e.g. age, function, 'geriatric giants'). Benchmarking data showed the LOS reduction to be greater than comparable hospitals.

CONCLUSION

CGA screening of acute medical inpatients leading to early geriatric intervention (ward-based case management, appropriate transfer to geriatric wards), improved clinical effectiveness and general hospital performance.

Dynamic production of hypoxia-inducible factor-1alpha in early transplanted islets

More than half of transplanted beta-cells undergo apoptotic cell death triggered by nonimmunological factors within a few days after transplantation. To investigate the dynamic hypoxic responses in early transplanted islets, syngeneic islets were transplanted under the kidney capsule of balb/c mice. Hypoxia-inducible factor-1alpha (HIF-1alpha) was strongly expressed at post-transplant day (POD) 1, increased on POD 3, and gradually diminished on POD 14. Insulin secretion decreased on POD 3 in association with a significant increase of HIF-1alpha-related beta-cell death, which can be suppressed by short-term hyperbaric oxygen therapy. On POD 7, apoptosis was not further activated by continually produced HIF-1alpha. In contrast, improvement of nerve growth factor and duodenal homeobox factor-1 (PDx-1) production resulted in islet graft recovery and remodeling. In addition, significant activation of vascular endothelial growth factor in islet grafts on POD 7 correlated with development of massive newly formed microvessels, whose maturation is advanced on POD 14 with gradual diminution of HIF-1alpha. We conclude that (1) transplanted islets strongly express HIF-1alpha in association with beta-cell death and decreased insulin production until adequate revascularization is established and (2) early suppression of HIF-1alpha results in less beta-cell death thereby minimizing early graft failure.

Beneficial effects of nerve growth factor on islet transplantation

OBJECTIVE

Development of the Edmonton protocol was a pivotal contribution to clinical islet transplantation (ITx). Persistent limitations to ITx include insufficient supply and posttransplant functional failure of islets. In this study, nerve growth factor (NGF) was used to enhance both cultured and transplanted beta-cell function, thus achieving prolonged graft survival.

METHODS

Fluorescence microscopy with ethidium bromide and SYTO green staining was used to evaluate balb/c mouse islet viability. Islets were syngeneically transplanted under the kidney capsule of recipients with streptozotocin-induced diabetes. Intraperitoneal glucose tolerance was used to test posttransplant function.

RESULTS

Improved viability was found in murine islets cultured for 48 hours in 500 ng/mL NGF (P < .05). A submarginal islet mass (260 islet equivalents/recipient) was used for ITx. The NGF-culture resulted in prolonged islet survival (24.7 days vs 5.5 days without NFG culture, n = 6). Intravenous injection of NGF (6 mug) on the day of transplant and postoperative days (POD) 1 + 2 prolonged islet survival from 4.1 days (no treatment) to 13.2 days (n = 6). Glucose tolerance testing performed at posttransplant day 4 showed improvement at 60 and 120 minutes in recipients treated intravenously with NGF (blood glucose of 95 +/- 15 vs 210 +/- 78 and 57 +/- 6 vs 176 +/- 70 mg/dL, respectively).

CONCLUSION

NGF may improve beta-cell function and result in prolonged survival of both cultured and transplanted islets.

Memory Impairments in Adults with Neurogenic Communication Disorders

Over the past few decades, there has been increasing interest in the nonlinguistic, cognitive abilities of adults with neurogenic communication disorders. In particular, a growing literature has documented deficits in a number of memory functions in this population. The purpose of this article is to summarize that literature and provide an overview of the presence and nature of memory impairments in aphasia, right hemisphere disorders, traumatic brain injury, and dementia. Ways that memory impairments may interact with the communication abilities of individuals with neurogenic communication disorders also are discussed.

Do hospital fall prevention programs work? A systematic review

OBJECTIVES

To analyze published hospital fall prevention programs to determine whether there is any effect on fall rates. To review the methodological quality of those programs and the range of interventions used. To provide directions for further research.

DESIGN

Systematic review of published hospital fall prevention programs. Meta-analysis.

METHODS

Keyword searches of Medline, CINAHL, monographs, and secondary references. All papers were included that described fall rates before and during intervention. Risk ratios and 95% Confidence Intervals (95% CI) were estimated and random effects meta-analysis employed. Begg's test was applied to detect possible publication bias. Separate meta-analysis regressions were performed to determine whether individual components of multifaceted interventions were effective.

RESULTS

A total of 21 papers met the criteria (18 from North America), although only 10 contained sufficient data to allow calculation of confidence intervals. A rate ratio of <1 indicates a reduction in the fall rate, resulting from an intervention. Three were randomized controlled trials (pooled rate ratio 1.0 (CI 0.60, 1.68)), seven prospective studies with historical control (0.76 (CI 0.65, 0.88)). Pooled effect rate ratio from these 10 studies was 0.79 (CI 0.69, 0.89). The remaining 11 studies were prospective studies with historical control describing fall rates only. Individual components of interventions showed no significant benefit.

DISCUSSION

The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased by studies that used historical controls not allowing for historical trends in the fall rate before and during the intervention. The randomized controlled trials apparent lack of effect might be due to a change in practice when patients and controls were in the same unit at the same time during a study. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions.

Potent inhibitory activities of hydrophobic aci-reductones (2-hydroxytetronic acid analogs) against membrane and human low-density lipoprotein oxidation

The effects of selected aci-reductones, which are hydrophobic ascorbate-related analogs including 4-chlorophenyl-2-hydroxytetronic acid (Cpd A), 4-(1,1'-biphenyl)-2-hydroxytetronic acid (Cpd B), and 4-(4'-chloro-1,1'-biphenyl)-2-hydroxytetronic acid (Cpd C), on membrane and low density lipoprotein (LDL) oxidation were assessed. Hepatic microsomal lipid peroxidation was induced by the ascorbate + Fe(II) chemical system. All three agents inhibited membrane lipid peroxidation in a concentration-dependent manner with the order of potency: Trolox (vitamin E) < or = Cpd A << Cpd B < Cpd C; based on the EC50 values, Cpd B and Cpd C were 11- and 19-fold, respectively, more potent than Trolox. In contrast to ascorbic acid, all three agents did not display any membrane prooxidative effect in the presence of iron. When human LDL was incubated with 10 microM of Cu(II), LDL oxidation, determined by the formation of thiobarbituric acid reactive substances, followed a typical sigmoidal curve with an initial lag phase. Preincubation of the LDL samples with low micromolar concentrations (1 and 3 microM) of each agents for 30 min before the addition of copper resulted in significant delays of the lag time of LDL oxidation, and the effectiveness of Cpd B and Cpd C was more prominent than that mediated by either Trolox or probucol. Since clinical evidence strongly supports the hypothesis that atherogenesis is initiated by LDL oxidation, the results suggest that these aryl tetronic acid analogs may serve as promising candidates for future therapeutic use as anti-atherogenic agents.

Clinical decision making, risk and occupational therapy

Little is known about the processes involved in risk taking, and complex decision making of the type encountered on acute medical wards in general hospitals. The purpose of the present study was to examine certain of these processes in the context of decisions to discharge elderly inpatients from hospital. Vignettes of hypothetical frail and disabled elderly in-patients were presented to student and qualified occupational therapists (OTs). All the vignettes represented high risk discharges and each of the patients expressed the desire to return to their own home. The additional diagnosis of early dementia was manipulated within and between vignettes. Subjects were asked to decide on the appropriateness of discharging each patient to (a) home and (b) a residential or nursing home. In addition, subjects completed a short demographic questionnaire which also probed aspects of their knowledge about elderly people. Results indicated that qualified OTs were less likely to overrule patients' wishes by favouring discharge of patients to residential or nursing home, and more likely to favour discharge to patients' own homes than student OTs. There was no overall main effect of dementia on subjects' decisions. In addition to clinical experience, certain areas of knowledge about elderly people were significantly associated with different approaches to risk taking in response to the vignettes. Undergraduate syllabi may need to be modified to incorporate more information about elderly people, the prevalence of different diseases, and direct experience of clinical decision making in the context of uncertain and risky situations.

A patient-centric approach to telemedicine database development

Computer and telecommunications technologies have unleashed a wide range of powerful tools for gathering, storing, and distributing patient information. Computerized records enable healthcare providers to rapidly access patient data and to closely monitor patients from a distance. These significant advantages can be further extended by using the technology to more fully involve patients in their own healthcare management. A patient-centric approach to telemedicine means that the patient takes on additional responsibility and control, and the benefits from increased patient involvement will translate into improved compliance, reduced litigation, lower costs, and better outcomes. Furthermore, there are often important ethical questions that are best decided by the informed patient. Patients have a right to know what information is being gathered and who will be authorized to access that information. Current health information systems do not adequately address these issues, and telemedicine applications--particularly home based telemedicine--is forcing everyone to take a closer look at patients' roles in their own healthcare. In this presentation, a patient-centric home telemedicine database is described, the limitations are discussed, and future directions are proposed.

Screening for diabetic retinopathy in primary care: retinal photography alone can be used efficiently and effectively to exclude those with sight threatening lesions

BACKGROUND

Good screening performance of retinal photography and ophthalmoscopy together in screening for diabetic retinopathy in primary care have been reported. This study reanalysed the data to evaluate the screening performance of photography alone.

METHODS

One thousand and ten patients screened by fundal photography and ophthalmoscopy were studied retrospectively. Fundal photographs were quality graded with poor quality pictures being excluded from the analysis. Each patient was reviewed initially by both retinal photographs and ophthalmoscopy by an ophthalmologist, the "gold standard". Six months later the fundal photographs were reviewed and reported in a blinded manner by the ophthalmologist.

RESULTS

Two thousand and fourteen photographs were obtained, of which 162 (8%) had to be excluded because of poor quality. On review of the remaining 1852 photographs in isolation, of 77 cases of severe retinopathy as determined by the "gold standard", 67 had severe changes on photography--detection rate 87%. Of the 1775 cases without sight threatening retinopathy only five were judged to have sight threatening changes on photography--false positive rate 0.3%. Considering sight threatening and background retinopathy together, the detection rate was 69% (257 of 375) and the false positive rate 1.6% (23 of 1477).

CONCLUSION

Good quality fundal photographs alone seem specific enough to screen for sight threatening diabetic retinopathy, but will underdetect background retinopathy.

Adding retinal photography to screening for diabetic retinopathy: a prospective study in primary care

OBJECTIVE

To evaluate whether adding retinal photography improved community screening for diabetic retinopathy.

SETTING

Mobile screening unit at rural and urban general practices in south west England.

SUBJECTS

1010 diabetic patients from primary care.

DESIGN

Prospective study; patients were examined by ophthalmoscopy by general practitioners or opticians without fundal photographs and again with photographs, and assessments were compared to those of an ophthalmologist.

MAIN OUTCOME MEASURES

Whether fundal photography improved the sensitivity of detection of retinopathy and referrable diabetic retinopathy, and whether this sensitivity could be improved by including a review of the films by the specialist.

RESULTS

Diabetic retinopathy was detected by the ophthalmologist in 205 patients (20.5%) and referrable retinopathy in 49 (4.9%). The sensitivity of the general practitioners and opticians for referrable retinopathy with ophthalmoscopy was 65%, and improved to 84% with retinal photographs. General practitioners' sensitivity in detecting background retinopathy improved with photographs from 22% to 65%; opticians' sensitivity in detecting background retinopathy improved from 43% to 71%. The sensitivity of detecting referrable retinopathy by general practitioners improved from 56% to 80% with photographs; for opticians it improved from 75% to 88%.

CONCLUSIONS

Combining modalities of screening by providing photography with specialist review of all films in addition to direct ophthalmoscopy through dilated pupils improves assessment and referral for diabetic retinopathy by general practitioners and opticians. With further training and experience, primary care screeners should be able to achieve a sensitivity that will achieve an effective, acceptable, and economical community based screening programme for this condition.

Quality assurance in outpatient departments

Outpatients departments are prime targets for quality assurance. They are probably the most visible department of a general hospital in terms of patient throughput and, clearly, the service quality standards projected to patients will significantly influence their perceptions of the hospital as a whole. Angela Hopper describes a research project funded by the Institute's Health Services Management Development Trust.

The metrobridge

This paper describes the Metrobridge project - a distributed switch for connecting PC cards via a high-speed ATM-style backbone network. Initially the system architecture is outlined, then certain aspects are examined in more detail. Topics discussed include learning and routing algorithms, access/routing control, management functions, and applications.

Rat fetal development and maternal exposure to trichloroethylene 100 p.p.m

Thirty-two inbred Wistar rats (study group) were exposed to trichloroethylene 100 p.p.m. in air for 4 h daily from day 8 to day 21 of pregnancy. A control group (31 rats) was exposed to the same experimental conditions but without the addition of trichloroethylene. All the rats were sacrificed on the 21st day of pregnancy and the ovaries, uterus, liver, lungs, heart and the fetuses were examined. There was no evidence of teratogenesis, but a delay in fetal maturation was suggested by reduced fetal weight (P less than 0.05) and by an increase in bipartite or absent skeletal ossification centres (P less than 0.005).