Evolving Project ECHO: delivery of pediatric pain core competency learning for interprofessional healthcare providers.

Introduction: Healthcare providers (HCPs) practicing in community settings are critical to improving access to pain care, yet there are significant gaps in training opportunities designed for interprofessional learners. Project Extension for Community Healthcare Outcomes (Project ECHO®) is an established model for delivering online HCP education through virtual clinics and cultivating a community of practice. However, to our knowledge, the integration of pain core competency education into the ECHO® model has not been previously attempted. This innovation could enhance the ECHO® model while also addressing the growing calls for more accessible interprofessional pain curricula. This paper describes efforts to implement and evaluate core competency curricula within the context of Pediatric Project ECHO for Pain, one of the first pediatric-pain focused ECHO programs in the world. Methods: Needs assessments informed curricula development. The first delivered core competency model consisted of synchronous webinar-style sessions while the second model included a mixture of asynchronous (eLearning course) and synchronous (virtual clinical debrief) elements. A convenience sample of HCPs was recruited from ECHO program registrants. Participants completed baseline and follow-up surveys to assess core competency acceptability as well as impact on knowledge and self-efficacy related to managing pediatric pain. Usability of the eLearning platform (model 2 only) was also evaluated. Surveys used 5-point Likert scales to capture outcomes. A priori targets included mean scores ≥4/5 for acceptability and ≥80% of learners reporting knowledge and self-efficacy improvements. The study received local research ethics approval. Results: The core competency was found to be highly acceptable to interprofessional learners (n = 31) across delivery models, surpassing a priori targets. Specifically, it was characterized as a worthwhile and satisfactory experience that was helpful in supporting learning. The core competency was also associated with improvements in knowledge and self-efficacy by 97% and 90% of learners, respectively. The eLearning platform was reported to have high usability with clinically realistic cases (100% of respondents) that were helpful to inform care delivery (94% of respondents). Conclusion: The integration of core competency learning within the Project ECHO® model was a successful approach to deliver pediatric pain education to interprofessional HCPs.

Pediatric Project ECHO® for Pain: implementation and mixed methods evaluation of a virtual medical education program to support interprofessional pain management in children and youth.

BACKGROUND: Pediatric pain is a complex health challenge requiring a multi-modal management approach. It is critical that healthcare providers (HCPs) have access to ongoing, flexible education and mentorship specific to pediatric pain. However, there are significant gaps in available pain education and a need for more opportunities to support interprofessional training. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a model for delivering online HCP education and cultivating a virtual community of practice. Within the pediatric pain setting, ECHO® has potential to improve local access to specialized pain knowledge, particularly among the physicians, nurses, and allied health providers who primarily manage these cases in community and hospital settings across rural and urban environments. The purpose of this study was three-fold. First, to evaluate the feasibility (participation levels, acceptability) of implementing Project ECHO® in the context of pediatric pain. Second, to measure preliminary program impacts on HCP knowledge, self-efficacy, and clinical practice. Third, to characterize HCP program engagement levels before and after onset of the COVID-19 pandemic. METHODS: A needs assessment was conducted to identify interprofessional education gaps and inform the program curriculum. The no-cost Pediatric ECHO® for Pain program offered TeleECHO sessions (didactic and case-based learning) as well as foundational education. Surveys were distributed at baseline and 6 months to assess outcomes using 7-point Likert scales. Participant engagement was assessed for periods prior to and during the COVID-19 pandemic. Descriptive and inferential statistical analyses were conducted. RESULTS: Eighty-five TeleECHO sessions were hosted, with a mean attendance of 34.1 ± 23.4 HCPs. Acceptability scores at 6 months (n = 33) ranged from 5.0 ± 1.4 to 6.5 ± 0.5. Participants reported statistically significant (p < 0.05) improvements in knowledge (7 out of 7 topics) and self-efficacy (8 out of 9 skills). Most participants reported positive practice impacts, including improved satisfaction with managing children with pain. Exploratory analyses showed a trend of greater engagement from ECHO® learners after onset of the COVID-19 pandemic. CONCLUSIONS: Project ECHO® is a feasible and impactful model for virtual education of interprofessional HCPs in managing pediatric pain.

Children's and young People's diabetes services: What works well and what doesn't?

Objectives: The first year of care, post diagnosis, is pivotal for children and young people diagnosed with type 1 diabetes. This study evaluated a paediatric type 1 diabetes intervention, the 'First Year of Care', designed to maximise the care that newly diagnosed children and young people received. Study design: An observational mixed methods approach, underpinned by the Influencer Framework. Methods: A purposeful, non-probability sample of children and young people with type 1 diabetes and their families, and healthcare professionals were invited to take part. Data were collected through medical records of thirty-two newly diagnosed children and young people, plus thirty seven semi-structured interviews and exposure to six concurrent sources of influence through a questionnaire. Results: For many participants, HbA1c levels were within the optimal range by the time of their first clinic visit post-diagnosis and continued to stay within this range throughout the first year of care. Healthcare professionals prioritised the 'First Year of Care' intervention. Positive practices included: a cohesive and collaborative approach; patient-centred care; latest health technology and embedded structured education. Unusually, different multidisciplinary team members were located in one place.Data indicated statistically significant differences in total sources of influence score (t [35] = 2.331, p = 0.026); healthcare professionals' scores were higher compared to children. This suggests that children and young people have less social capital to self-manage their diabetes effectively. Greater encouragement and assistance from healthcare professionals and social networks may be needed. Conclusions: This paper identifies contemporary issues in practice and highlights the strengths and challenges for a paediatric diabetes intervention. The findings confirm the potential of layered approaches to behaviour change in managing type 1 diabetes across multiple domains of influence. Our study strongly suggests enhancing social motivation among children, young people and families to support successful long-term engagement in a paediatric diabetes intervention. Findings demonstrate healthcare professionals are key in delivering the intervention, along with opportunities to improve patient care, experience and outcomes.

A Luminescent 1D Silver Polymer Containing [2.2]Paracyclophane Ligands.

[2.2]Paracyclophane scaffolds have seen limited use as building blocks in supramolecular chemistry. Here, we report the synthesis and characterization of a 1D coordination polymer consisting of silver(I) ions bound to a [2.2]paracyclophane scaffold functionalized with two 4-pyridyl units. The structure of the polymer has been determined from single crystal X-ray diffraction analysis and reveals two different silver coordination motifs that alternate along the 1D coordination polymer. The coordination polymer exhibits strong blue and sky-blue fluorescence in solution and in the crystalline solid state, respectively.

A scoping review of the experience of implementing population testing for SARS-CoV-2.

OBJECTIVES: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) - also known as the coronavirus disease (COVID-19) - pandemic has led to the swift introduction of population testing programmes in many countries across the world, using testing modalities such as drive-through, walk-through, mobile and home visiting programmes. Here, we provide an overview of the literature describing the experience of implementing population testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). STUDY DESIGN: Scoping review. METHODS: We conducted a scoping review using Embase, Medline and the Cochrane library in addition to a grey literature search. We identified indicators relevant to process, quality and resource outcomes related to each testing modality. RESULTS: In total, 2999 titles were identified from the academic literature and the grey literature search, of which 22 were relevant. Most studies were from the USA and the Republic of Korea. Drive-through testing centres were the most common testing modality evaluated and these provided a rapid method of testing whilst minimising resource use. CONCLUSIONS: The evidence base for population testing lacks high quality studies, however, the literature provides evaluations of the advantages and limitations of different testing modalities. There is a need for robust evidence in this area to ensure that testing is deployed in a safe and effective manner in response to the COVID-19 pandemic.

Wide-Bite-Angle Diphosphine Ligands in Thermally Activated Delayed Fluorescent Copper(I) Complexes: Impact on the Performance of Electroluminescence Applications.

We report a series of seven cationic heteroleptic copper(I) complexes of the form [Cu(P^P)(dmphen)]BF4, where dmphen is 2,9-dimethyl-1,10-phenanthroline and P^P is a diphosphine chelate, in which the effect of the bite angle of the diphosphine ligand on the photophysical properties of the complexes was studied. Several of the complexes exhibit moderately high photoluminescence quantum yields in the solid state, with ΦPL of up to 35%, and in solution, with ΦPL of up to 98%. We were able to correlate the powder photoluminescence quantum yields with the % Vbur of the P^P ligand. The most emissive complexes were used to fabricate both organic light-emitting diodes and light-emitting electrochemical cells (LECs), both of which showed moderate performance. Compared to the benchmark copper(I)-based LECs, [Cu(dnbp)(DPEPhos)]+ (maximum external quantum efficiency, EQEmax = 16%), complex 3 (EQEmax = 1.85%) showed a much longer device lifetime (t1/2 = 1.25 h and >16.5 h for [Cu(dnbp)(DPEPhos)]+ and complex 3, respectively). The electrochemiluminescence (ECL) properties of several complexes were also studied, which, to the best of our knowledge, constitutes the first ECL study for heteroleptic copper(I) complexes. Notably, complexes exhibiting more reversible electrochemistry were associated with higher annihilation ECL as well as better performance in a LEC.

A new method for investigating osteoarthritis using Fast Field-Cycling nuclear magnetic resonance.

Osteoarthritis in synovial joints remains a major cause of long-term disability worldwide, with symptoms produced by the progressive deterioration of the articular cartilage. The earliest cartilage changes are thought to be alteration in its main protein components, namely proteoglycan and collagen. Loss of proteoglycans bound in the collagen matrix which maintain hydration and stiffness of the structure is followed by collagen degradation and loss. The development of new treatments for early osteoarthritis is limited by the lack of accurate biomarkers to assess the loss of proteoglycan. One potential biomarker is magnetic resonance imaging (MRI). We present the results of a novel MRI methodology, Fast Field-Cycling (FFC), to assess changes in critical proteins by demonstrating clear quantifiable differences in signal from normal and osteoarthritic human cartilage for in vitro measurements. We further tested proteoglycan extracted cartilage and the key components individually. Three clear signals were identified, two of which are related predominantly to the collagen component of cartilage and the third, a unique very short-lived signal, is directly related to proteoglycan content; we have not seen this in any other tissue type. In addition, we present the first volunteer human scan from our whole-body FFC scanner where articular cartilage measurements are in keeping with those we have shown in tissue samples. This new clinical imaging modality offers the prospect of non-invasive monitoring of human cartilage in vivo and hence the assessment of potential treatments for osteoarthritis. Keywords: Fast Field-Cycling NMR; human hyaline cartilage; Osteoarthritis; T1 dispersion; quadrupolar peaks; protein interactions.

Anatomical study of the human sacral hiatus and implications for successful caudal epidural injection.

BACKGROUND: Caudal epidural injection (CEI) is a commonly used procedure to treat back and leg pain secondary to nerve root irritation, predominantly in the context of spinal canal stenosis. Key to a successful outcome is correct needle placement. Although fluoroscopic guidance confirms accurate needle placement, it does not help in determining the starting point, which can lead to multiple needle insertions. OBJECTIVE: This study aimed to determine the variability in size and position of the sacral hiatus and to identify reproducible surface landmarks to locate its position. METHODS AND STUDY DESIGN: 250 human sacral bones were examined, measuring morphology and structure. Vernier callipers accurate to 0.1 mm were used for measurements. Results were analysed using SPSS statistical software. RESULTS: Two specimens were excluded due to agenesis of the hiatus (0.8%). Of the remaining 248 specimens, it was found that the mean internal diameter of the sacral hiatus was 5.12 mm (SD 1.61). The position of the hiatus was variable but was most commonly found at the level of the fourth sacral vertebrae (62.9%, n = 156). Mean distance between the two superolateral sacral prominences was 64.15 mm (SD 6.5) and between superolateral sacral prominences (left and right) and apex of the hiatus were 63.21 mm (SD 10.9) and 63.34 mm (SD 10.87) respectively. CONCLUSION: Although there is a clear anatomical variance in the position and size of the sacral hiatus, this study suggests that surface anatomy landmarks can be used to form an equilateral triangle of which the inferior apex should correspond to the sacral hiatus. Knowledge of this surface anatomy may assist the correct location of the sacral hiatus and hence subsequently improve the efficacy of CEI.

Health professionals' views about who would benefit from using a closed-loop system: a qualitative study.

AIM: To explore health professionals' views about who would benefit from using a closed-loop system and who should be prioritized for access to the technology in routine clinical care. METHODS: Health professionals (n = 22) delivering the Closed Loop from Onset in type 1 Diabetes (CLOuD) trial were interviewed after they had ≥ 6 months' experience supporting participants using a closed-loop system. Data were analysed thematically. RESULTS: Interviewees described holding strong assumptions about the types of people who would use the technology effectively prior to the trial. Interviewees described changing their views as a result of observing individuals engaging with the closed-loop system in ways they had not anticipated. This included educated, technologically competent individuals who over-interacted with the system in ways which could compromise glycaemic control. Other individuals, who health professionals assumed would struggle to understand and use the technology, were reported to have benefitted from it because they stood back and allowed the system to operate without interference. Interviewees concluded that individual, family and psychological attributes cannot be used as pre-selection criteria and, ideally, all individuals should be given the chance to try the technology. However, it was recognized that clinical guidelines will be needed to inform difficult decisions about treatment allocation (and withdrawal), with young children and infants being considered priority groups. CONCLUSIONS: To ensure fair and equitable access to closed-loop systems, prejudicial assumptions held by health professionals may need to be addressed. To support their decision-making, clinical guidelines need to be made available in a timely manner.

The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis.

PURPOSE: Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented. METHODS: Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance. RESULTS: Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3-49.4) years, a median weight of 69.8 (61.0-81.5) Kg and a median body mass index of 23.8 (21.5-27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7-8) preoperatively and 3 (0.25-5.75) at 5 years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016). CONCLUSION: Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.

Working with Insulin, Carbohydrates, Ketones and Exercise to Manage Diabetes (WICKED): evaluation of a self-management course for young people with Type 1 diabetes.

AIMS: To evaluate a 5-day self-management education course for young people with Type 1 diabetes and assess its effects on knowledge, self-efficacy, beliefs, distress, self-management behaviours and HbA1c . METHODS: This is an evaluation of a structured education course. Young people (aged 16-24 years) with Type 1 diabetes were recruited from three diabetes centres. In the first centre, participants completed self-report measures of knowledge, self-efficacy, positive and negative outcome expectancies, and hypoglycaemic worries at baseline (n=47) and the end of the course (n=42). In two additional centres, participants completed these and other measures assessing self-management behaviours, cognitive adaptation to diabetes and diabetes distress at baseline (n=32), the end of the course (n=27) and 3-month follow-up (n = 27). HbA1c levels were recorded at baseline (n=79), 6 months (n=77) and 12 months (n=65). RESULTS: There were statistically significant increases in self-report knowledge, self-efficacy, positive outcome expectancies and self-management behaviours, and a statistically significant decrease in negative outcome expectances, between baseline and the end of the course. There were also statistically significant increases in self-report knowledge, self-efficacy, self-management behaviours and cognitive adaptation to diabetes between baseline and 3-month follow-up. Compared with baseline, HbA1c levels decreased by a mean (sd) of 5.44 (19.93) mmol/mol (0.48%) at 6 months (P=0.019), and by 5.98 (23.32) mmol/mol (0.54%) at 12 months (P =0.043). DISCUSSION: The results indicate the potential benefits of a self-management course designed to address the developmental needs and challenges faced by young people with Type 1 diabetes. Further studies with larger numbers and appropriate controls are required to confirm these initial findings.

The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers.

AIMS: An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians. METHODS: Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. Brief intervention was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics. RESULTS: We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women. CONCLUSIONS: Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

Use of sensor-integrated pump therapy to reduce hypoglycaemia in people with Type 1 diabetes: a real-world study in the UK.

AIMS: To assess the efficacy of insulin pumps with automated insulin suspension systems in a real-world setting. METHODS: We analysed anonymized data uploaded to CareLink™ by people (n=920) with Type 1 diabetes using the MiniMed Paradigm Veo system and the MiniMed 640G system (Medtronic International Trading Sàrl, Tolochanez, Switzerland) with SmartGuard technology, with or without automated insulin suspension enabled, between February 2016 and June 2018. Users with ≥15 days of sensor data and ≥70% sensor-wear time were classified as sensor-augmented pump alone, sensor-integrated pump with low glucose suspend enabled or sensor-integrated pump with predictive low glucose management enabled. RESULTS: The median (25th -75th percentile) system use was 161 (58-348) days. The median time spent with sensor glucose values ≤3 mmol/l was 0.8 (0.3-1.7)% in the sensor-augmented pump group, 0.3 (0.1-0.7)% in the sensor-integrated pump with low glucose suspend group, and 0.3 (0.1-0.5)% in the sensor-integrated pump with predictive low glucose management group. In individuals switching from sensor-augmented pump to sensor-integrated pump with low glucose suspend (n=31), there were significant reductions in the monthly rate of hypoglycaemic events <3 mmol/l (rate ratio 0.63, 95% CI 0.45-0.89; P=0.009) and in the percentage of time with glucose values ≤3 mmol/l [sensor-augmented pump: 0.63% (95% CI 0.34-1.29), sensor-integrated pump with low glucose suspend: 0.33% (95% CI 0.16-0.64); P=0.001]. The monthly rate of hypoglycaemic events decreased further in individuals (n=139) switching from sensor-integrated pump with low glucose suspend to sensor-integrated pump with predictive low glucose management [rate ratio 0.82 (95% CI 0.69-0.98); P<0.0274]. Similar results were seen for events <3.9 mmol/l. There was no difference in median time spent in target glucose range. CONCLUSION: Real-world UK data show that increasing automation of insulin suspension reduces hypoglycaemia exposure in people with Type 1 diabetes.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma.

INTRODUCTION: There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection. METHODS: Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre. RESULTS: There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant. CONCLUSION: Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.

Robot-Assisted Excision of Congenital Mega-Seminal Vesicle Associated with Zinner's Syndrome.

Background: Abnormalities of mesonephric ducts are rare congenital conditions, which can present with vague symptoms in otherwise healthy men. Zinner's syndrome is the association of an enlarged seminal vesicle cyst with ipsilateral renal agenesis, which can be symptomatic and require operative interventions. Case: We present the case of an otherwise healthy 24-year-old man who presented with a symptomatic 15 cm seminal vesicle cyst, which was completely excised using a robot-assisted approach. Conclusion: Use of robotic surgery for excision of large seminal vesicle cysts is a safe and effective operative procedure.

Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging.

BACKGROUND: Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy. METHODS: Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer. RESULTS: There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age. CONCLUSION: Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

A Type 1 diabetes technology pathway: consensus statement for the use of technology in Type 1 diabetes.

In both adults and children with diabetes, technologies such as continuous subcutaneous insulin infusion using insulin pumps and continuous glucose monitoring can help improve diabetes control, reduce hypoglycaemia and improve quality of life. Access to these technologies in the UK is very variable. Some technologies are recommended by the National Institute for Health and Care Excellence, while others have not been appraised, and new technologies are emerging all the time. Additionally, different guidelines for adults and children further complicate access to diabetes technology in the transition from paediatric to adult care. Against this background, Diabetes UK and NHS England have brought together a multidisciplinary group of experts, including clinicians and people with diabetes, to develop this consensus guideline, combining the different technologies into a common pathway to aid clinical and policy decision-making. We created a pathway that supports the incremental addition of technology as monotherapy and then dual therapy in the same way that we incrementally add in therapeutic agents to support people with Type 2 diabetes to achieve their personalized glycaemic targets. The pathway emphasizes the importance of structured education, specialist support and appropriate access to psychological therapies, as essential pillars for optimized use of diabetes-related technology, and recommends the re-evaluation of its use when the individual is unable either to use the technology appropriately or to achieve the intended outcomes. This pathway is endorsed by UK-wide clinical and patient associations and we recommend that providers and commissioners use it to ensure the right individual with diabetes has access to the right technology in a timely way to help achieve better outcomes.

Penetrating facial trauma from a Taser barb.

The Taser X26® (Axon) is a conducted energy device that is used by the police forces in the United Kingdom to deliver a high voltage shock that will disable a person. Injuries related to its use are uncommon but can be serious, the extent of the damage caused being related to the structures targeted and the length of deployment of the electrical charge. We describe a 15-year-old boy who had a penetrating midfacial injury after deployment of a Taser, the barb of which became embedded in the subtarsal region of his left cheek. Removal under general anaesthetic was uncomplicated, and exploration of the wound showed that there was no damage to adjacent structures. Case reports of this type are limited, and we know of none of a penetrating injury of the midface.

HbA1c values and hospital admissions in children and adolescents receiving continuous subcutaneous insulin infusion therapy.

AIMS: To assess HbA1c values and hospitalization rates before, during and after continuous subcutaneous insulin infusion (CSII) therapy. METHODS: Demographic and hospitalization data were extracted from 161 individuals with Type 1 diabetes who received continuous subcutaneous insulin infusion (CSII) therapy between 2002 and 2013 at the Leeds Children and Young People's Diabetes Service for those aged < 20 years. The median (range) age at CSII start was 11.9 (1.1-17.6) years. The median (range) follow-up time was 2.3 (0-8.1) years. Random intercept models were used to compare HbA1c values before and during CSII initiation (and after CSII for those who discontinued it). Hospitalization rates were calculated for diabetic ketoacidosis and severe hypoglycaemia. RESULTS: The mean HbA1c concentration decreased by 7 mmol/mol [95% CI 6-8; 0.6% (95% CI 0.5-0.7%)]. For the discontinued group (n=30), mean HbA1c decreased by 5 mmol/mol [95% CI 2-8; 0.4% (95% CI 0.2-0.7%)]. HbA1c returned to pre-CSII start levels at the end of this therapy. Diabetic ketoacidosis admissions increased threefold during CSII compared with before CSII start [2.2 per 100 person-years (95% CI 1.3 to 3.6) vs 7.4 per 100 person-years (95% CI 5.1 to 10.8)] and was highest during the first year of CSII. No difference in severe hypoglycaemia incidence rate was found during CSII compared with the pre-CSII period. CONCLUSIONS: Despite significant reductions in HbA1c levels for individuals treated with CSII, improvements are needed to reduce diabetic ketoacidosis hospitalizations for those new to the therapy.

The impact of using a closed-loop system on food choices and eating practices among people with Type 1 diabetes: a qualitative study involving adults, teenagers and parents.

AIMS: We explored whether, how and why moving onto and using a hybrid day-and-night closed-loop system affected people's food choices and dietary practices to better understand the impact of this technology on everyday life and inform recommendations for training and support given to future users. METHODS: Twenty-four adults, adolescents and parents were interviewed before commencing use of the closed-loop system and following its 3-month use. Data were analysed thematically and longitudinally. RESULTS: While participants described preparing and/or eating similar meals to those consumed prior to using a closed-loop, many described feeling more normal and less burdened by diabetes in dietary situations. Individuals also noted how the use of this technology could lead to deskilling (less precise carbohydrate counting) and less healthy eating (increased snacking and portion sizes and consumption of fatty, energy-dense foods) because of the perceived ability of the system to deal with errors in carbohydrate counting and address small rises in blood glucose without a corrective dose needing to be administered. CONCLUSIONS: While there may be quality-of-life benefits to using a closed-loop, individuals might benefit from additional nutritional and behavioural education to help promote healthy eating. Refresher training in carbohydrate counting may also be necessary to help ensure that users are able to undertake diabetes management in situations where the technology might fail or that they take a break from using it.