混合学习环境下学生自我监控能力的培养

混合学习强调学生的自主学习。如何有效地培养学生的自我监控能力，是调动学生自主性学习、创建自主课堂及实施新教育理念的基本要求。文章主要阐述了影响学生学习的自我监控能力因素，提出了在混合学习环境下如何培养学生自我监控能力的方法。     

The value of education and self-monitoring in the management of warfarin therapy in older patients with unstable control of anticoagulation

Of 125 patients aged 65 years or over, with atrial fibrillation taking warfarin for at least 12 months, with a standard deviation (SD) of prothrombin time, expressed as the International Normalized Ratio (INR) >0.5 over the previous 6 months, 40 were randomized to continue with usual clinic care and 85 to receive education about warfarin. Of these, 44 were randomized to self-monitor their INR and 41 returned to clinic. Compared with the previous 6 months there was a significant increase in percentage time within the therapeutic range for the 6 months following education [61.1 vs. 70.4; mean difference 8.8; 95% confidence interval (CI): -0.2-17.8; P = 0.054] and following education and self-monitoring (57 vs. 71.1; mean difference 14.1; 95% CI: 6.7-21.5; P < 0.001), compared with those patients following usual clinic care (60.0 vs. 63.2; mean difference 3.2; 95% CI: -7.3-13.7). Using the same comparative periods, the INR SD fell by 0.24 (P < 0.0001) in the group allocated to education and self-monitoring, 0.26 (P < 0.0001) in the group receiving education alone and 0.16 (P = 0.003) in the control group. Inter-group differences were not statistically significant (intervention groups 0.26 +/- 0.30 vs. control 0.16 +/- 0.3, P = 0.10). Quality-of-life measurements and health beliefs about warfarin were unchanged (apart from emotional role limitation) with education or education and self-monitoring. Patient education regarding anticoagulation therapy could be a cost-effective initiative and is worthy of further study.     

Continuous glucose monitoring in children with type 1 diabetes: before and after insulin pump therapy

Abstract: Objective: The aim of continuous subcutaneous insulin infusion (CSII) therapy in patients with type 1 diabetes mellitus (T1DM) is to mimic as closely as possible the normal physiologic pattern seen in individuals without diabetes. This study was undertaken to determine the specific areas of improved glycemic control in subjects after initiation of insulin pump therapy and times where further improvement is needed. Research design and methods: Eight patients with T1DM (age 7.5–17 yr) wore the Continuous Glucose Monitoring System (CGMS) (Medtronic MiniMed, Northridge, CA, USA) for 3 d before and 3 months after initiation of insulin pump therapy. The CGMS, which measures inter‐ stitial glucose concentrations every 5 min for a 72‐h period, was used to evaluate glucose profiles. Patients entered 4–5 fingerstick blood glucose measurements daily into the sensor for calibration. Detailed logs of food intake, exercise, and hypoglycemic symptoms were also recorded. Results: Hemoglobin A1c (HbA1C) was reduced (p < 0.007) following 3 months of insulin pump therapy. Post‐CSII continuous glucose profiles demonstrated an overall improvement in hourly mean glucose over a 24‐h period (p < 0.001) as well as a reduction in the area under the curve for glucose (27 ± 4 prepump vs. 8.6 ± 1.4 mg/dL/d postpump, p < 0.004). This improvement was a result of an attenuation of the maximal postprandial glycemic excursions. Postbreakfast 349 ± 24 vs. 267 ± 16 mg/dL, p < 0.003; lunch 340 ± 16 vs. 217 ± 20 mg/dL, p < 0.003. Postdinner average similarly decreased after 3 months of CSII by 22%, p < 0.04. Conclusions: Pump therapy specifically improved the postprandial glucose excursions in children.     

Placental lactogen,progesterone, total estriol and prolactin plasma levels in pregnant women with insulin-dependent diabetes mellitus

Fifteen insulin-dependent diabetic (White's class B-C) and 10 healthy pregnant women were examined from the 12th to the 36th wk. Every 4 wk, a blood sample was drawn to determine total estriol, progesterone, placental lactogen and prolactin.Throughout the pregnancy, total estriol and progesterone in diabetic and non-diabetic women are very similar. On the contrary, the PRL levels are constantly lower in diabetic pregnant women, even though the difference is statistically significant only for the 24th wk determination. The hPL level is instead significantly lower in diabetic pregnant women at the 12th, 20th, 24th, 32nd and 36th wk. A negative correlation exists between the hPL value and the mean blood glucose level, performed the same day as the hormonal test. This correlation is statistically significant at the 12th, 16th, 20th, 28th and 36th wk. No significant difference is found between the two groups examined for the delivery week, the placental weight, the birth weight and the fetal body weight index.To conclude, while estriol and progesterone are not affected by the higher variability of glucose levels during pregnancy in diabetics, compared to normals, hPL and perhaps also PRL may be influenced by the mild hyperglycemia consequent to diabetes.     

An fMRI study of verbal self-monitoring: neural correlates of auditory verbal feedback

The ability to recognize one's own inner speech is essential for a sense of self. The verbal self-monitoring model proposes that this process entails a communication from neural regions involved in speech production to areas of speech perception. According to the model, if the expected verbal feedback matches the perceived feedback, then there would be no change in activation in the lateral temporal cortices. We investigated the neural correlates of verbal self-monitoring in a functional magnetic resonance (fMRI) study. Thirteen healthy male volunteers read aloud presented adjectives and heard their auditory feedback which was experimentally modified. Decisions about the source of the feedback were made with a button-press response. We used a 'clustered' fMRI acquisition sequence, consisting of periods of relative silence in which subjects could speak aloud and hear the feedback in the absence of scanner noise, and an event-related design which allowed separate analysis of trials associated with correct attributions and misattributions. Subjects made more misattribution responses when the feedback was a distorted version of their voice. This condition showed increased superior temporal activation relative to the conditions of hearing their own voice undistorted and hearing another person's voice. Furthermore, correct attributions during this condition were associated with greater temporal activation than misattributions. These findings support the self-monitoring model as mismatches between expected and actual auditory feedback were associated with greater temporal activation.     

Examining the Impact of Missing Data on Propensity Score Estimation in Determining the Effectiveness of Self-Monitoring of Blood Glucose (SMBG)

In many health services applications, research to determine the effectiveness of a particular treatment cannot be carried out using a controlled clinical trial. In settings such as these, observational studies must be used. Propensity score methods are useful tools to employ in order to balance the distribution of covariates between treatment groups and hence reduce the potential bias in treatment effect estimates in observational studies. A challenge in many health services research studies is the presence of missing data among the covariates that need to be balanced. In this paper, we compare three simple propensity models using data that examine the effectiveness of self-monitoring of blood glucose (SMBG) in reducing hemoglobin A1c in a cohort of 10,566 type 2 diabetics. The first propensity score model uses only subjects with complete case data (n=6,687), the second incorporates missing value indicators into the model, and the third fits separate propensity scores for each pattern of missing data. We compare the results of these methods and find that incorporating missing data into the propensity score model reduces the estimated effect of SMBG on hemoglobin A1c by more than 10%, although this reduction was not clinically significant. In addition, beginning with the complete data, we artificially introduce missing data using a nonignorable missing data mechanism and compare treatment effect estimates using the three propensity score methods and a simple analysis of covariance (ANCOVA) method. In these analyses, we find that the complete case analysis and the ANCOVA method both perform poorly, the missing value indicator model performs moderately well, and the pattern mixture model performs even better in estimating the original treatment effect observed in thecomplete data prior to the introduction of artificial missing data. We conclude that in observational studies onemust not only adjust for potentially confounding variables using methods such as propensity scores, but oneshould also account for missing data in these models in order to allow for causal inference more appropriately to be applied.     

Type 2 Diabetes Phenotype and Progression Is Significantly Different if Diagnosed before versus after 65 Years of Age

Background

The incidence of type 2 diabetes is increasing disproportionately in individuals <65 years of age. It is not known whether disease characteristics in these younger patients are similar to “classic” late-onset type 2 diabetes.

Methods

In the epidemiological cohort study entitled “Retrolective Study: Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes,” a total of 3268 patients from randomly contacted primary care practices were documented during a mean follow-up period of 6.5 years. All newly diagnosed patients of these practices were included.

Results

At diagnosis, 64.2% of the patients were aged ≤65 years. Thereof, 57.2% were male, whereas in the age group >65 years only 35.0% were male (p < 0.001). The younger group exhibited more severe metabolic deterioration at diagnosis and in the following years than the older group. Conversely, the older group presented at diagnosis with a higher prevalence of cardiovascular risk factors. Self-monitoring of blood glucose (SMBG) was more prominent in the younger group. In both age groups, the use of SMBG was associated with a significantly lower risk (p = 0.003) of a combined end point (severe diabetic complication or all-cause mortality).

Conclusions

There are considerable differences in disease characteristics between people diagnosed with type 2 diabetes during 45–65 years of age versus diagnosis at a later age. Type 2 diabetes diagnosed before the age of 65 years disproportionately affected men and exhibited a more severe disease course, but was characterized by significantly less cardiovascular risk factors in comparison to type 2 diabetes diagnosed at a later age. The use of SMBG was associated with a better clinical outcome in both age groups.     

Approaches to Display of Multiple-Point Glucose Profiles: A UK Patient’s Perspective

Multiple-point glucose profiles are now acknowledged, in the diabetes literature, as a key way for people with diabetes to analyze and interpret blood glucose control (BGC).^1-3 Combined methods to visualize relevant blood glucose information are increasingly recognized as a more effective method of explaining actionable glucose profiles.^4,15(p564) This commentary is written from the perspective of a person with type 1 diabetes and might add value to the existing understanding about relevant ways to display BGC data. Through discussion of the limits to current multiple-point glucose displays, for example, AGP “dashboard,” a proposed alternative method of graphical display that brings together HbA1c and self-monitored blood glucose (SMBG) test data is presented.