External validation and sub-cohort analysis of stochastic forecasting models in NICU cohorts

Hyperglycaemia is a prevalent complication in the neonatal intensive care unit (NICU) and is associated with worsened outcomes. It occurs as a result of prematurity, under-developed endogenous glucose regulatory systems, and clinical stress. The stochastic targeting (STAR) framework provides patient-specific, model-based glycaemic control with a clinically proven level of confidence on the outcome of treatment interventions, thus directly managing the risk of hypo- and hyper-glycaemia. However, stochastic models that are over conservative can limit control performance. Retrospective clinical data from 61 episodes (25 retrospective to STAR, and 36 from a prospective-STAR blood glucose control study) of insulin therapy in very-low birth weight (VLBW) and extremely-low birth weight (ELBW) neonates are used to create a new stochastic model of model-based insulin sensitivity (S_I [L/mU/min]). Sub-cohort models based on gestational age (GA) and birth weight (BW) are also created. Performance is assessed by the percentage of patients who have 90% of actual intra-patient variability in S_I captured by the 90% confidence bands of the cohort based (inter-patient) stochastic variability model created. This assessment measures per-patient accuracy for any given cohort model.Per-patient coverage trends were very similar between prospective and retrospective cohorts, providing a measure of external validation of cohort similarity. Per-patient coverage was improved through the use of BW and GA dependent stochastic models, which ensures that the stochastic models more accurately capture both inter- and intra-patient variability. Stochastic models based on insulin sensitivities during insulin treatment periods are tighter, and give better and safer glycaemic control. Overall it seems that inter-patient variation is more significant than intra-patient variation as a limiting factor in this stochastic forecasting model, and a small number of patients are essentially different in behaviour. More patient specific methods, particularly in the modelling of endogenous insulin and glucose production, will be required to further improve forecasting and glycaemic control.     

Criticizing and Reforming Segregated Facilities for Persons with Disabilities

In this paper, we critically appraise institutions for people with disabilities, from residential facilities to outpatient clinics to social organizations. While recognizing that a just and inclusive society would reject virtually all segregated institutional arrangements, we argue that in contemporary American society, some people with disabilities may have needs that at this time can best be met by institutional arrangements. We propose ways of reforming institutions to make them less isolating, coercive, and stigmatizing, and to provide forms of social support the larger society denies many people with disabilities. Although these reforms far fall far short of abolition, they draw heavily on the work of disability scholars and advocates who call for the complete replacement of institutional arrangements with systems of supported living. The consideration of non-ideal-solutions is useful not only in reforming existing institutional arrangements, but in bringing disability scholarship and advocacy to bear on bioethics, which has paid little attention to institutions for people with disabilities. We intend this paper to redress the neglect within mainstream bioethics of the complex ethical problems posed by institutions.     

More Active Mums in Stirling (MAMMiS): a physical activity intervention for postnatal women. Study protocol for a randomised controlled trial

ABSTRACT: BACKGROUND: Many postnatal women are insufficiently physically active in the year after childbirth and could benefit from interventions to increase activity levels. However, there is limited information about the efficacy, feasibility and acceptability of motivational and behavioural interventions to promoting postnatal physical activity in the UK. METHODS: The MAMMiS study is a randomised controlled trial, conducted within a large National Health Service (NHS) region in Scotland. 76 postnatal women will be recruited to test the impact of two physical activity consultations and a 10-week group pram-walking programme on physical activity behaviour change. The intervention uses evidence-based motivational and behavioural techniques and will be systematically evaluated using objective measures (accelerometers) at 3-months, with a maintenance measure taken at 6-months follow-up. Secondary health and well-being measures and psychological mediators of physical activity change are included. DISCUSSION: The MAMMiS study will provide a test of a theoretical and evidence-based physical activity behaviour change intervention for postnatal women and provide information to inform future intervention development and testing within this population.