Assessing the influence of insulin type (ultra-rapid vs rapid insulin) and exercise timing on postprandial exercise-induced hypoglycaemia risk in individuals with type 1 diabetes: a randomised controlled trial.

AIMS/HYPOTHESIS: The relationship between pre-meal insulin type, exercise timing and the risk of postprandial exercise-induced hypoglycaemia in people living with type 1 diabetes is unknown. We aimed to evaluate the effects of exercise timing (60 vs 120 min post meal) and different insulin types (aspart vs ultra-rapid aspart) on hypoglycaemic risk. METHODS: This was a four-way crossover randomised trial including 40 individuals with type 1 diabetes using multiple daily injections (mean HbA1c 56 mmol/mol [7.4%]). Participants, who were recruited from the Montreal Clinical Research Institute, undertook 60 min cycling sessions (60% of V ˙ O 2 peak ) after breakfast (60 min [EX60min] or 120 min [EX120min] post meal) with 50% of their usual insulin dose (aspart or ultra-rapid aspart). Eligibility criteria included age ≥18 years old, clinical diagnosis of type 1 diabetes for at least 1 year and HbA1c ≤80 mmol/mol (9.5%). Participants were allocated using sequentially numbered, opaque sealed envelopes. Participants were masked to their group assignment, and each participant was allocated a unique identification number to ensure anonymisation. The primary outcome was change in blood glucose levels between exercise onset and nadir. RESULTS: Prior to exercise onset, time spent in hyperglycaemia was lower for EX60min vs EX120min (time >10.0 mmol/l: 56.6% [1.2-100%] vs 78.0% [52.7-97.9%]; p<0.001). The glucose reduction between exercise onset and nadir was less pronounced with EX60min vs EX120min (-3.8±2.7 vs -4.7±2.5 mmol/l; p<0.001). A similar number of hypoglycaemic events occurred during both exercise timings. Blood glucose between exercise onset and nadir decreased less with ultra-rapid aspart compared with aspart (-4.1±2.3 vs -4.4±2.8 mmol/l; p=0.037). While a similar number of hypoglycaemic events during exercise were observed, less post-exercise hypoglycaemia occurred with ultra-rapid aspart (n=0, 0%, vs n=15, 38%; p=0.003). No interactions between insulin types and exercise timings were found. CONCLUSIONS/INTERPRETATION: EX60min blunted the pre-exercise glucose increase following breakfast and was associated with a smaller glucose reduction during exercise. Ultra-rapid aspart led to a smaller blood glucose reduction during exercise and might be associated with diminished post-exercise hypoglycaemia. TRIAL REGISTRATION: ClinicalTrials.gov NCT03659799 FUNDING: This study was funded by Novo Nordisk Canada.

The responsibility to care: lessons learned from emergency department workers' perspectives during the first wave of the COVID-19 pandemic in Canada.

BACKGROUND: This study's objective was to examine emergency department (ED) workers' perspectives during the Canadian COVID-19 first wave. METHODS: This qualitative study included workers from nine Canadian EDs who participated in 3 monthly video focus groups between April and July 2020 to explore (1) personal/professional experiences, (2) patient care and ED work, (3) relationships with teams, institutions and governing bodies. Framework analysis informed data collection and analysis. RESULTS: Thirty-six focus groups and 15 interviews were conducted with 53 participants (including 24 physicians, 16 nurses). Median age was 37.5 years, 51% were female, 79% had more than 5 years' experience. Three main themes emerged. (1) Early in this pandemic, participants felt a responsibility to provide care to patients and solidarity toward their ED colleagues and team, while balancing many risks with their personal protection. (2) ED teams wanted to be engaged in decision-making, based on the best available scientific knowledge. Institutional decisions and clinical guidelines needed to be adapted to the specificity of each ED environment. (3) Working during the pandemic created new sources of moral distress and fatigue, including difficult clinical practices, distance with patients and families, frequent changes in information and added sources of fatigue. Although participants quickly adapted to a "new normal", they were concerned about long-term burnout. Participants who experienced high numbers of patient deaths felt especially unprepared. INTERPRETATION: ED workers believe they have a responsibility to provide care through a pandemic. Trust in leadership is supported by managers who are present and responsive, transparent in their communication, and involve ED staff in the development and practice of policies and procedures. Such practices will help protect from burnout and ensure the workforce's long-term sustainability.

RéSUMé: CONTEXTE: Cette étude avait pour objectif d'examiner le point de vue des travailleurs des services d'urgence pendant la première vague de la COVID-19 au Canada. MéTHODES: Cette étude qualitative a inclus des travailleurs de neuf services d'urgence canadiens qui ont participé à 3 groupes de discussion monsuels par visioconférence entre avril et juillet 2020, pour explorer: (1) leurs expériences personnelles/professionnelles, (2) les soins aux patients et le travail au service d'urgence, (3) leurs relations avec les équipes, les institutions et instances dirigeantes. Le "framework analysis" a guidé le receuil et l'analyse des données. RéSULTATS: Trente-six groupes de discussion et 15 entretiens individuels ont été menés avec 53 participants (dont 24 médecins et 16 infirmières). L'âge médian était de 37,5 ans, 51% étaient des femmes, 79% avaient plus de 5 ans d'expérience. Trois thèmes principaux sont ressortis. (1) Au début de cette pandémie, les participants se sont sentis responsables de prodiguer des soins aux patients et solidaires envers leurs collègues et leurs équipes des urgences, tout en cherchant à équilibrer la gestion de nombreux risques et leur protection personnelle. (2) Les équipes des services d'urgence souhaitaient participer aux prises de décision, informées par les meilleures connaissances scientifiques disponibles. Les décisions institutionnelles et les lignes directrices cliniques doivent être adaptées à la spécificité de chaque salle d'urgence. (3) Travailler pendant la pandémie a créé de nouvelles sources de détresse morale et de fatigue, notamment des pratiques cliniques difficiles, la distance avec les patients et les familles, les changements fréquents d'information. Bien que les participants se soient rapidement adaptés à une « nouvelle normalité¼, ils étaient préoccupés par l'épuisement professionnel des travailleurs au long terme. Les participants qui ont vécu un nombre élevé de décès de patients à l'urgence se sentaient particulièrement mal préparés. INTERPRéTATION: Les travailleurs des services d'urgence estiment qu'ils ont la responsabilité de fournir des soins en cas de pandémie. Un sentiment de confiance dans les décideurs peut être soutenu par des gestionnaires qui sont présents et réactifs, transparents dans leur communication, et qui impliquent le personnel des services d'urgence dans le développement des politiques et procédures cliniques. De telles pratiques aideront à protéger contre l'épuisement professionnel pour garantir le bien-être des travailleurs d'urgence.