Catherine Yu

Prenatal Glucocorticoid Modifies Hypothalamo-Pituitary-Adrenal Regulation in Prepubertal Guinea Pigs

We hypothesized that exposure to synthetic glucocorticoid during rapid brain growth (d50–52, birth = 68 days) in fetal guinea pigs modifies hypothalamo-pituitary-adrenal (HPA) function after birth, and that this involves changes in central corticosteroid receptor regulation. On the basis of our previous studies, we proposed that this effect is sex-specific. Pregnant guinea pigs were treated with dexamethasone (1 mg/kg) or vehicle on d50–51 of gestation, and juvenile offspring were euthanized at rest or following isolation stress on postnatal day 18. Dexamethasone increased the length of gestation (1.5 days) and altered body and organ (brain, heart, adrenal) growth. Resting plasma cortisol concentrations were significantly elevated in young male, but not female guinea pigs exposed to dexamethasone as fetuses. In female offspring born to dexamethasone-treated mothers, cortisol responses to isolation stress were attenuated. In males, elevated basal cortisol levels were not increased further by isolation. In the brain, hippocampal glucocorticoid receptor (GR) mRNA levels were significantly lower (10–25%) in females exposed to dexamethasone in utero. In contrast, GR mRNA levels were elevated (10–20%) in males from this prenatal treatment group. Mineralocorticoid receptor mRNA in the limbic system and GR mRNA levels in the pars distalis were unaffected. Pro-opiomelanocortin mRNA was significantly lower (30%) in the male pars intermedia following dexamethasone exposure. In conclusion, prenatal glucocorticoid exposure affects growth and HPA function as well as limbic and hypothalamic GR expression in juvenile offspring, and these effects are highly sex-specific.

Site-specific incorporation of photoisomerizable azobenzene groups into ribonuclease S

Abstract Syntheses of S-peptide analogues bearing phenylazophenylalanine (Pap) residues at positions 4, 8, and 11 are described. Noncovalent reassociation of the Pap-4 and Pap-11 peptides with S-protein reconstitutes ribonuclease activity. Photoisomerization of the Pap-4 peptide is found to modulate the enzyme activity.

Systematic review and evaluation of web-accessible tools for management of diabetes and related cardiovascular risk factors by patients and healthcare providers.

Objective To identify and evaluate the effectiveness, clinical usefulness, sustainability, and usability of web-compatible diabetes-related tools. Data sources Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, world wide web. Study selection Studies were included if they described an electronic audiovisual tool used as a means to educate patients, care givers, or clinicians about diabetes management and assessed a psychological, behavioral, or clinical outcome. Data extraction Study abstraction and evaluation for clinical usefulness, sustainability, and usability were performed by two independent reviewers. Results Of 12616 citations and 1541 full-text articles reviewed, 57 studies met inclusion criteria. Forty studies used experimental designs (25 randomized controlled trials, one controlled clinical trial, 14 before–after studies), and 17 used observational designs. Methodological quality and ratings for clinical usefulness and sustainability were variable, and there was a high prevalence of usability errors. Tools showed moderate but inconsistent effects on a variety of psychological and clinical outcomes including HbA1c and weight. Meta-regression of adequately reported studies (12 studies, 2731 participants) demonstrated that, although the interventions studied resulted in positive outcomes, this was not moderated by clinical usefulness nor usability. Limitation This review is limited by the number of accessible tools, exclusion of tools for mobile devices, study quality, and the use of non-validated scales. Conclusion Few tools were identified that met our criteria for effectiveness, usefulness, sustainability, and usability. Priority areas include identifying strategies to minimize website attrition and enabling patients and clinicians to make informed decisions about website choice by encouraging reporting of website quality indicators.

Self-Management Education

Offer collaborative and interactive self-management education (SME) interventions as they are more effective than didactic SME. Incorporate problem-solving skills for ongoing self-management of medical, social and emotional aspects of care into the traditional knowledge and technical skills content of educational interventions. Design patient-centred learning to empower individuals to make informed decisions toward achievement of patient-chosen goals. Individualize SME interventions according to type of diabetes and recommended therapy, the patient’s ability and motivation for learning and change, and his or her culture and literacy level. Provide ongoing SME and comprehensive healthcare collaboratively to make SME most effective.

Designing and evaluating a web-based self-management site for patients with type 2 diabetes - systematic website development and study protocol

BackgroundGiven that patients provide the majority of their own diabetes care, patient self-management training has increasingly become recognized as an important strategy with which to improve quality of care. However, participation in self management programs is low. In addition, the efficacy of current behavioural interventions wanes over time, reducing the impact of self-management interventions on patient health. Web-based interventions have the potential to bridge the gaps in diabetes care and self-management.MethodsOur objective is to improve self-efficacy, quality of life, self-care, blood pressure, cholesterol and glycemic control and promote exercise in people with type 2 diabetes through the rigorous development and use of a web-based patient self-management intervention. This study consists of five phases: (1) intervention development; (2) feasibility testing; (3) usability testing; (4) intervention refinement; and (5) intervention evaluation using mixed methods. We will employ evidence-based strategies and tools, using a theoretical framework of self-efficacy, then elicit user feedback through focus groups and individual user testing sessions. Using iterative redesign the intervention will be refined. Once finalized, the impact of the website on patient self-efficacy, quality of life, self-care, HbA1c, LDL-cholesterol, blood pressure and weight will be assessed through a non-randomized observational cohort study using repeated measures modeling and individual interviews.DiscussionIncreasing use of the World Wide Web by consumers for health information and ongoing revolutions in social media are strong indicators that users are primed to welcome a new era of technology in health care. However, their full potential is hindered by limited knowledge regarding their effectiveness, poor usability, and high attrition rates. Our development and research agenda aims to address these limitations by improving usability, identifying characteristics associated with website use and attrition, and developing strategies to sustain patient use in order to maximize clinical outcomes.

Designing and evaluating an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes in clinical care - systematic decision aid development and study protocol

BackgroundCare of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and goal setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. However, these strategies have not been taken up extensively in clinical practice.ObjectivesTo systematically develop and test an interprofessional SDM and goal-setting toolkit for patients with diabetes and other chronic diseases, following the Knowledge to Action framework.Methods1. Feasibility study: Individual interviews with primary care physicians, nurses, dietitians, pharmacists, and patients with diabetes will be conducted, exploring their experiences with shared decision-making and priority-setting, including facilitators and barriers, the relevance of a decision aid and toolkit for priority-setting, and how best to integrate it into practice.2. Toolkit development: Based on this data, an evidence-based multi-component SDM toolkit will be developed. The toolkit will be reviewed by content experts (primary care, endocrinology, geriatricians, nurses, dietitians, pharmacists, patients) for accuracy and comprehensiveness.3. Heuristic evaluation: A human factors engineer will review the toolkit and identify, list and categorize usability issues by severity.4. Usability testing: This will be done using cognitive task analysis.5. Iterative refinement: Throughout the development process, the toolkit will be refined through several iterative cycles of feedback and redesign.DiscussionInterprofessional shared decision-making regarding priority-setting with the use of a decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Adhering to principles of user-centered design, we will develop and refine a toolkit to assess the feasibility of this approach.

Initiating insulin in patients with type 2 diabetes

Type 2 diabetes has become a worldwide epidemic[1][1] and is associated with multiple complications that can be prevented by modifying risk factors and optimizing glycemic control.[2][2] The optimization of glycemic control often requires the use of multiple agents, including insulin. Insulin is an

Insulin Order Sets Improve Glycemic Control and Processes of Care

OBJECTIVE The study objective was to evaluate the impact of a standardized preprinted subcutaneous correctional insulin order set on glycemic control, processes of care, and nursing satisfaction. METHODS This was a controlled before/after, qualitative study using focus group interviews. The intervention group consisted of patients with diabetes who were admitted to the cardiovascular surgery ward. The control group consisted of patients with diabetes who were admitted to the vascular surgery ward. Registered nurses on the cardiovascular surgery floor participated in focus groups and completed surveys. We used a multifaceted intervention including standardized insulin order sheet, educational workshops, verbal and printed reminders, printed enabler, reference sheet, and overnight helpline. Glycemic control and hypoglycemia were assessed through chart review, and nursing satisfaction with the insulin order sets was assessed through surveys and nursing focus groups, performed before and 6 months after implementation of the insulin order set. RESULTS There was a 39% reduction in proportion of blood glucose>11.0 mmol/L (198 mg/dL) in the intervention group compared with the control group (0.17 vs 0.28, P=.03). The proportion of hypoglycemia (blood glucose<4.0 mmol/L [72 mg/dL]) was no different between the 2 groups. Nurse satisfaction increased significantly (P<.02); order sets were easy to use and improved glycemic control, processes, and efficiency of care, and reduced the number of pages between nursing and medical staff. CONCLUSIONS Standardized insulin order sets reduced hyperglycemia and improved nursing satisfaction and processes of care. Successful implementation required stakeholder engagement, identification of barriers and facilitators in local practice, and tailoring the intervention to target these factors.

Evaluation of a toolkit to improve cardiovascular disease screening and treatment for people with type 2 diabetes: protocol for a cluster-randomized pragmatic trial

BackgroundThe gap between the level of care recommended by evidence-based clinical practice guidelines and the actual care delivered to patients in practice has been well established. The Canadian Diabetes Association (CDA) created an implementation strategy to improve the implementation of its 2008 guidelines. This study will evaluate the impact of the strategy to improve cardiovascular disease (CVD) screening, prevention and treatment for people with diabetes.DesignA pragmatic cluster-randomized trial will be conducted to evaluate the CDAs CVD Toolkit. All family physicians in Ontario, Canada were randomly allocated to receive the Toolkit, which includes several printed educational materials targeting CVD screening, prevention and treatment, either in spring 2009 (intervention arm) or in spring 2010 (control arm). Randomization occurred at the level of the practice. Forty family physicians from each arm will be recruited to participate, and the medical records for 20 of their diabetic patients at high risk for CVD will be retrospectively reviewed. Outcome measures will be assessed for each patient between July 2009 and March 2010. The primary outcome will be that the patient is receiving a statin. Secondary outcomes will include 1) the receipt of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 2) various intermediate measures (A1c, blood pressure, LDL-cholesterol, total-/HDL-cholesterol ratio, body mass index and waist circumference), and 3) clinical inertia (the failure to change therapy in response to an abnormal A1c, blood pressure or cholesterol reading). The analysis will be carried out using multilevel hierarchical logistic regression models to account for the clustered nature of the data. The group assignment will be a physician-level variable. In addition, a process evaluation study with six focus groups of family physicians will assess the acceptability of the CDAs Toolkit and will explore factors contributing to any change or lack of change in behaviour, from the perspectives of family physicians.DiscussionPrinted educational materials for physicians have been shown to exert small-to-moderate changes in patient care. The CDAs CVD Toolkit is an example of a practice guideline implementation strategy that can be disseminated to a wide audience relatively inexpensively, and so demonstrating its effectiveness at improving diabetes care could have important consequences for guideline developers, policy makers and clinicians.Trial RegistrationThe trial is registered with http://www.clinicaltrials.gov, ID # NCT01026688

Evaluation of a Behavioral Mobile Phone App Intervention for the Self-Management of Type 2 Diabetes: Randomized Controlled Trial Protocol

Background Patients with type 2 diabetes mellitus (T2DM) struggle with the management of their condition due to difficulty relating lifestyle behaviors with glycemic control. While self-monitoring of blood glucose (SMBG) has proven to be effective for those treated with insulin, it has been shown to be less beneficial for those only treated with oral medications or lifestyle modification. We hypothesized that the effective self-management of non-insulin treated T2DM requires a behavioral intervention that empowers patients with the ability to self-monitor, understand the impact of lifestyle behaviors on glycemic control, and adjust their self-care based on contextualized SMBG data. Objective The primary objective of this randomized controlled trial (RCT) is to determine the impact of bant2, an evidence-based, patient-centered, behavioral mobile app intervention, on the self-management of T2DM. Our second postulation is that automated feedback delivered through the mobile app will be as effective, less resource intensive, and more scalable than interventions involving additional health care provider feedback. Methods This study is a 12-month, prospective, multicenter RCT in which 150 participants will be randomly assigned to one of two groups: the control group will receive current standard of care, and the intervention group will receive the mobile phone app system in addition to standard of care. The primary outcome measure is change in glycated hemoglobin A1c from baseline to 12 months. Results The first patient was enrolled on July 28, 2015, and we anticipate completing this study by September, 2018. Conclusions This RCT is one of the first to evaluate an evidence-based mobile app that focuses on facilitating lifestyle behavior change driven by contextualized and structured SMBG. The results of this trial will provide insights regarding the usage of mobile tools and consumer-grade devices for diabetes self-care, the economic model of using incentives to motivate behavior change, and the consumption of test strips when following a rigorously structured approach for SMBG. Trial Registration ClinicalTrials.gov NCT02370719; https://clinicaltrials.gov/ct2/show/NCT02370719 (Archived at http://www.webcitation.org/6jpyjfVRs)