Self-care barriers and facilitators in older adults with T1D during a time of sudden isolation.

Older adults with type 1 diabetes (T1D) have unique challenges and needs. In this mixed-methods study, we explored the impact of isolation during a pandemic on diabetes management and overall quality of life in this population. Older adults (age ≥ 65 years) with T1D receiving care at a tertiary care diabetes center participated in semi-structured interviews during COVID-19 pandemic isolation between June and August 2020. A multi-disciplinary team coded transcripts and conducted thematic analysis. Thirty-four older adults (age 71 ± 5 years, 97% non-Hispanic white, diabetes duration of 38 ± 7 years, A1C of 7.4 ± 0.9% (57.3 ± 10.1 mmol/mol) were recruited. Three themes related to diabetes self-care emerged regarding impact of isolation on: (1) diabetes management and self-care behaviors (how isolation prompted changes in physical activity and dietary habits); (2) emotional stress and anxiety (related to isolation and lack of support system, economic concerns); and (3) concerns regarding the COVID-19 pandemic (impact on timely medical care and access to information). Our findings identify modifiable barriers and challenges faced by older adults with T1D during isolation. As this population has a higher risk of decline in physical and psychosocial support even during non-pandemic times, clinicians will benefit from understanding these issues to improve care of this population.

Genomic instability after allogeneic hematopoietic cell transplantation is frequent in oral mucosa, particularly in patients with a history of chronic graft-versus-host disease, and rare in nasal mucosa.

Genomic instability (GI) of cells may lead to their malignant transformation. Carcinoma after hematopoietic cell transplantation (HCT) frequently involves some (eg, oral) but not other (eg, nasal) epithelia. We examined GI in oral and nasal mucosal specimens from 105 subjects, including short-term (7-98 days, n = 32) and long-term (4-22 yrs, n = 25) allogeneic HCT survivors. Controls included autologous HCT survivors (n = 11), patients treated with chemotherapy without HCT (n = 9) and healthy controls (n = 27). GI was detected in 60% oral versus only 4% nasal specimens in long-term allogeneic HCT survivors (P < .001). None of the controls showed GI. In oral specimens, GI was significantly associated with history of oral chronic graft-versus-host disease (cGVHD). We conclude that GI after HCT is frequent in some (oral) but rare in other (nasal) epithelia. This may explain why some epithelia (especially those involved with cGVHD) are prone to develop cancer.

Can Smart Pens Help Improve Diabetes Management?

Smart pen technology has evolved over the past decade with new features such as Bluetooth connectivity, bolus dose calculators, and integration with mobile apps and continuous glucose monitors. While similar in appearance to a traditional insulin pen, smart pens have the ability to record and store data of insulin injections. These devices have the potential to transform diabetes management for clinicians, and patients with type 1 and type 2 diabetes on insulin therapy by improving adherence, glycemic control, and addressing barriers to diabetes management. Smart pens can also highlight the relationship between insulin, food, and physical activity, and provide insight into optimizing insulin regimens. Education of clinicians and patients, and more clinical studies showing the benefits of smart pens and cost-effectiveness, are needed.

External validation of the hospital frailty risk score among older adults receiving mechanical ventilation.

To externally validate the Hospital Frailty Risk Score (HFRS) in critically ill patients. We selected older adult (≥ 75 years old) hospitalizations receiving mechanical ventilation, using the Nationwide Readmissions Database (January 1, 2016-November 30, 2018). Frailty risk was subcategorized into low-risk (HFRS score < 5), intermediate-risk (score 5-15), and high-risk (score > 15). We evaluated the HFRS to predict in-hospital mortality, prolonged hospitalization, and 30-day readmissions, using multivariable logistic regression, adjusting for patient and hospital characteristics. Model performance was assessed using the c-statistic, Brier score, and calibration plots. Among 649,330 weighted hospitalizations, 9.5%, 68.3%, and 22.2% were subcategorized as low-, intermediate-, and high-risk for frailty, respectively. After adjustment, high-risk patient hospitalizations were associated with increased risks of prolonged hospitalization (adjusted odds ratio [aOR] 5.59 [95% confidence interval [CI] 5.24-5.97], c-statistic 0.694, Brier 0.216) and 30-day readmissions (aOR 1.20 [95% CI 1.13-1.27], c-statistic 0.595, Brier 0.162), compared to low-risk hospitalizations. Conversely, high-risk hospitalizations were inversely associated with in-hospital mortality (aOR 0.46 [95% CI 0.45-0.48], c-statistic 0.712, Brier 0.214). The HFRS was not successfully validated to predict in-hospital mortality in critically ill older adults. While it may predict other outcomes, its use should be avoided in the critically ill.

Defining Minimum Necessary Communication During Care Transitions for Patients on Antihyperglycemic Medication: Consensus of the Care Transitions Task Force of the IPRO Hypoglycemia Coalition.

INTRODUCTION: Antihyperglycemic agents are significant contributors to adverse drug events, responsible for emergency department visits, hospitalizations, and death. Nationally, the rate of serious hypoglycemic events associated with these agents remains high despite widespread efforts to improve drug safety. Transitions of care between healthcare settings can lead to communication challenges between care professionals and increase the risk of adverse drug events. System-based improvements are needed to assure the safe transitions for patients with diabetes who are on antihyperglycemic agents. The objective of this study was to develop a consensus list of requisite elements that should be communicated between care settings during transitions of patients who are prescribed antihyperglycemic agents. METHODS: The Island Peer Review Organization (IPRO) Hypoglycemia Coalition identified suboptimal transitions of care as a barrier to improving patient safety and quality of diabetes care. The Coalition formed a multidisciplinary Task Force with experts in the field of diabetes care. The Task Force created a draft list of requisite communication elements through literature review and deliberation on monthly conference calls. A blinded iterative Delphi process was subsequently performed to generate a consensus list of requisite communication elements that participating experts agreed were necessary to safely and effectively assume the management of patients with diabetes upon care transitions. RESULTS: The Task Force completed a series of four iterative polls from September 2015 to August 2016, resulting in a final list of 22 requisite communication elements (the Diabetes Management Discharge Communication List), with the elements conceptually categorized into three domains: diagnosis and treatment, factors affecting glycemic control or patient risk, and patient self-management. CONCLUSIONS: The Diabetes Management Discharge Communication List provides an initial framework for the development of diabetes-specific resources to improve clinical communication between care settings.

Use of Telecommunication and Diabetes-Related Technologies in Older Adults With Type 1 Diabetes During a Time of Sudden Isolation: Mixed Methods Study.

BACKGROUND: The COVID-19 lockdown imposed a sudden change in lifestyle with self-isolation and a rapid shift to the use of technology to maintain clinical care and social connections. OBJECTIVE: In this mixed methods study, we explored the impact of isolation during the lockdown on the use of technology in older adults with type 1 diabetes (T1D). METHODS: Older adults (aged ≥65 years) with T1D using continuous glucose monitoring (CGM) participated in semistructured interviews during the COVID-19 lockdown. A multidisciplinary team coded the interviews. In addition, CGM metrics from a subgroup of participants were collected before and during the lockdown. RESULTS: We evaluated 34 participants (mean age 71, SD 5 years). Three themes related to technology use emerged from the thematic analysis regarding the impact of isolation on (1) insulin pump and CGM use to manage diabetes, including timely access to supplies, and changing Medicare eligibility regulations; (2) technology use for social interaction; and (3) telehealth use to maintain medical care. The CGM data from a subgroup (19/34, 56%; mean age 74, SD 5 years) showed an increase in time in range (mean 57%, SD 17% vs mean 63%, SD 15%; P=.001), a decrease in hyperglycemia (>180 mg/dL; mean 41%, SD 19% vs mean 35%, SD 17%; P<.001), and no change in hypoglycemia (<70 mg/dL; median 0.7%, IQR 0%-2% vs median 1.1%, IQR 0%-4%; P=.40) during the lockdown compared to before the lockdown. CONCLUSIONS: These findings show that our cohort of older adults successfully used technology during isolation. Participants provided the positive and negative perceptions of technology use. Clinicians can benefit from our findings by identifying barriers to technology use during times of isolation and developing strategies to overcome these barriers.

Donor serostatus has an impact on cytomegalovirus-specific immunity, cytomegaloviral disease incidence, and survival in seropositive hematopoietic cell transplant recipients.

More cytomegalovirus (CMV)-specific T cells are transferred with grafts from CMV seropositive than seronegative donors. We hypothesized that seropositive recipients of grafts from seropositive donors (D+R+) have higher counts of CMV-specific T cells than seropositive recipients of grafts from seronegative donors (D-R+), and that this is clinically relevant in the setting of in vivo T cell depletion using rabbit-antihuman thymocyte globulin (ATG). We reviewed charts of 298 ATG-conditioned, seropositive recipients for CMV reactivation (pp65 antigenemia or CMV DNAemia above institutional threshold for preemptive therapy), recurrent CMV reactivation, CMV disease, and death. In 77 of these patients, we enumerated CMV-specific T cells. Median follow-up was 564 days. CMV-specific CD4+ and, to a lesser degree, CD8+ T cell counts were higher in D+R+ than D-R+ patients. D+R+ patients had lower cumulative incidence of CMV reactivation (21% versus 48%, P < .001), recurrent reactivation (4% versus 15%, P = .003), CMV disease (3% versus 13%, P = .005) and mortality (42% versus 56%, P = .006). We conclude that in the setting of in vivo T cell depletion using ATG, seropositive donors should be used for seropositive recipients. For scenarios where only seronegative donors are available, strategies to improve CMV-specific immunity (e.g., donor vaccination) should be explored.

A Successful Diabetes Management Model of Care in Long-Term Care Facilities.

The management of diabetes in long-term care (LTC) facilities requires facility staff to perform most self-care activities on the behalf of the residents. A practical model of care to improve diabetes management was developed and implemented at 6 LTC facilities in the Northeast United States between 2009 and 2012. The components of the program included (1) developing an individualized education curriculum and educating LTC interdisciplinary staff; (2) educating patients and caregivers; and (3) developing a clinical care algorithm. Over 500 staff members were educated and achieved competence. There were 1031 residents screened for risk of hypo- or hyperglycemia on admission, and 245 residents (24%) experienced hypoglycemia and 240 residents (23%) experienced hyperglycemia. Hypoglycemia episodes resolved without recurrence in 73%-90% cases because of interventions initiated by LTC staff. The implementation of a practical model of diabetes management in LTC facilities can improve staff education and lead to improved diabetes management.

Nasal epithelial cells of donor origin after allogeneic hematopoietic cell transplantation are generated at a faster rate in the first 3 months compared with later posttransplantation.

Detection of donor-type epithelial cells (ECs) after allogeneic hematopoietic cell transplantation (allo-HCT) using XY chromosome fluorescein in situ hybridization (FISH) has suggested that hematopoietic stem cells carry a degree of developmental plasticity. This is controversial, given artifacts of XY-based detection and the possibility of hematopoietic-nonhematopoietic cell fusion. Moreover, the kinetics of donor-type ECs (quantity at different time points after transplant) is unknown. Here, we document unequivocally the existence of donor-type ECs using a method obviating the artifacts of XY-FISH and study their kinetics. Nasal scrapings and blood specimens were collected from 60 allo-HCT survivors between 7 days and 22 years posttransplantation. DNA extracted from laser-captured nasal ECs (ie, CK(+)CD45(-) cells) and blood leukocytes was polymerase chain reaction-amplified for a panel of 16 short tandem repeat markers. The median percentage of donor-type ECs (among nasal ECs) was 0% on day 7 posttransplantation, 2.8% at 3 months posttransplantation, and 8.5% at 12-22 years posttransplantation. Cell fusion was ruled out by FISH analysis for two autosomes. We conclude that donor-type nasal ECs exist after HCT, and that their percentage rises rapidly in the first 3 months posttransplantation and more slowly thereafter.

The metabolic demands of internal medicine residency.

BACKGROUND: North American and European accreditation bodies have legislated progressively more strict work hour restrictions for residents in light of evidence that sleep deprivation leads to increased medical errors and decreased wellbeing. The purpose of the study is to determine the physiologic demands of internal medicine training during residency as well as document average sleep (on- and off-call) and physical activity performed using accelerometers. METHODS: A total of 40 internal medicine residents working on the clinical teaching unit at a single center were enrolled in the study from November 2011 to March 2016. There were 22 subjects that completed the study and were included in the analysis. SenseWear PRO 2 armband monitors were worn for 5 consecutive days including one call day. The primary outcomes of the study were to quantify and compare the calories per day, steps per day, METs per hour, hours of activity, hours of sleep, and sleep efficiency for on call versus post-call and non-call days. RESULTS: The average activity per day, calories per day, steps per day and METs per hour for the call day were 7.6 ± 7.6 h, 2647.0 ± 541.1, 11,261.1 ± 2355.9, and 1.7 ± 0.2 respectively. Each of these parameters had a statistically significant F statistic compared to post-call and non-call days. The subjects had a mean of 1.8 ± 2.0 h of sleep per day with a sleep efficiency of 77.3 ± 23.8% for the call day. The F statistic for sleep per day was significant with a p value < 0.001. CONCLUSION: This study shows that overnight call has a substantial impact on multiple metabolic parameters. These findings have potentially important implications on future resident working hour restrictions.

Natural IgM and innate immune collectin SP-D bind to late apoptotic cells and enhance their clearance by alveolar macrophages in vivo.

Innate immune collectin surfactant protein D (SP-D) and natural immunoglobulin M (IgM) are two soluble proteins. These opsonic proteins are good candidates for enhancing late apoptotic cell clearance. However, effects of these proteins on late apoptotic cell clearance in the lungs are not clearly established. We have recently shown that SP-D can bind several immunoglobulin isotypes, including IgM. Here we hypothesized that IgM and SP-D bind to late apoptotic cells and enhance their clearance from the lungs. We show that IgM and SP-D bind to late apoptotic secondary necrotic cells, and that IgM and SP-D either co-localize to the same regions or to different regions of late apoptotic Jurkat T cells. Mouse alveolar macrophages internalized late apoptotic cells, in vivo. We induced lung inflammation in mice using LPS and show that airway IgM and SP-D levels and the clearance of late apoptotic cells by alveolar macrophages increases under these conditions. We then coated late apoptotic cells with IgM, SP-D, or both and instilled them into the mouse airways. We found that alveolar macrophages internalize IgM- and SP-D-coated late apoptotic cells more effectively than uncoated late apoptotic cells, in vivo. None of these conditions cause inflammation in the naïve lungs. Therefore, these data suggest that both IgM and SP-D effectively opsonize late apoptotic cells and directly enhance their clearance by alveolar macrophages in the lungs.