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Background: Continuous glucose monitoring (CGM) can improve glycemic control for adults with type 1 diabetes (T1D) but certain barriers interfere with consistent use including cost, data overload, alarm fatigue, physical discomfort, and unwanted social attention. This pilot study aimed to examine feasibility and acceptability of a behavioral intervention, ONBOARD (Overcoming Barriers and Obstacles to Adopting Diabetes Devices) to support adults with T1D in optimizing CGM use. Methods: Adults (18–50 years) with T1D in their first year of CGM use were invited to participate in a tailored, multicomponent telehealth-based intervention delivered over four 60-min sessions every 2–3 weeks. Participants completed surveys (demographics; diabetes distress, Diabetes Distress Scale for adults with type 1 diabetes; satisfaction with program) and provided CGM data at baseline and postintervention (3 months). Data were analyzed using paired t-tests and Wilcoxon signed-rank tests. Results: Twenty-two participants (age = 30.95 ± 8.32 years; 59% women; 91% non-Hispanic; 86% White, 5% Black, 9% other; 73% pump users) completed the study. ONBOARD demonstrated acceptability and a high rate of retention. Moderate effect sizes were found for reductions in diabetes distress (P = 0.01, r = −0.37) and increases in daytime spent in target range (70–180 mg/dL: P = 0.03, r = −0.35). There were no significant increases in hypoglycemia. Conclusions: Findings show preliminary evidence of feasibility, acceptability, and efficacy of ONBOARD for supporting adults with T1D in optimizing CGM use while alleviating diabetes distress. Further research is needed to examine ONBOARD in a larger sample over a longer period.

To slow the spread of COVID-19, a shelter in place (SIP) order was imposed in California between 03/16/2020 - 05/31/2020. We assessed the impact of SIP on glycemic control in a pediatric population with T1D using a continuous glucose monitor (CGM). We hypothesized that glucose control would improve due to increased supervision at home. The retrospective study included 96 patients between the ages of 3-22 years who were diagnosed with T1D at least one year earlier. We analyzed CGM data during three time periods: baseline, SIP, and post SIP (06/01/2020 - 07/30/2020) and compared standard CGM metrics controlling for gender (56% male), race (55% White), ethnicity (70% non-Hispanic), age (mean 11 yrs ± 3.9), and insurance type (8.4% public). The mean time in range (70-180 mg/dL: TIR) increased across the three time periods: from 59.9% ± 15.1 at baseline to 62.8% ± 15.9 during SIP (p

Background: Access to psychosocial services is limited, especially during a pandemic. A Zoom-delivered family-based intervention for adolescents with type 1 diabetes has the potential to enhance access to psychosocial services. Methods: Nine families enrolled in a pilot of a 6-session online (Zoom) intervention for adolescents with type 1 diabetes and their parents during the COVID-19 pandemic. Qualitative and quantitative data were collected via online focus groups and surveys. Results: Teens’ ages ranged from 12-17 years (M=14.9, SD=1.76) and most self-identified as male (78%). All parents self-identified as female and most families self-identified as non-Hispanic white (78%). Qualitative results revealed that participants found the program to be generally helpful and would recommend the program to others. Perceived benefits included increased parental empathy toward teens, enhanced parental involvement in teens’ diabetes management, and decreased parent-teen conflict. Participants conveyed that these benefits were particularly impactful given increased family contact and tensions related to the COVID-19 pandemic. Identified areas for improvement included adding follow-up group sessions with parents to maintain program impact on parenting over time and to target teens in early adolescence, when family dynamics are more malleable. Quantitative results from paired t-tests of pre-post comparisons revealed no significant differences in teen or parental diabetes distress or depression (all p>0.05), but should be interpreted with caution due to small sample size. Conclusions: Adolescents with type 1 diabetes and their parents responded positively to this program and found it particularly relevant during the current pandemic. Zoom delivery of these programs may be instrumental in their feasibility, acceptability, and ultimately dissemination in the future. Disclosure J. J. Wong: None. M. S. Lanning: None. J. Ngo: None. C. A. Wu: None. S. Hanes: None. H. M. Linzmeyer: None. D. Naranjo: None. K. K. Hood: Consultant; Self; Cecelia Health, Cercacor, LifeScan Diabetes Institute. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1K23DK121771-01A1)

Aim This study aimed to capture the experience of parents of youth with recent onset Type 1 diabetes who initiated use of continuous glucose monitoring (CGM) technology soon after diagnosis, which is a new practice. Methods Focus groups and individual interviews were conducted with parents of youth with Type 1 diabetes who had early initiation of CGM as part of a new clinical protocol. Interviewers used a semi-structured interview guide to elicit feedback and experiences with starting CGM within 30 days of diagnosis, and the benefits and barriers they experienced when adjusting to this technology. Groups and interviews were audio recorded, transcribed and analysed using content analysis. Results Participants were 16 parents (age 44.13 ± 8.43 years; 75% female; 56.25% non-Hispanic White) of youth (age 12.38 ± 4.15 years; 50% female; 50% non-Hispanic White; diabetes duration 10.35 ± 3.89 months) who initiated CGM 11.31 ± 7.33 days after diabetes diagnosis. Overall, parents reported high levels of satisfaction with starting CGM within a month of diagnosis and described a high level of reliance on the technology to help manage their child's diabetes. All participants recommended early CGM initiation for future families and were committed to continue using the technology for the foreseeable future, provided that insurance covered it. Conclusion Parents experienced CGM initiation shortly after their child's Type 1 diabetes diagnosis as a highly beneficial and essential part of adjusting to living with diabetes.

Author(s): Bellino, Andrew; Staats, Katherine; Ngo, Jessica | Abstract: Case Presentation: A 33-year-old gravid female was brought to the emergency department after she collapsed in the street. Point-of-care ultrasound showed free fluid in the abdomen and confirmed an intrauterine pregnancy. Surgical teams were consulted, and cross-sectional imaging revealed a spontaneously ruptured splenic artery aneurysm (SAA). The patient was taken expeditiously to the operating room for splenic artery ligation and subsequent splenectomy.Discussion: Ruptured SAA in pregnant patients is associated with significant mortality for both mother and fetus. Maintaining a high index of suspicion in the correct population is crucial to avoid diagnostic errors and provide definitive care with operative repair.

Purpose: Corneal culturing requires understanding of aseptic non-touch technique and avoidance of possible contaminants. Currently, there is no formal training in the technique and registrars are typically taught by another registrar in the emergency setting.The aim of the study was to develop an evidence-based instructional video for the corneal scrape procedure in microbial keratitis. The study then aims to assess the effect of the instructional video on clinician performance of the corneal scrape procedure.Method: An instructional video for corneal scraping was developed by identifying key steps for the procedure based on available evidence from a review of the literature and clinical practice. A prospective observational comparative case series that included clinicians at the Sydney Hospital/Sydney Eye Hospital, NSW Australia was conducted. Clinicians performing corneal scrapes had their performance of the procedure assessed prior to and after viewing the instructional video.Results: Sixteen key steps to follow in performing the corneal scrape procedure were found and demonstrated in the instructional video. Fourteen clinicians were observed performing 24 corneal scrapes in 24 patients with a median age of 56 years (IQR 34-65 years) and 45% male. Pre-video 11 scrapes were observed vs 13 scrapes post-video. Descriptive data were summarised and non-parametric categorical data analyzed using IBM SPSS (version 1.0.0.800) to perform chi-square and Wilcoxon signed-rank tests. Statistical significance was defined as p < .05. The steps of the corneal scrape procedure were performed correctly by a greater number of clinicians post-video compared to pre-video (p = .003). There was a significant improvement in inoculation of agar plates with cross-hatched streaks (92% post- vs 55% pre-video) and the maintenance of an intact agar surface (92% post vs 55% pre-video) (p = .033).Conclusion: An instructional video optimized the performance of corneal scraping, by ophthalmology trainees, in patients with microbial keratitis.

The genetic model organism, Caenorhabditis elegans (C. elegans), shares many genes with humans and is the best-annotated of the eukaryotic genome. Therefore, the identification of new genes and pathways is unlikely. Nevertheless, host-pathogen interaction studies from viruses, recently discovered in the environment, has created new opportunity to discover these pathways. For example, the exogenous RNAi response in C. elegans by the Orsay virus as seen in plants and other eukaryotes is not systemic and transgenerational, suggesting different RNAi pathways between these organisms. Using a bioinformatics meta-analysis approach, we show that the top 17 genes differentially-expressed during C. elegans infection by Orsay virus are functionally uncharacterized genes. Furthermore, functional annotation using similarity search and comparative modeling, was able to predict folds correctly, but could not assign easily function to the majority. However, we could identify gene expression studies that showed a similar pattern of gene expression related to toxicity, stress and immune response. Those results were strengthened using protein-protein interaction network analysis. This study shows that novel molecular pathway components, of viral innate immune response, can be identified and provides models that can be further used as a framework for experimental studies. Whether these features are reminiscent of an ancient mechanism evolutionarily conserved, or part of a novel pathway, remain to be established. These results reaffirm the tremendous value of this approach to broaden our understanding of viral immunity in C. elegans.

Summary Accurate measurement of clonal genotypes, mutational processes, and replication states from individual tumor-cell genomes will facilitate improved understanding of tumor evolution. We have developed DLP+, a scalable single-cell whole-genome sequencing platform implemented using commodity instruments, image-based object recognition, and open source computational methods. Using DLP+, we have generated a resource of 51,926 single-cell genomes and matched cell images from diverse cell types including cell lines, xenografts, and diagnostic samples with limited material. From this resource we have defined variation in mitotic mis-segregation rates across tissue types and genotypes. Analysis of matched genomic and image measurements revealed correlations between cellular morphology and genome ploidy states. Aggregation of cells sharing copy number profiles allowed for calculation of single-nucleotide resolution clonal genotypes and inference of clonal phylogenies and avoided the limitations of bulk deconvolution. Finally, joint analysis over the above features defined clone-specific chromosomal aneuploidy in polyclonal populations., Graphical Abstract, Highlights • Scaled method and resource of > 50K single-cell whole genomes from diverse cell types • Clonal merging can resolve clone specific mutations to single-nucleotide level • Image analysis of single cells permits correlation of morphology and genome features • Clonal replication states and rare aneuploidy patterns of single cells measured, A high-throughput method for amplication-free single-cell whole-genome sequencing can be scaled up to analyze tens of thousands of cells from different tissues and clinical sample types and identifies replication states, aneuploidies, and subclonal mutations.

Per the American Society of Civil Engineer's (ASCE’s) ethical code, civil engineers are expected to respect the infrastructure sustainable development needs of involved stakeholders while upholding the profession’s integrity. There is a great need to design civil engineering curriculum to prepare students to address the challenges of future ethical decision dilemmas. This paper presents the development and implementation of a group-based infrastructure development exercise where students apply life-cycle analysis principles to design and plan a toll road project under challenging ethical vignettes. The students were formed in groups to act as a private JV company to propose a toll highway design and life-cycle plan with highest benefit-cost ratio while maintaining a profitable private company. Also, the groups were challenged with five main ethical vignettes that tie the public and private financial viability to hard decisions related to social justice, law compliance, honest competition, and labor relations. Exercise results analysis revealed that students were inclined to utilize higher public benefits to justify taking varying levels of unethical project decisions. The proposed exercise supports civil engineers ethics training by challenging them to adhere to professional ethical standards in hard decision-making situations.

ObjectiveFew established curricula are available for teaching disaster medicine. We describe a comprehensive, multi-modality approach focused on simulation to teach disaster medicine to emergency medicine residents in a 3-year curriculum.MethodsResidents underwent a 3-year disaster medicine curriculum incorporating a variety of venues, personnel, and roles. The curriculum included classroom lectures, tabletop exercises, virtual reality simulation, high-fidelity simulation, hospital disaster drills, and journal club discussion. All aspects were supervised by specialty emergency medicine faculty and followed a structured debriefing. Residents rated the high-fidelity simulations by using a 10-point Likert scale.ResultsThree classes of emergency medicine residents participated in the 3-year training program. Residents found the exercise to be realistic, educational, and relevant to their practice. After participating in the program, residents felt better prepared for future disasters.ConclusionsGiven the large scope of impact that disasters potentiate, it is understandably difficult to teach these skills effectively. Training programs can utilize this simulation-based curriculum to better prepare the nation’s emergency medicine physicians for future disasters. (Disaster Med Public Health Preparedness. 2016;10:611–614)

To evaluate whether playing ball sports during childhood and adolescence is associated with the risk of stress fractures in runners later in life.Retrospective cohort study.National track and field championships, held at Stanford University.One hundred fifty-six elite female and 118 elite male distance runners, age 18 to 44 years.A 1-page questionnaire was used to collect data regarding ages during which athletes played basketball and soccer, as well as other important covariates and outcomes.Athletes reported the ages when stress fractures occurred. Time to event was defined as the number of years from beginning competitive running to the first stress fracture or to current age, if no fracture had occurred.In both men and women, playing ball sports in youth correlated with reduced stress fracture incidence later in life by almost half, controlling for possible confounders. In men, each additional year of playing ball sports conferred a 13% decreased incidence of stress fracture (adjusted hazard ratio [HR] and 95% confidence interval, 0.87 [0.79-0.95]. Among women with regular menses, the HR for each additional year of playing ball sports was similar: 0.87 (0.75-1.00); however, there was no effect of length of time played among women with irregular menses (HR, 1.03 [0.92-1.16]). In men, younger ages of playing ball sports conferred more protection against stress fractures (HR for each 1-year-older age at first exposure, 1.29 [1.14, 1.45]).Runners who participate during childhood and adolescence in ball sports may develop bone with greater and more symmetrically distributed bone mass, and with enhanced protection from future stress fractures.

To determine whether volunteers (with or without prior medical training) can correctly apply pressure immobilization (PI) in a simulated snakebite scenario after receiving standard instructions describing the technique.Twenty emergency medicine physicians (residents and attendings) and 20 lay volunteers without prior formal medical training were given standard printed instructions describing the application of PI for field management of snakebite. They were then supplied with appropriate materials and asked to apply the technique five separate times (twice to another individual [one upper and one lower extremity] and three times to themselves [nondominant upper extremity, dominant upper extremity, and one lower extremity]). Successful application was defined a priori by four criteria previously published in the literature: wrap begins at the bite site, entire extremity is wrapped, splint or sling is applied, and pressures under the dressing are between 40 and 70 mm Hg in upper-extremity application and between 55 and 70 mm Hg in lower-extremity use. Pressures were determined using a specially designed skin interface pressure-measuring device placed at the simulated bite site.The technique was correctly applied as judged by the preset criteria in only 13 out of 100 applications by emergency medicine physicians and in only 5 out of 100 applications by lay people. There was no significant difference in success rates between physicians and lay volunteers. Likewise, there was no significant difference in success based on which extremity was being wrapped. More detailed analysis revealed that the major contributor to failure was inability to achieve recommended target pressures.Volunteers in a simulated snakebite scenario have difficulty applying PI correctly, as defined in the literature. The major source of failure is an inability to achieve recommended pressure levels under the dressing. New methods of instructing people in the proper use of PI or new technologies to guide or automate application are needed if this technique is to be used consistently in an effective manner for field management of bites by venomous snakes not known to cause significant local wound necrosis.

Summary The incidence of nephrogenic systemic fibrosis in subjects receiving gadoversetamide for cardiovascular magnetic resonance is low (0.026% overall and 1.274% in those subjects with CKD Stage 5 on hemodialysis). Background Since 2006, the US Food and Drug Administration (FDA) has recommended restricting gadolinium based contrast agents (GBCAs) for magnetic resonance in patients with renal impairment due to an association of GBCA use with nephrogenic systemic fibrosis (NSF). The multiple FDA warnings have listed different glomerular filtration rate (GFR) cut-off values for restricting GBCA use. Consequently, hospital policies vary in renal impairment screening criteria and restrictions for both agent-specific and GFR cut-off values for GBCA use. Determining the incidence of developing NSF after exposure to specific GBCAs, and when stratified by chronic kidney disease (CKD) stage, may clarify which agents and patients are at highest risk for developing NSF. Currently, the incidence of developing NSF after exposure to gadoversetamide (Covidien, Mansfield MA) is unknown. The objective of this study was to determine the incidence and patients at highest risk of developing NSF in a large cohort of patients with suspected cardiovascular disease receiving gadoversetamide. Methods

Introduction While de qi, the acupuncture needling sensation, has been considered as an important component of acupuncture, little is known of the acupuncture patient's experience and beliefs about de qi in clinical settings. The aim of this study was to describe Chinese acupuncture patients’ perceived sensations of, and beliefs about, acupuncture needling. Methods We developed a questionnaire and conducted a survey study at two time periods among 200 subjects at six outpatient acupuncture clinics in Beijing, China. Results Respondents were 55% female and had a mean age of 41 years. The most common types of needling sensations reported by subjects were the terms ‘distended’(94%), ‘sore’(81%), ‘electric’(81%) and ‘numb’ (78%). Eighty-nine percent of subjects reported that the needling sensation travelled away from the puncturing points or travelled among the needling points. Eighty-two percent of subjects believed that the needling sensation was very important for acupuncture treatment, and 68% further indicated that the stronger the needling sensation, the more effective the therapy. Eighty-one percent of subjects found the acupuncture process to be very comfortable and relaxing. Conclusion Chinese acupuncture patients described the common characteristics of de qi and its migratory nature. The sensations were believed to be important in producing clinical efficacy by most patients. Measuring the sensations described as de qi in future prospective studies will help us understand the degree to which this phenomenon has an effect on the physiological outcome and clinical response to acupuncture. There appears to be a limit to the number of sensations that can be discriminated by each individual patient, and further development of the questionnaire is planned.

To investigate the association of soccer playing and long-distance running with total and regional bone mineral density (BMD).Cross-sectional study.Academic medical centre.Elite male soccer players (n = 15), elite male long-distance runners (n = 15) and sedentary male controls (n = 15) aged 20-30 years.BMD (g/cm2) of the lumbar spine (L1-L4), right hip, right leg and total body were assessed by dual-energy x-ray absorptiometry, and a scan of the right calcaneus was performed with a peripheral instantaneous x-ray imaging bone densitometer.After adjustment for age, weight and percentage body fat, soccer players had significantly higher whole body, spine, right hip, right leg and calcaneal BMD than controls (p = 0.008, p = 0.041, p0.001, p = 0.019, p0.001, respectively) and significantly higher right hip and spine BMD than runners (p = 0.012 and p = 0.009, respectively). Runners had higher calcaneal BMD than controls (p = 0.002). Forty percent of the runners had T-scores of the lumbar spine between -1 and -2.5. Controls were similar: 34% had T-scores below -1 (including 7% with T-scores lower than -2.5).Playing soccer is associated with higher BMD of the skeleton at all sites measured. Running is associated with higher BMD at directly loaded sites (the calcaneus) but not at relatively unloaded sites (the spine). Specific loading conditions, seen in ball sports or in running, play a pivotal role in skeletal adaptation. The importance of including an appropriate control group in clinical studies is underlined.