Background. Individuals with cystic fibrosis (CF) have persistent lung infections, necessitating the frequent use of antibiotics for pulmonary exacerbations. Some respiratory pathogens have intrinsic resistance to the currently available antibiotics, and any pathogen may acquire resistance over time, posing a challenge to CF care. Gaseous nitric oxide has been shown to have antimicrobial activity against a wide variety of microorganisms, including common CF pathogens, and offers a potential inhaled antimicrobial therapy. Case Presentation. Here, we present the case of a 16-year-old female with CF who experienced a precipitous decline in lung function over the prior year in conjunction with worsening antibiotic resistance of her primary pathogen, Burkholderia multivorans. She received 46 intermittent inhalations of 160 parts-per-million nitric oxide over a 28-day period. The gas was administered via a mechanical ventilator fitted with nitrogen dioxide scavenging chambers. Conclusions. High-dose inhaled nitric oxide was safe, well tolerated, and showed clinical benefit in an adolescent with cystic fibrosis and pulmonary colonization with Burkholderia multivorans.

AimThis study investigates the relationship between basal insulin regimen and glycaemic outcomes 12 months after skills‐based structured education in the UK Dose Adjustment for Normal Eating (DAFNE) programme for Type 1 diabetes mellitus.MethodRetrospective analysis of data from 892 DAFNE participants from 11 UK centres.ResultsMean HbA1c 12 months after DAFNE was lower in those using twice‐ rather than once‐daily basal insulin after correcting for differences in baseline HbA1c, age and duration of diabetes; difference –2 (95% CI –3 to –1) mmol/mol [–0.2 (–0.3 to –0.1)%], P = 0.009. The greatest fall in HbA1c of –5 (–7 to –3) mmol/mol [–0.4 (–0.6 to –0.3)%], P < 0.001 occurred in those with less good baseline control, HbA1c ≥ 58 mmol/mol, who switched from once‐ to twice‐daily basal insulin. There was no difference in the 12‐month HbA1c between users of glargine, detemir and NPH insulin after correcting for other variables. Relative risk of severe hypoglycaemia fell by 76% and ketoacidosis by 63% 12 months after DAFNE. The rate of severe hypoglycaemia fell from 0.82 to 0.23 events/patient year in twice‐daily basal insulin users. In the group with greatest fall in HbA1c, the estimated relative risk for severe hypoglycaemia in twice‐daily basal insulin users versus once daily at 12 months was 1.72 (0.88–3.36, P = 0.110).ConclusionAfter structured education in adults with Type 1 diabetes mellitus, use of basal insulin twice rather than once daily was associated with lower HbA1c, independent of insulin type, with significant reductions in severe hypoglycaemia and ketoacidosis in all groups.

Background: Perioperative hyperglycemia can have an even more detrimental effect on postoperative outcomes in patients without diabetes than in patients with diabetes, but it has not been established if the treatment of patients without diabetes is safe and effective. We hypothesized that sliding-scale insulin for severe postoperative hyperglycemia (glucose ≥180 mg/dL) could lower mean postoperative glucose levels and minimize short-term complications in patients without diabetes undergoing major joint replacement. Methods: In a prospective study group, 1,398 consecutive patients, with and without diabetes, undergoing joint replacement were monitored and treated for hyperglycemia and were compared with 886 historical, less frequently monitored controls. The primary outcome was the mean glucose level in patients with and without diabetes within 48 hours after the surgical procedure. Two secondary outcomes could be examined only in the prospective study group, which, by design, had much more frequent glucose sampling and insulin use than the historical controls. First, the contribution of comorbidities and procedural factors to postoperative hyperglycemia in patients without diabetes was assessed with multivariable linear regression. Second, the ability of insulin treatment to reduce complications in patients without diabetes who developed hyperglycemia was evaluated. Results: In comparison with 886 historical controls, enhanced glucose management lowered the mean glucose (and standard deviation) from 129 ± 28 mg/dL to 123 ± 23 mg/dL for patients without diabetes (p = 0.041). Multivariable linear regression revealed factors that contributed to elevated mean glucose in patients without diabetes: preoperative fasting glucose (p < 0.001), perioperative steroid use (p < 0.001), general anesthesia (p < 0.001), procedure duration (p = 0.003), and transfusion (p 0.008). Of 968 patients without diabetes, 203 developed severe hyperglycemia. The recommended insulin coverage was given to 129 of these patients, and 74 patients did not receive it for various clinical reasons. Insulin treatment reduced the frequency of positive cultures from any site (p = 0.025) and a composite of positive cultures and readmissions (p = 0.006) in comparison with no insulin treatment. No patient without diabetes who received insulin experienced mild or severe hypoglycemia. Conclusions: Postoperative hyperglycemia is frequent in patients without diabetes after orthopaedic surgery, but an enhanced glucose management program can lower mean postoperative glucose levels. The treatment of hyperglycemia in patients without diabetes reduced short-term complications and was associated with minimal side effects. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Perceptions of police trustworthiness are linked to citizens' willingness to cooperate with police. Trust can be fostered by introducing accountability mechanisms, or by increasing a shared police/citizen identity, both which can be achieved digitally. Digital mechanisms can also be designed to safeguard, engage, reassure, inform, and empower diverse communities. We systematically scoped 240 existing online citizen-police and relevant third-party communication apps, to examine whether they sought to meet community needs and policing visions. We found that 82% required registration or login details, 55% of those with a reporting mechanism allowed for anonymous reporting, and 10% provided an understandable privacy policy. Police apps were more likely to seek to reassure, safeguard and inform users, while third-party apps were more likely to seek to empower users. As poorly designed apps risk amplifying mistrust and undermining policing efforts, we suggest 12 design considerations to help ensure the development of high quality/fit for purpose Police/ Citizen apps.

A patient with diabetes developed a foot ulcer after wearing new slippers.⇓ Fourteen patients with new ulcers were seen in the diabetic foot clinic in the first 10 working days of 2012. Seven of them stated that new slippers for Christmas were implicated in their ulceration. Appropriate footwear is a critical component of diabetic foot care. Patients are educated about the need for adapted shoes and insoles, but also need to be aware of the risk of using non-prescribed footwear, including slippers.