Proactive review for people with diabetes in hospital: a cluster randomised feasibility trial with process evaluation, protocol V3.1.

BACKGROUND: Diabetes inpatient specialist services vary across the country, with limited evidence to guide service delivery. Currently, referrals to diabetes inpatient specialists are usually 'reactive' after diabetes-related events have taken place, which are associated with an increased risk of morbidity/mortality and increased length of hospital stay. We propose that a proactive diabetes review model of care, delivered by diabetes inpatient specialist nurses, may contribute to the prevention of such diabetes-related events and result in a reduction in the risk of harm. METHOD: We will conduct a cluster randomised feasibility study with process evaluation. The proactive diabetes review model (PDRM) is a complex intervention that focuses on the prevention of potentially modifiable diabetes-related harms. All eligible patients will receive a comprehensive, structured diabetes review that aims to identify and prevent potentially modifiable diabetes-related harms through utilising a standardised review structure. Reviews are undertaken by a diabetes inpatient specialist nurse within one working day of admission. This differs from usual care where patients are often only seen after diabetes-related harms have taken place. The trial duration will be approximately 32 weeks, with intervention delivery throughout. There will be an initial 8-week run-in phase, followed by a 24-week data collection phase. Eight wards will be equally randomised to either PDRM or usual care. Adult patients with a known diagnosis of diabetes admitted to an included ward will be eligible. Data collection will be limited to that typically collected as part of usual care. Data collected will include descriptive data at both the ward and patient level and glucose measures, such as frequency and results of capillary glucose testing, ketonaemia and hypoglycaemic events. The analysis aims to determine the fidelity and acceptability of the intervention and the feasibility of a future definitive trial. Whilst this study is primarily about trial feasibility, the findings of the process evaluation may lead to changes to both trial processes and modifications to the intervention. A qualitative process evaluation will be conducted in parallel to the trial. A minimum of 22 patients, nurses, doctors, and managers will be recruited with methods including direct non-participant observation and semi-structured interviews. The feasibility of a future definitive trial will be assessed by evaluating recruitment and randomisation processes, staffing resources and quality of available data. DISCUSSION: The aim of this cluster randomised feasibility trial with a process evaluation is to explore the feasibility of a definitive trial and identify appropriate outcome measures. If a trial is feasible and the effectiveness of PDRM can be evaluated, this could inform the future development of inpatient diabetes services nationally. TRIAL REGISTRATION: UK Clinical Research Network, 51,167. ISRCTN, ISRCTN70402110. Registered on 21 February 2022.

Implementation of fully closed-loop insulin delivery for inpatients with diabetes: Real-world outcomes.

AIMS: Fully closed-loop insulin delivery has been shown in clinical trials to be safe and improve glucose control compared with standard insulin therapy in the inpatient setting. We investigated the feasibility of implementing the approved CamAPS HX fully closed-loop system in a hospital setting. METHODS: This implementation project was conducted in a large teaching hospital in Cambridge, UK. Healthcare professional training was multimodal including face-to-face workshops, online learning modules and supported by standard operating procedures. Set-up and maintenance of closed-loop devices were undertaken by the inpatient diabetes team. Selection of suitable patients was multidisciplinary and prioritised those with more challenging diabetes management. Demographic and clinical data were collected from electronic health records and diabetes data management platforms. RESULTS: In the 12 months since the closed-loop system was implemented, 32 inpatients (mean ± SD age 61 ± 16 years, 8 females, 24 males) used closed-loop insulin delivery during their admission, across medical and surgical wards in the hospital with a total of 555 days of closed-loop glucose control (median [IQR]: 14 [6, 22] days per inpatient). The time spent in target glucose range 3.9-10.0 mmol/L was 53.3 ± 18.3%. Mean glucose was 10.7 ± 1.9 mmol/L with 46.0 ± 18.2% of time spent with glucose >10.0 mmol/L. Time spent with sensor glucose below 3.9 mmol/L was low (median [IQR]: 0.38 [0.00, 0.85]). There were no episodes of severe hypoglycaemia or diabetic ketoacidosis during closed-loop use. CONCLUSIONS: We have demonstrated that the fully closed-loop system can be safely and effectively implemented by a diabetes outreach team in complex medical and surgical inpatients with challenging glycaemic control.

The Effects of a Teacher-Implemented Video-Enhanced Activity Schedule Intervention on the Mathematical Skills and Collateral Behaviors of Students with Autism.

This study used a multiple probe design to evaluate the effects of a teacher-implemented video-schedule intervention on the mathematical skills and untargeted challenging behaviors of five elementary-school students with autism. Results indicated that the intervention was effective in improving participants' academic performance, and a decrease in the level of challenging behaviors and stereotypy was observed for participants following the introduction of intervention. Additionally, academic gains generalized across academic problems and to a small group setting, suggesting that this technology-based intervention is an efficient use of instructional time. Future research targeting a variety of academic skills and examining intervention implementation by additional practitioners (e.g., teaching assistants) is warranted.

Teaching Children with Autism Abduction-Prevention Skills May Result in Overgeneralization of the Target Response.

We replicated previous research using behavioral skills training (BST) to teach four children with autism to engage in a safety response following lures from civilian strangers. This study extends previous research by (a) employing abduction lures incorporating highly preferred tangible items; (b) assessing for maintenance and generalization across settings and caregivers; and (c) probing for overgeneralization of the safety response. A multiple baseline across participants design demonstrated target behavior acquisition and generalization to novel settings and caregivers. However, children who complied with directions from police officers during baseline emitted the safety response (e.g., running away) when approached by police officers following BST. Overgeneralization of the targeted safety response was corrected with discrimination training procedures. Maintenance of appropriate responses to civilians and officers was inconsistent and booster sessions were required for two participants. Results suggest practitioners should incorporate discrimination training and program for maintenance when teaching abduction-prevention skills to children with autism.

Behavioral Skills Training to Improve the Abduction-Prevention Skills of Children with Autism.

A concurrent multiple baseline across participants design evaluated the effects of behavioral skills training (BST) on abduction-prevention skills of four children with autism. Across phases, confederates presented four types of abduction lures: (a) simple requests, (b) appeals to authority, (c) assistance requests, and (d) incentives. During baseline, lures resulted in children leaving with confederate strangers. During intervention, BST targeted a three-step response (i.e., refuse, move away, and report) and the abduction-prevention skills of all participants improved. Improvements generalized to novel settings and confederates and were maintained at 4 weeks. There is currently limited research on abduction-prevention pertaining to individuals with ASD. BST can be used to teach abduction-prevention skills to individuals with ASD. BST can be effective at teaching appropriate responses to multiple types of abduction lures. The effects of BST on multiple responses to multiple types of lures can generalize across settings and people and maintain over time.

Effects of script training on the peer-to-peer communication of children with autism spectrum disorder.

A multiple baseline design across participants was used to demonstrate the effects of a script-training procedure on the peer-to-peer communication of 3 children with autism spectrum disorder during group play with peers. Both scripted and unscripted initiations as well as responses to peers increased for all 3 participants. Stimulus generalization across novel toys, settings, and peers was observed. Novel unscripted initiations, responses, and appropriate changes in topics during peer-to-peer exchanges were analyzed by considering the cumulative frequency of these behaviors across phases of the study. Treatment gains were maintained during 4-week follow-up sessions. Results are discussed in terms of recommendations for practitioners, response variability, and potential future avenues of research.

Comparison of therapist implemented and iPad-assisted interventions for children with autism.

OBJECTIVE: This study compares intervention delivered by a therapist to intervention delivered using an iPad for two children with autism. Further, this study evaluates the influence of choice between the conditions. METHODS: Time on-task, challenging behaviour, session duration and correct responses were compared across conditions in an alternating treatment design. The effect of choice was evaluated in an ABAB design. RESULTS: The iPad was associated with shorter intervention sessions, more time on-task and less challenging behaviour for one participant. There was no difference between conditions for the second participant. Both participants selected the iPad when given the choice and, although the effect of choice was modest, choosing was associated with more time on-task and less challenging behaviour. CONCLUSIONS: These data suggest that iPad-assisted intervention can be as effective as therapist-implemented intervention. Further, even for children for whom no differences between the interventions exist, offering a choice may be beneficial.

Functional analysis and treatment of diurnal bruxism.

An analogue functional analysis identified attention as a function for a 5-year-old boy's bruxism (teeth grinding). Functional communication training resulted in a reduction of bruxism and an increase in alternative mands for attention. Results were maintained 3 weeks following the intervention.

An analysis of the generalization and maintenance of eye contact taught during play.

PURPOSE: Differential reinforcement and most-to-least prompting were implemented within the context of developmentally appropriate play activities in an effort to improve the eye contact between a 4-year-old boy with pervasive developmental disorder-not otherwise specified (PDD-NOS) and his three therapists. METHODS: A multiple baseline design across therapists was used to examine the eye contact of a 4-year-old boy with PDD-NOS. Maintenance data were collected at 1, 2 and 3 months post intervention. RESULTS: The intervention was effective and improvements in eye contact were maintained for at least 3 months post intervention. However, eye contact did not readily generalize across communication partners. CONCLUSIONS: Results suggest that eye contact may not generalize to communication partners who are not directly involved in intervention. Results are discussed in terms of implications for practitioners and directions for future research.

Successful use of acarbose to manage post-prandial glycaemia in two patients with type 1 diabetes on continuous subcutaneous insulin infusion.

Post-prandial hyperglycaemia is a particular problem for some patients with diabetes despite administering continuous subcutaneous insulin infusion (CSII) to deliver insulin flexibly. We describe two cases of patients on CSII with persistent post-prandial hyperglycaemia despite varying insulin doses and timing. Treatment with acarbose improved their glycaemic control.