Technology Integration: The Role of the Diabetes Care and Education Specialist in Practice.

PURPOSE: Technology is rapidly evolving and has become an integral component of diabetes care. People with diabetes and clinicians are harnessing a variety of technologies, including connected blood glucose meters, continuous glucose monitors, insulin pumps, automated insulin delivery systems, data-sharing platforms, telehealth, remote monitoring, and smartphone mobile applications to improve clinical outcomes and quality of life. Although diabetes technology use is associated with improved outcomes, this is enhanced when the person using it is knowledgeable and actively engaged; simply wearing the device or downloading an app may not automatically translate into health benefits. The diabetes care and education specialist (DCES) has a central role in defining and establishing a technology-enabled practice setting that is efficient and sustainable. The purpose of this article is to describe the role of the DCES in technology implementation and to demonstrate the value of diabetes technology in both the care of the individual and as a tool to support population-level health improvements. CONCLUSION: By following the recommendations in this article, DCESs can serve as technology champions in their respective practices and work to reduce therapeutic inertia while improving health outcomes and providing patient-centered care for the populations they serve.

Convergent molecular evolution among ash species resistant to the emerald ash borer.

Recent studies show that molecular convergence plays an unexpectedly common role in the evolution of convergent phenotypes. We exploited this phenomenon to find candidate loci underlying resistance to the emerald ash borer (EAB, Agrilus planipennis), the United States' most costly invasive forest insect to date, within the pan-genome of ash trees (the genus Fraxinus). We show that EAB-resistant taxa occur within three independent phylogenetic lineages. In genomes from these resistant lineages, we detect 53 genes with evidence of convergent amino acid evolution. Gene-tree reconstruction indicates that, for 48 of these candidates, the convergent amino acids are more likely to have arisen via independent evolution than by another process such as hybridization or incomplete lineage sorting. Seven of the candidate genes have putative roles connected to the phenylpropanoid biosynthesis pathway and 17 relate to herbivore recognition, defence signalling or programmed cell death. Evidence for loss-of-function mutations among these candidates is more frequent in susceptible species than in resistant ones. Our results on evolutionary relationships, variability in resistance, and candidate genes for defence response within the ash genus could inform breeding for EAB resistance, facilitating ecological restoration in areas invaded by this beetle.

A better way to die.

When palliative care expert Jane Carpenter's homeless cousin died in a traffic accident and a post-mortem revealed he had advanced cancer, she decided to make a difference for others like him.

Gardening your way to health.

A King's Fund report published in May found overwhelming evidence of the beneficial effects of gardening on physical and mental wellbeing.

Taking the plunge with lipoedema.

Women wait decades for an accurate diagnosis of lipoedema. Earlier diagnosis is essential to prevent the condition progressing to lymphoedema, with its risk of life-threatening cellulitis.

Raising the standard of brain cancer care.

Survival rates for people with brain cancer are poor, and some patients do not receive the specialist support they need. Nurse specialist Ingela Oberg calls for earlier diagnosis and improved access to nurse-led clinics and rehabilitation services.

Shaping the future of epilepsy care.

Juliet Ashton has a national role supporting CCGs to improve epilepsy services. Her role involves raising healthcare professionals' awareness of this complex and under-resourced condition, and working closely with clinical commissioning groups to redesign services and encourage investment.

Understanding and measuring health care insecurity.

PURPOSE: To define the concept of "health care insecurity," validate a new self-report measure, and examine the impact of beginning care at a free clinic on uninsured patients' health care insecurity. METHODS: Consecutive new patients presenting at a free clinic completed 15 items assessing domains of health care insecurity (HCI) at their first visit and again four to eight weeks later. Psychometrics and change of the HCI measure were examined. RESULTS: The HCI measure was found to have high internal consistency (α=0.94). Evidence of concurrent validity was indicated by negative correlation with VR-12 health-related quality of life physical and mental health components and positive correlation with the Perceived Stress Scale. Predictive validity was shown among the 83% of participants completing follow-up: HCI decreased after beginning care at a free clinic (p<.001). CONCLUSION: Reliably assessing patient experience of health care insecurity is feasible and has potential to inform efforts to improve quality and access to care among underserved populations.

How well do physician and patient visit priorities align?

This study found that there is alignment between a patient's reason for a visit and the physician's main concern 69% of the time. Less than fully aligned priorities were associated with insurance status and the number of problems addressed.

Creating a culture of inquiry in family medicine.

BACKGROUND AND OBJECTIVES: Strengthening the contribution of reflective practice and new knowledge generation to the learning relationships forged during graduate and undergraduate medical training offers a possibility to create a climate more conducive to the recruitment and retention of family physicians. The Culture of Inquiry (CI) fellowship, an immersive, experientially based training program, combines didactic instruction, workshops, and mentoring to develop the capacity of family medicine's teachers to imagine, implement, and disseminate clinically relevant research and stimulate collaborations with those whom they train. This article outlines the CI fellowship program, summarizes its outcomes, and offers insights about programmatic features contributing to its success. METHODS: The Department of Family Medicine and Community Health at Case Western Reserve University selected CI fellows from interested local family physicians who train residents and medical students. Over 10 months, with 10% effort expected from fellows, the CI fellowship exposed each fellow to the entire research process and provided technical and logistical support for the design and completion of two research projects. Quantitative and qualitative program evaluation were used to assess outcomes. RESULTS: Scholarly productivity of fellows exceeded expectations. Collaborations with students and residents produced a ripple effect that amplified the fellowship's impact by strengthening those relationships crucial to the creation of a culture of inquiry among family medicine's teachers, learners, and practitioners. CONCLUSIONS: The CI fellowship represents a highly replicable program to connect committed and interested clinicians to research mentors with the goal of increasing scholarship and creating a growing culture of inquiry in family medicine.

Acute teams respond to emergency cancer call.

Acutely ill cancer patients who present at A&E can receive inadequate care. Innovative acute oncology services are being introduced to fill gaps in emergency staff's knowledge and ensure rapid referral to appropriate care.

Teachable moments for health behavior change and intermediate patient outcomes.

OBJECTIVE: Teachable moments (TM) are opportunities created through physician-patient interaction and used to encourage patients to change unhealthy behaviors. We examine the effectiveness of TMs to increase patients' recall of advice, motivation to modify behavior, and behavior change. METHODS: A mixed-method observational study of 811 patient visits to 28 primary care clinicians used audio-recordings of visits to identify TMs and other types of advice in health behavior change talk. Patient surveys assessed smoking, exercise, fruit/vegetable consumption, height, weight, and readiness for change prior to the observed visit and 6-weeks post-visit. RESULTS: Compared to other identified categories of advice (i.e. missed opportunities or teachable moment attempts), recall was greatest after TMs occurred (83% vs. 49-74%). TMs had the greatest proportion of patients change in importance and confidence and increase readiness to change; however differences were small. TMs had greater positive behavior change scores than other categories of advice; however, this pattern was statistically non-significant and was not observed for BMI change. CONCLUSION: TMs have a greater positive influence on several intermediate markers of patient behavior change compared to other categories of advice. PRACTICE IMPLICATIONS: TMs show promise as an approach for clinicians to discuss behavior change with patients efficiently and effectively.

Easing ICU trauma.

There is growing awareness that patients in intensive care can be severely stressed by their experiences and are at risk of developing mental health problems. A major trial, beginning in a London ICU, will test simple nursing techniques that may reduce patients' stress, and offer support to patients who are most affected.

A technological approach.

Interventional radiology is a growth area for nurses. The micro-invasive procedures are safer for patients than conventional surgical techniques. They are also highly rewarding for nurses who enjoy working with technology and supporting patients, says specialist nurse Mary Donnelly.

Another first for nursing.

Traditionally, doctors have ordered blood transfusions, but nurses are learning to take on this role. Since his training last year, nurse practitioner and prescriber Steve Wright has been authorising blood transfusions on a surgical ward in a London hospital and seeing the benefits for patients.

A case control study of bacterial species and colony count in milk of breastfeeding women with chronic pain.

BACKGROUND: An infectious etiology for chronic breast pain in breastfeeding women continues to be debated. Although recent data suggest that Staphylococcus aureus and coagulase-negative Staphylococcus (CNS) may cause chronic breast pain, no studies have used quantitative cultures to address this question. In this study we compared bacterial species and colony counts between breastfeeding women with (cases) and without (controls) chronic pain. SUBJECTS AND METHODS: We enrolled 114 breastfeeding women in a prospective cohort study. Cases (n=61), breastfeeding women with breast pain for >1 week and no signs of acute infection, were matched with controls (n=53) by weeks postpartum and parity. RESULTS: More cases had a history of mastitis (14% vs. 2%, p=0.036), cracked nipples (64% vs. 17%, p=0.001), and other breastfeeding difficulties. Enterobacter species growth was less likely in cases (0% vs. 7.5%, p=0.029). Cases had a significantly higher growth of S. aureus (19.7% vs. 1.9%, p=0.003). CNS frequency was similar between groups (75% vs. 79%, p=0.626), but median colony count growth was significantly lower in cases (900 colony-forming units/mL vs. 5,000 colony-forming units/ml, p=0.003). Growth of CNS and S. aureus was negatively correlated (r=-0.265, p=0.004). CONCLUSIONS: Higher S. aureus growth in cases supports a pathogenic role for S. aureus and reinforces the need for future antibiotic treatment studies in breastfeeding women with chronic pain. In contrast, similar CNS frequency between groups, lower CNS colony counts in cases, and a negative correlation between S. aureus and CNS growth suggest that neither CNS, nor its overgrowth, causes chronic breast pain.