Compliance of Type 2 Diabetes Applications to International Guidelines: Protocol for a Quantitative App Assessment.

BACKGROUND: Diabetes is among the most common chronic conditions people live with across the world. While it can be managed to a substantial degree, it can result in significant complications. As such, easy access to accurate tools to aid diabetes management is useful in minimizing these complications. Mobile apps are highly accessible and widely used, but there is a gap in the literature examining their compliance with medical guidelines. OBJECTIVE: The aims of this study are to develop the Analysis of Diabetes Apps (ADA) checklist to evaluate apps' compliance to guidelines set by the International Diabetes Federation (IDF) on the treatment and management of type 2 diabetes; to assess type 2 diabetes apps in the Apple App Store and the Android Google Play Store, and their compliance with international guidelines using the ADA framework; and to compare the novel ADA checklist against both the Mobile App Rating Scale (MARS) tool kit and app ratings for each store. METHODS: We will develop a checklist based on the "IDF Clinical Practice Recommendations for Managing Type 2 Diabetes in Primary Care." Type 2 diabetes apps will be scraped from 6 countries' app stores using web scraping tools. These countries include Australia, Brazil, India, Nigeria, the United States, and the United Kingdom, which were selected based on the largest population of English-speaking people in each continent. The apps will be searched on the web-based scraper using the search terms "blood sugar," "diabetes," "glucose level," "insulin," "sugar level," and "type 2 diabetes." Apps will be excluded if they are paid or are not in English. The apps will be assessed using the ADA checklist to evaluate their compliance to the international diabetes guidelines. Once scored, the results will be analyzed with descriptive statistics. The most popular apps will be further analyzed using the MARS tool kit. The ADA checklist scores will then be compared to both the MARS tool kit score and app ratings for each store. RESULTS: The ADA checklist developed based on the IDF guidelines focuses on general information, risk factors, diagnosis, pharmacology, lifestyle modification, glycemic recommendations, and medications. The initial stress testing of the protocol resulted in 173 included apps. This will vary in the final search as the app stores are constantly changing. CONCLUSIONS: The protocol presents the development of a checklist to investigate the compliance of type 2 diabetes apps with international guidelines. The checklist will hopefully form the basis of a scoring system for future research on compliance of mobile apps with international guidelines. High standardization of the ADA checklist will make it a robust tool for people with diabetes and their health care providers alike in assessing type 2 diabetes apps in the future. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/48781.

Normal multiple sleep latency test values in adults: A systematic review and meta-analysis.

Sleep latency is a measure of time it takes to enter sleep. Very short sleep latencies are indicative of excessive daytime sleepiness and pathological sleep conditions such as narcolepsy. The normal range of mean sleep latency calculated from the multiple sleep latency test in healthy adults is not well-established. We provide a review of normative mean sleep latency values on the multiple sleep latency test by synthesizing data from 110 healthy adult cohorts. We also examine the impact of demographic variables such as age, sex, body mass index, sleep architecture and sleep-disordered breathing as well as methodological variables such as sleep onset definitions and multiple sleep latency test protocols. The average mean sleep latency was 11.7 min (95% CI: 10.8-12.6; 95% PI: 5.2-18.2) for cohorts evaluated using the earlier definition of sleep onset and 11.8 min (95% CI: 10.7-12.8; 95% PI: 7.2-16.3) for those evaluated using the later definition. There were no significant associations between mean sleep latency and demographic or methodological variables. A negative association of -0.29 per one unit increase (95% CI: -0.55 to -0.04) was found between mean sleep latency and apnea-hypopnea index on prior night polysomnography. Establishing updated ranges for mean sleep latency among healthy adults may guide clinical decision-making surrounding sleep pathologies and inform future research into the associations between patient variables, daytime sleepiness, and sleep pathologies.

Respiratory decompensation with proning - when prone positioning can worsen respiratory mechanics.

Prone positioning recently gain- ed more popularity from its use in COVID-19 management. It is gene--rally considered to improve respiratory mechanics via increased lung compliance. In surgery, prone positioning is typically encountered when it is a necessity to access certain posterior anatomic structures. Though certain post-operative complications from prone positioning are well known (e.g., postoperative vision loss), the potential intraoperative complications that it can have for respiratory com-pliance and O2 saturation, in the setting of general anaesthesia, are perhaps less familiar, as only a few studies showed improved respiratory mechanics in the setting of ge-neral anaesthesia [1-3] and one study showed that prone positioning led to a 30-35% drop in respiratory compliance under general anaesthesia [4]. As the following case illustrates, proning is a critical point in the intraoperative course as it can sometimes lead to negative respiratory sequelae disrupting homeostasis.

Enhanced Recovery After Surgery (ERAS) protocols for spine surgery - review of literature.

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach that uses a combination of evidence-based methods to improve patient care. Different ERAS protocols are used in various surgical fields but for spine surgery there is no widely used standard ERAS protocol. We compiled and examined the multiple available publications on ERAS protocols for spine surgery. Some general commonalities exist between ERAS protocols; however, a great deal of variety is observed in the granularity of important details such as differing drug choices or specific dosing. To assess and relate the different available ERAS protocols, we conducted a comprehensive narrative literature review focused on comparing commonalities and differences among the following aspects of ERAS protocols: mechanisms of action, post-surgery pain levels, opioid consumption, utilization of muscle relaxants, use of anti-inflammation drugs, and ambulation after surgery. Our goal in this project was to simplify the search process for institutions who review the literature. In this review, certain ERAS elements such as early ambulation, blood loss, pain management, and patient positioning are further explored in more depth.

Contrived Breathing Circuit Connection for Emergency Percutaneous Transtracheal Ventilation by Needle Cricothyrotomy in the Field.

Surgical airway approaches are, at times, last resort options in difficult airway management. In Special Operations these interventions confront distorted anatomy from combat trauma, extreme conditions, and may be performed by non-medically trained personnel. Under these circumstances, needle cricothyroidotomy using a large bore intravenous catheter can be considered. A small syringe connected to the needle can confirm transtracheal placement through air aspiration before passing the angiocatheter over the needle. Button activated retracting needles should be avoided for this when possible. We recommend a 3-mL Luer-lock syringe because a small syringe is better suited for generating pressure and once the catheter is in the trachea, this same syringe can be connected to bag valve ventilation by replacing its plunger with a connector from a 6.5-, 7-, or 7.5-mm endotracheal tube. Adding these small and light high-yield items to the Tactical Combat Casualty Care medic inventory should be considered in future revisions.

Quality Fade in Medical Device Manufacturing: Thinness of Airway Breathing Circuit Plastic.

Mechanical respirators typically use a plastic circuit apparatus to pass gases from the ventilator to the patient. Structural integrity of these circuits is crucial for maintaining oxygenation. Anesthesiologists, respiratory therapists, and other critical care professionals rely on the circuit to be free of defects. The American Society for Testing and Materials maintains standards of medical devices and had a standard (titled Standard Specification for Anesthesia Breathing Tubes) that included circuits. This standard, which was last updated in 2008, has since been withdrawn. Lack of a defined standard can invite quality fade-the phenomenon whereby manufacturers deliberately but surreptitiously reduce material quality to widen profit margins. With plastics, this is often in the form of thinner material. A minimum thickness delineated in the breathing circuit standard would help ensure product quality, maintain tolerance to mechanical insults, and avert leaks. Our impression is that over the recent years, the plastic in many of the commercially available breathing circuits has gotten thinner. We experienced a circuit leak in the middle of a laminectomy due to compromised plastic tubing in a location that evaded the safety circuit leak check that is performed prior to surgery. This compromised ventilation and oxygenation in the middle of a surgery in which the patient is positioned prone and hence with a minimally accessible airway; it could have resulted in anoxic brain injury or death. The incident led us to reflect on the degree of thinness of the circuit's plastic.

Deviation from Clinical Routines Can Reveal Sources of Device Design Vulnerability.

The ability to adequately ventilate a patient is critical and sometimes a challenge in the emergency, intensive care, and anesthesiology settings. Commonly, initial ventilation is achieved through the use of a face mask in conjunction with a bag that is manually squeezed by the clinician to generate positive pressure and flow of air or oxygen through the patient's airway. Large or small erroneous openings in the breathing circuit can lead to leaks that compromise ventilation ability. Standard procedure in anesthesiology is to check the circuit apparatus and oxygen delivery system prior to every case. Because the face mask itself is not a piece of equipment that is associated with a source of leak, some common anesthesia machine designs are constructed such that the circuit is tested without the mask component. We present an example of a leak that resulted from complete failure of the face mask due to a tiny tear in its cuff by the patient's sharp teeth edges. This subsequently prevented formation of a seal between the face mask and the patient's face and rendered the device incapable of generating the positive pressure it is designed to deliver. This instance depicts the broader lesson that deviation from clinical routines can reveal unappreciated sources of vulnerability in device design.

The Rheology of the Carotid Sinus: A Path Toward Bioinspired Intervention.

The association between blood viscosity and pathological conditions involving a number of organ systems is well known. However, how the body measures and maintains appropriate blood viscosity is not well-described. The literature endorsing the function of the carotid sinus as a site of baroreception can be traced back to some of the earliest descriptions of digital pressure on the neck producing a drop in blood delivery to the brain. For the last 30 years, improved computational fluid dynamic (CFD) simulations of blood flow within the carotid sinus have demonstrated a more nuanced understanding of the changes in the region as it relates to changes in conventional metrics of cardiovascular function, including blood pressure. We suggest that the unique flow patterns within the carotid sinus may make it an ideal site to transduce flow data that can, in turn, enable real-time measurement of blood viscosity. The recent characterization of the PIEZO receptor family in the sinus vessel wall may provide a biological basis for this characterization. When coupled with other biomarkers of cardiovascular performance and descriptions of the blood rheology unique to the sinus region, this represents a novel venue for bioinspired design that may enable end-users to manipulate and optimize blood flow.

Human life cost in anaesthesiology cost-benefit decisions.

The United States (US) aviation industry provides a potentially useful mental model for dealing with certain cost-benefit decisions in aesthesiology. The Federal Aviation Administration (FAA), the national aviation authority of the United States, quantifies a price for the value of a human life based on the U.S. Department of Transportation's (DOT) value of a statistical life (VSL) unit. The current VSL is around $9.6 million, indexed to grow with consideration given to inflation and wage changes from the 2016 baseline of $9.4 million [1]. To illustrate the concept, if the FAA estimates that 100 people are likely to die in the future given the current practice standards then the monetary cost of this loss will be $940 million. The FAA uses this estimated monetary value as an official reference point in its regulatory decisions, and the agency publishes in detail how it derives the estimated value. When proposing new regulations, the FAA bases its decisions on comparisons of the human life cost associated with the existing regulation versus the alternative cost that the industry stakeholders will incur subsequent to the adoption of the regulation. In this example, if the cost incurred by the industry is more than the $940 million cost then the FAA will not adopt the proposed regulation and hence will not require the industry to undertake this cost.

Even the Simplest Devices May Malfunction: Split Septum Design Revisited.

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

A sudden presentation of abdominal compartment syndrome.

Abdominal compartment syndrome (ACS) is defined as sustained intra-abdominal pressure (IAP) exceeding 20 mm Hg, which causes end-organ damage due to impaired tissue perfusion, as with other compartment syndromes [1, 2]. This dysfunction can extend beyond the abdomen to other organs like the heart and lungs. ACS is most commonly caused by trauma or surgery to the abdomen. It is characterised by interstitial oedema, which can be exacerbated by large fluid shifts during massive transfusion of blood products and other fluid resuscitation [3]. Normally, IAP is nearly equal to or slightly above ambient pressure. Intra-abdominal hypertension is typically defined as abdominal pressure greater than or equal to 12 mm Hg [4]. Initially, the abdomen is able to distend to accommodate the increase in pressure caused by oedema; however, IAP becomes highly sensitive to any additional volume once maximum distension is reached. This is a function of abdominal compliance, which plays a key role in the development and progression of intra-abdominal hypertension [5]. Surgical decompression is required in severe cases of organ dysfunction - usually when IAPs are refractory to other treatment options [6]. Excessive abdominal pressure leads to systemic pathophysiological consequences that may warrant admission to a critical care unit. These include hypoventilation secondary to restriction of the deflection of the diaphragm, which results in reduced chest wall compliance. This is accompanied by hypoxaemia, which is exacerbated by a decrease in venous return. Combined, these consequences lead to decreased cardiac output, a V/Q mismatch, and compromised perfusion to intra-abdominal organs, most notably the kidneys [7]. Kidney damage can be prerenal due to renal vein or artery compression, or intrarenal due to glomerular compression [8] - both share decreased urine output as a manifestation. Elevated bladder pressure is also seen from compression due to increased abdominal pressure, and its measurement, via a Foley catheter, is a diagnostic hallmark. Sustained intra-bladder pressures beyond 20 mm Hg with organ dysfunction are indicative of ACS requiring inter-vention [2, 8]. ACS is an important aetiology to consider in the differential diagnosis for signs of organ dysfunction - especially in the perioperative setting - as highlighted in the case below.

The Carotid Sinus as a Viscometer.

Our group thought the study by Lee and Kim entitled "Hemodynamic Changes in the Carotid Artery after Infusion of Normal Saline Using Computational Fluid Dynamics" was a very elegant method to discern the changes in blood rheology within the carotid sinus after administration of crystalloid [...].

Enabling health information exchange at a US Poison Control Center.

OBJECTIVE: The objective of this project was to enable poison control center (PCC) participation in standards-based health information exchange (HIE). Previously, PCC participation was not possible due to software noncompliance with HIE standards, lack of informatics infrastructure, and the need to integrate HIE processes into workflow. MATERIALS AND METHODS: We adapted the Health Level Seven Consolidated Clinical Document Architecture (C-CDA) consultation note for the PCC use case. We used rapid prototyping to determine requirements for an HIE dashboard for use by PCCs and developed software called SNOWHITE that enables poison center HIE in tandem with a poisoning information system. RESULTS: We successfully implemented the process and software at the PCC and began sending outbound C-CDAs from the Utah PCC on February 15, 2017; we began receiving inbound C-CDAs on October 30, 2018. DISCUSSION: With the creation of SNOWHITE and initiation of an HIE process for sending outgoing C-CDA consultation notes from the Utah Poison Control Center, we accomplished the first participation of PCCs in standards-based HIE in the US. We faced several challenges that are also likely to be present at PCCs in other states, including the lack of a robust set of patient identifiers to support automated patient identity matching, challenges in emergency department computerized workflow integration, and the need to build HIE software for PCCs. CONCLUSION: As a multi-disciplinary, multi-organizational team, we successfully developed both a process and the informatics tools necessary to enable PCC participation in standards-based HIE and implemented the process at the Utah PCC.

The carotid sinus acts as a mechanotransducer of shear oscillation rather than a baroreceptor.

The carotid sinus is a dilated area at the base of the internal carotid artery of humans and is located immediately superior to the bifurcation of the internal and external carotid arteries. It is widely accepted, in the fields of medicine and physiology, to function as a baroreceptor in its central control role. This paper presents a hypothesis challenging this paradigm - that the carotid sinus functions by detecting oscillations at the vessel wall which result from shear stress due to vortical flow. This is contrary to conventional thinking which presumes that the carotid sinus responds to blood pressure or wall pressure. Our hypothesis is based on anatomy, physiology and physical properties of fluid which make the sinus the area of highest vorticity. Utilizing magnetic resonance angiograms of undiseased carotid vessels, we computed the oscillatory shear index (OSI) via a computational fluid dynamics simulation of flow. This region of highest OSI coincides with the area where the nerve to the carotid sinus lies within the vessel wall. Accordingly, the hypothesis is that the carotid sinus acts as a mechanotransducer of wall shear stress oscillation and not as a baroreceptor.