UNSUSPECTED FACTORS IN ‘SELF-LIMITING’ AILMENTS

An unsuspected subtotally perforated eardrum treated with wax softening drops shows how clinical findings do not always correlate with symptoms or history. Attention is drawn to the dilemma posed by delegating matters such as diagnosis and prescribing which have been considered to be purely in the medical sphere.     

HLA, GM, KM, and Diego blood group typing of Chippewa Indians

This is the first report characterizing HLA antigen distribution in North American Indians of the Chippewa tribe. One hundred seventy-four Chippewa from Minnesota underwent HLA-A,B,C,DR, and DQ typing in a search for a single unrelated bone marrow donor. The high matching rate of this successful search is attributed to homozygosity and the extreme frequency of certain antigens in this small ethnic community. It is emphasized that smaller donor pools are required in searches within a minority population. GM and KM allotype typing as well as blood group Diego typing show patterns similar to those reported in other North American Indian groups.     

Modular headache theory

Many people experience headaches that do not fulfil the International Headache Society's criteria for a specific headache disorder yet behave biologically like that disorder. Others fulfil criteria for one headache disorder and yet have features of another disorder. To explain these observations, we propose that groups of neurones called modules become activated to produce each symptom of a primary headache disorder, and that each module is linked to other modules that together produce an individual's headache. This theory has implications for the classification, research and treatment of primary and secondary headache patients.     

4-(2-酰胺基-2-乙氧羰基)乙硫基-4-脱氧-4′-去甲表鬼臼毒素衍生物的合成与抗肿瘤活性

为考察4′-去甲基表鬼臼毒素4位上取代基结构变化与抗肿瘤活性的关系,设计并合成了23个标题化合物。体外L₁₂₁₀白血病细胞与KB细胞生长抑制试验的结果表明,化合物11,16和18的抗肿瘤活性超过依托泊甙,化合物8的活性与依托泊甙相当。     

4-S-(5-酰氨基-1,3,4-噻二唑-2-基)-4-脱氧-4′-去甲基表鬼臼毒素衍生物的合成与抗肿瘤活性

基于在4′-去甲基表鬼臼毒素母核C₄位上联结含有杂原子的芳香环取代基,以此考察其结构与活性关系的设想,设计并合成了10个标题化合物。体外L₁₂₁₀白血病细胞与KB细胞生长抑制试验结果表明,这类化合物有较强的抗肿瘤活性。其中化合物SIPI-92-1772,1774,1775,1776,1777与1779的活性超过临床用药依托泊甙。其余化合物活性与依托泊甙相当或略低。     

Quality Improvement in Diabetes Care: A Review of Initiatives and Outcomes in the T1D Exchange Quality Improvement Collaborative

Despite immense strides in therapeutic advances, clinical outcomes continue to be less than ideal for people with type 1 diabetes. This discrepancy has prompted an outpouring of quality improvement (QI) initiatives to address the medical, psychosocial, and health equity challenges that complicate ideal type 1 diabetes care and outcomes. This article reviews a framework for QI in diabetes care that guided the development of the T1D Exchange Quality Improvement Collaborative to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology, outcomes, and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care.

Type 1 diabetes is characterized by immune-mediated depletion of pancreatic β-cells, resulting in lifelong dependence on insulin. Among the U.S. population, an estimated 187,000 youths and 1.4 million adults have type 1 diabetes (1). This prevalence is further intensified by the impact of the burden of disease as related to its complications, excess mortality, and challenges in access and affordability of insulin (2). The life expectancy for individuals with type 1 diabetes is estimated to be 3.6 years less than the general population (3).Since the Diabetes Control and Complications Trial provided irrefutable evidence for the benefit of optimal glycemic control in mitigating risks of long-term micro- and macrovascular complications (4–8), many important advances in diabetes therapy have been made. However, youths and adults with type 1 diabetes continue to struggle to meet the glycemic targets outlined by the American Diabetes Association (ADA) (9,10), with just 17% of youths in the TID Exchange clinic registry achieving an A1C <7.5% and 21% of adults having an A1C <7.0% between 2016 and 2018 (11). Even more concerning, the adjusted mean A1C increased by 0.6% from 2010–2012 to 2016–2018 (11).The discrepancy between therapeutic innovations and clinical outcomes is likely the result of ongoing gaps in care delivery, psychosocial needs, self-management, health system design, and equity of care. A 2016 meta-analysis (12) highlighted a lack of high-quality, well-designed interventions to improve clinical and psychosocial outcomes in type 1 diabetes. The awareness of this incongruence in care advancement and patient outcomes has prompted a surge of quality improvement (QI) initiatives to address the medical challenges, as well as the equally significant psychosocial aspects of type 1 diabetes, including diabetes distress, depression, anxiety, disordered eating behaviors, and diabetes-related family conflict (13).QI methods are systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups (14). In turn, the implementation of QI methodologies provides reliable application of evidence-based care. In this review, we discuss QI projects in the United States that have been implemented to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care, which will ultimately improve clinical outcomes, reduce psychosocial burden, and improve health-related quality of life.     

Multi-Clinic Quality Improvement Initiative Increases Continuous Glucose Monitoring Use Among Adolescents and Young Adults With Type 1 Diabetes

Continuous glucose monitoring (CGM) use is associated with improved A1C outcomes and quality of life in adolescents and young adults with diabetes; however, CGM uptake is low. This article reports on a quality improvement (QI) initiative of the T1D Exchange Quality Improvement Collaborative to increase CGM use among patients in this age-group. Ten centers participated in developing a key driver diagram and center-specific interventions that resulted in an increase in CGM use from 34 to 55% in adolescents and young adults over 19–22 months. Sites that performed QI tests of change and documented their interventions had the highest increases in CGM uptake, demonstrating that QI methodology and sharing of learnings can increase CGM uptake.

Consistent glycemic management is necessary to prevent long-term microvascular and macrovascular complications in individuals with type 1 diabetes (1,2). In the American Diabetes Association’s (ADA’s) most recent Standards of Medical Care in Diabetes (3), an A1C target of <7% is recommended for most children and adults with type 1 diabetes but should be personalized. However, data from the T1D Exchange have shown that a majority of children, adolescents, and young adults in the United States did not meet an earlier A1C target of <7.5% (4). In fact, patients in the 2016–2018 T1D Exchange cohort had worse A1C outcomes than those in the 2010–2012 cohort (mean A1C of 7.8% in the 2010–2012 cohort and 8.4% in the 2016–2018 cohort) (4,5).Data from the T1D Exchange collected before the widespread use of continuous glucose monitoring (CGM) technology suggests that increased frequency of self-monitoring of blood glucose (i.e., with a glucose meter) is strongly associated with lower A1C (6). CGM provides more data (up to 288 glucose readings per day), as well as glycemic trends and alerts to improve clinical outcomes. Newer-generation CGM systems are more accurate, factory-calibrated, and have nonadjunctive use indications. In contrast, earlier CGM systems required fingerstick glucose checks for calibration, making these devices less attractive for use, particularly by adolescents and young adults (7).Uptake of CGM is increasing worldwide, including in the United States (8). In 2017 data from the T1D Exchange, ∼20% of youth and young adults between the ages of 13 and 26 years used CGM. Recent data from a randomized control trial demonstrated that adolescents and young adults started on CGM sustained CGM use and had a mean A1C reduction of 0.37% after 6 months of CGM use (9). Several studies have demonstrated that initiating CGM early in the course of type 1 diabetes can improve clinical outcomes (10,11).However, there are barriers to technology adoption at the structural, patient, and provider levels (12,13). Structural barriers to CGM adoption include financial challenges related to insurance coverage and associated out-of-pocket costs. Patient-level barriers may include reluctance to wear a diabetes device, exacerbation of diabetes distress (potentially resulting from CGM alarms [12]), or simply inadequate information or perceptions about CGM. Examples of provider-level barriers include lack of time to learn about, promote, and complete paperwork for insurance approval of CGM.The T1D Exchange Quality Improvement Collaborative (T1DX-QI) is a learning collaborative established to improve care delivery for people with type 1 diabetes (14). Between May 2018 and March 2020, the 10 sites initially participating in the collaborative worked on improving CGM use among adolescents and young adults (12–26 years of age) from an aggregated baseline of 34% to a collaborative target of 50% over a 2-year time frame. Each center adapted preexisting barriers questionnaires (15) to assess barriers to CGM adoption in their populations and developed targeted interventions to address structural-, patient-, and provider-level barriers to CGM use.