CAPT. Chad Garrett 0:33 Mr. Smith, my clock says 10 o'clock. Do you want to go ahead and kick us off? I can do that. Thanks, Christopher Smith, NPA 0:40 Captain Garrett, and good afternoon or good morning everybody, depending on where you are, hello and good and welcome to the National Institute of Corrections clinical pearls webinar series. My name is Chris Smith, and I'm a national program advisor with the National Institute of Corrections, and we are thrilled that you have joined us for our for this episode of our informative nine part series exploring the integration of clinical pharmacists into primary care and highlighting proven approaches for correctional team medicine. Before we begin today's session, I would like to cover a few important housekeeping items. First, each webinar in this series is scheduled to last approximately an hour, the sessions will be recorded and once captioned and made, 508 compliant will be available on the NIC website. This is a Listen Only event, meaning participant microphones are muted. However, we strongly encourage engagement through the web chat or the WebEx chat function. Please use the chat to share your thoughts, ask questions and request technical support. We will address as many questions as possible during the Q and A portion at the end of the webinar. To practice the chat function, everyone, please type the answer to the following question into your chat. What is your favorite food dish? So if everybody could practice typing into their chat what their favorite food dish is, CAPT. Chad Garrett 2:07 Amy says sushi. Christopher Smith, NPA 2:13 That would be my son's favorite. Not mine. Got lasagna, barbecue. I excellent chocolate cake gumbo, thanks guys. All right. If you experience any audio difficulties, we recommend connecting to the webinar, audio via telephone using the number provided in your registration confirmation email throughout this series, we want to hear from you. You can always email the Health Programs Manager, Captain Chad Garrett at ca Garrett at C, A, G, A, R, R, E, T, T, dot B O P, or at B O p.gov, with any questions, concerns or ideas for future events. I and my team here at Nic, including some great staff from the NIC library, will be posting information in the chat during this presentation. Again, if you have any questions, please type them in the chat. I'll collect them, and then at the end, we'll answer as many as we can at the end of the webinar, thank you again for joining our webinar, and now I hand you over to Captain Chad Garrett. Hey. CAPT. Chad Garrett 3:20 Thank you, Chris. Welcome everybody. As we begin the clinical pearls webinar series, and we're bringing it to a close, we're proud to highlight a session that epitomizes the intersection of innovation and clinical practicality diabetes technology in a secure environment, in an era where rapid advances in diabetes technology or transforming care, clinicians working in secure facilities must navigate the dual challenge of staying current while adapting these tools to the realities personal health care. So today's presentation showcases two Trail Blazers in the Federal Bureau of Prisons who have pioneered the integration of diabetes technology into correctional practice, Commander Josh bell gardeson and Commander Drew switer, let me introduce you to him. Drew is an advanced practice clinical pharmacist serving the Federal Bureau of Prisons at USP Lewisburg, Pennsylvania. Since joining the Commission Corps in 2011 he has led chronic disease state management services with a focus on HIV care, metabolic disorders and medication optimization, rather Swedish expertise as a regional clinical consultant and is hands on leadership in the field, making a national resource for best practices in pharmacy driven care. Joining him is Commander Josh bell gotterson, who currently serves as the chief of clinical pharmacy programs for the Bureau of Prisons. A residency trained clinical pharmacist. He began his career with the Indian Health Services in Gallup, New Mexico, where he developed a deep expertise in diabetes, nephrology and emergency medicine. At the bo piece button or complex he further specialized in oncology and diabetes management, while also serving as a pharmacy residency director, as a systems thinker and a clinical clinical strategist. He now oversees the National Clinical Pharmacy activities, spearheading initiatives to expand pharmacists role and improve outcomes system wide. Together, these distinguished officers will review the current landscape of diabetes technology, highlight clinical evidence supporting its use, and offer real world strategies for implementation and correctional facilities. Their presentation promises to equip clinicians with the insight and tools needed to bridge the technological innovation with practical directional care. So if everyone would please help me welcome our speakers. Commanders, the floor is yours. Unknown Speaker 5:55 Alright? Thank you Unknown Speaker 5:57 so much, Captain. Get our slides loaded here. Unknown Speaker 6:08 Okay, Speaker 1 6:13 of course, now it's behaving differently than I did earlier. Are we on the first slide? Unknown Speaker 6:21 Yes, but it's not presentation view. Unknown Speaker 6:24 Okay, I will fix that. Unknown Speaker 6:28 We good now. Yes, yes, okay, thank Speaker 1 6:32 you sorry for that. Of course, all the practice in the world doesn't follow through when you want to when the prime time comes. So thank you, captain for the introduction again, Commander swagger myself, well, we're excited to share some of our experiences, as well as hopefully learn some things. We look forward to interactions with those who may have experience, especially outside of the Bureau of Prisons, is something that we've spent a good amount of time over the last several years working through some of the technical aspects, and I feel like we're still learning something new every day. So and as well as the technology is changing every day, so I'm gonna actually share some of the newer technologies I had to learn more about myself in preparing for this presentation that I'm less familiar with. So, all right, Unknown Speaker 7:21 okay, Speaker 1 7:23 so just as as is probably appropriate, just want to disclose. Neither of us have any financial disclosures affiliations with any of the products or material that we'll be sharing today, as well as the information we're sharing is our opinions, and nothing is a direct representation of the Bureau of Prisons or the Department of Justice. So kind of give you a landscape. What we're hoping to do today. We want to kind of look at as we've done, hopefully close out this series of outstanding presentations for those who have been on others of the pharmacist impact. And last week, we talked about, sort of the management of type two diabetes and the pharmacist function there, but we want to kind of expand that now and see how we've brought pharmacists into using technology in the Bureau of Prisons. We'll look at some of the advances in these diabetes technologies and just things to be thinking about when considering what needs to be done to maybe bring them into an incarcerated setting. And then finally, we'll kind of wrap these things up. We didn't talk much about the management of type one diabetes last week, and I think there's some good applicability to some of the information we'll share today. So we'll briefly look at management of type one diabetes, and then emphasizing use of diabetes technology. So I'd like to just pop a poll here to get a sense. These are kind of some questions for those who've been on these before. With us. If you could, there's three separate questions on the poll, so if you could just let us know, first, what your discipline is, we can get an idea of who we're talking to today. I'd like to know you know, how committed Have you been to this NIC series? Maybe you just heard about us, and that's great. If you're a first timer, if you've been with all of us through all of these we're we're thankful, hopefully we have engaged you throughout each of these presentations. And finally, we'd like to know how often you're using your diabetes technology at your practice sites currently, because give us a sense of kind of what our audience is familiar with to help us better understand what we need many to cover today. CAPT. Chad Garrett 9:20 Okay, if everyone wants to mark those answers in the poll. Looks like we have about 40% of you who have not started yet. I so right now it looks like majority of folks joining us are pharmacists, nursing and. We have a lot of folks who have attended a couple of the different presentations, but we also have a few first timers. Thank you so much for joining us. Speaker 1 10:19 I want to know who the faithful viewer and has been on all nine of them, is that is that you Chad? No, CAPT. Chad Garrett 10:24 no, that is not me. Well, it is me. But no, that's not my answer. Speaker 1 10:34 Think, I think whoever that person is deserves some sort of award of some kind. CAPT. Chad Garrett 10:42 And then it looks like there is a little bit all over the board, with most places using some technology. But we've got every where from none, and they're not even considering it all the way up to pretty regular user. Okay, Speaker 1 11:00 that's good. So a good spread there. All right, great. Well, so I will say some of this content for those who are regular users, you know, I think we're going to kind of touch some of the basics. We were kind of thinking that some may not be as familiar with some of these. So we will go through some basic components of diabetes technology pieces. But really, we hoped that there'll be some things you'll find applicable, and regardless of where you're at in its use, and, you know, thinking about things that you can implement at your local institution. As I said at the end, we'll share our contact information, and we would love to have, you know, connections with people, because we always like to learn better ways to do things for sure. Alright, so to jump in, we're going to introduce you to our patient. We'll follow, follow Mr. DT throughout this presentation today. So get get a little bit comfortable with this gentleman. So it's a 48 year old, incarcerated male. So he presents today to our clinic, and he has difficulty managing his blood sugars. And I'm sure those who manage diabetes may never see something like this, or this may be a regular occurrence, as we tend to see. So he self reported his history of diabetes since age 22 and no other significant family history. So he's, you know, looking at over 25 years, essentially with diagnosis, He comes to us with a current active problem list with type two diabetes, hypertension, hypothyroidism. You can see a list of his medications there. Obviously kind of emphasize the ones for diabetes management, the empagliflozin, which we talked about last week, for those who attended, Metformin for type two diabetes, often used. And then he is on insulin. So he's on a once daily long acting insulin in the morning. And then he has sliding scale, a regular insulin to cover two meals, breakfast and dinner. For him, you can see his labs, relevant labs, so most recent, a one. See at 10.4% not his goal is those who may be familiar with our presentation last week are familiar obviously, less than seven probably for a patient who's otherwise healthy would probably be the target we would shoot for. For this gentleman, no real major concerns with his kidneys or his cholesterol. So you can see it's pretty much his blood sugar is concerning today. He does bring a blood sugar log to us today. So you can see he's testing about twice a day, fairly consistently before his breakfast and his dinner meals, and his average sugars in the morning about one, you know, 155 or so. And then in the evening, after he kind of eats through the day. You can see, you know, up in the 230s but you can see the spread, especially in the morning, is a little bit wide. So he's can be as low as 49 on one day he had on his meter, and then as high as 278 as soon as he clearly, kind of patients, not in the greatest of shape. I think our poll question, we like to kind of get an idea from the audience now is, what would you do for this patient? So we've got three options here, so or, sorry, four. So one would be to increase his Glargine from 40 units in the morning to 50 units. As you can see, next would be to or change the sliding scale insulin to a scheduled insulin, giving them 10 units of regular insulin twice a day. Consider adding ozempic or semaglutide, 0.25 milligrams once weekly. Or would you refer him to your diabetes pharmacist? CAPT. Chad Garrett 14:08 That poll is open. If you guys want to go ahead and put your answer in there, I would probably pick something like ozembic, because it's got the best theme song on The commercial. It looks like we're getting some answers. You and we've got people selecting in every category, Speaker 1 14:50 excellent. That's great. Actually, we were kind of hoping to get a little bit of a smattering. And I will say probably all answers would be, would be appropriate. I don't think any of them would be a wrong choice. Yes for this patient, but because I have access to a pharmacist in my clinic, and I know that the pharmacist does a great job, especially for some of these complicated patients, I think what I'm going to choose to do today is I'm going to refer this patient to my diabetes clinical pharmacist. So I'm going to refer him to my clinical pharmacist. Commander drew swagger to pick him up from Speaker 2 15:18 here. Hi everyone. Commander swagger here, and so like commander Val garden said, Yes, we, at least in the bup, we have a lot of clinical pharmacists that work in the diabetes area, as this chart shows here. And you may have seen a similar one. We talk a lot about collaborative practice agreements, and that's how our pharmacists and the BOP are able to get involved in the clinical care of our patients. And when it comes to diabetes, as of last year, we're up to 83 different pharmacists that are practicing comprehensive management, and so comprehensive I want to focus on that, because that means that we're not just looking at the patient's diabetes and turning a blind eye to everything else. It means that when we have that patient in front of us, we're we're treating them as a whole patient. We're looking at their hypertension, their lipids, everything. And when it comes to technology, which we're talking about today, this is really where we've seen in the BOP, our greatest advancement that it's the pharmacists that are are running these clinics that are kind of the champions to bring this technology into their care. And so that's how I got involved, and that's what we're going to talk CAPT. Chad Garrett 16:14 about today Next slide. Speaker 2 16:17 But first, before I get back to our patient, dt, I want to talk about some of the challenges that we face. So, you know, Corrections is a unique environment, and I just want to be upfront about the fact that when it comes to bringing technology in, there are going to be some challenges and barriers, things that commander Val guardson And I have dealt with on different times. And so just want to discuss them a little bit, to maybe give you a starting point, if you're thinking about bringing some of this technology into your care setting. We're going to look at these four different areas, security, and then the appropriations conscious environment would be like budget different movement issues, and then communication and psychosocial barriers. So next slide. So beginning with security, it should come as no surprise to everyone on this call that maintaining the security of our institutions is our paramount mission, and so that is a primary focus of everything that we do, especially when it comes to bringing some new device into our settings. We have some challenges with security, with technology, though, first one being communication and data transmission. There are certain communication channels that the BOP has approved phones and things that are monitored emails, and so if we bring a device in that would allow an inmate to communicate outside of those channels, that would certainly be a communication or a security concern. And what we find with technology, especially as time goes on, the technology that's out there increasingly relies on smartphones as their interface. So because we cannot have a phone in our setting, it's becoming more and more challenging to to work with the technologies as one device gets out phased and a new ones come in. A lot of times we're seeing that that there's no longer the ability to use it because we have to now have a smartphone involved. So those are definitely concerns that we have needles and sharps accountability in the Bureau of Prisons, as I would imagine, almost all correctional settings, needles and sharps are a concern that they have to be on a perpetual inventory and count and always be accounted for. We have concerns for tattoo use and IV drug abuse, and some of these technologies include needles and sharps. And so if we're going to be issuing these devices or storing them, that needs to be a consideration whenever we're looking at to bring them in, and then the potential for weapons or escape paraphernalia. There are many times, as I'm sure most people on this call can attest to, that we have a device or a piece of equipment that seems relatively harmless, but because our patients have pretty much unlimited time and are very creative in most cases, that they can turn something harmless into something that's dangerous in many cases. So certainly, another consideration that we have to actually look at whenever we want to bring a new device CAPT. Chad Garrett 18:51 in next slide. And now for budget. Speaker 2 18:58 So the Bureau of Prisons budget is just a subset of the whole US, Department of Justice budget that's approved by Congress, and because it is a fixed amount, we have to be good stewards of those tax dollars, and that often means weighing the benefits of this technology versus the other needs of the institution. A lot of this technology does come with a as high cost a recurring cost for supplies. And so when we only have certain amount of money to work with, we have to decide, you know, is it something that is worth it compared to the other things that we need to purchase to keep our our ship afloat? And also, anything that we do buy has to go through this bpap, the Bureau of Prisons acquisition policy. That's a policy that is used to approve in the process the purchases, and it just makes sure that everything that we buy is the best value for the BOP, considering cost and other other factors. But it's another hurdle that we have to go through if we want to bring a new device in. It would have to be looked at in this regard to make sure it is a good, cost effective technology and where we get it from, would be appropriate. CAPT. Chad Garrett 19:56 Next slide, there are challenges. With movement, both within the institution and without, in our Speaker 2 20:05 in our bop setting, we have what we call 10 minute moves, and because of that, it can sometimes be difficult to get access to our patients. If the patient is supposed to visit our health services area at a certain time, and for whatever reason, does not make it on that move, then we're often unable to see him until perhaps the next move comes around. Or there might be times when the entire institution gets locked down, and that creates another barrier to being able to access this patient, and, you know, to speak with them about their technology. And then there's times where a patient may actually move housing units. The most significant would be if they went from what we call our general population to our special housing, usually for disciplinary reasons. When that happens, all their property gets packed up, and with it, a lot of their supplies that they would need for their technology. So different types of movement concerns that would interrupt the technology that we're using with our patients within the institution, and then movement outside the institution as well. There are times where we get a patient, he shows up at our door and he's already using a certain technology, but if it's not an approved technology, or perhaps we don't have the approval to use it without getting approval, we may not have the paperwork we need to show that this is a warranted technology, and so there would likely be an interruption in that patient's technology used when he first came to our institution, and when we just and there are lots of times whenever we move inmates between institutions, and in those cases, I know at least on my end, we try and set the receiving institution up for success as much as possible by giving them a heads up and providing as much materials and supplies as we can in the transfer. That way, it's as seamless as possible. But as you can imagine, if, if a patient goes from one facility to another that has never seen that technology, there might be a learning curve for them to get on board with what needs to happen and how it needs to happen. So there could definitely be some interruptions and concerns there. And when a patient leaves our custody, there might be certain socioeconomic factors at play, perhaps his education or housing, security or health care access, those are all things that we would have to consider that just because he was using it well within our our walls, that when he leaves, we need to try to set him up for success when he does leave with it. CAPT. Chad Garrett 22:10 Next slide. And Speaker 2 22:14 then the final challenge area I'm going to speak to here would be communication or psychosocial issues. Certainly it seems like the world is getting smaller all the time and and diversity is increasing everywhere, and the BOP is especially diverse. We have a lot of different cultures and gangs and religions represented, and with that comes different values and beliefs regarding how they're willing to incorporate technology into their care. We also have significant language barriers, many different languages spoken with our populations, and sometimes it can be difficult just to communicate a medication care plan to a patient. Now imagine trying to communicate how they're going to use this new technological device in a whole different language that you may not understand. So that can certainly be a barrier. And the average education level within the BOP is an eighth grade education level, so with the technology and the different things that need to happen to use it appropriately, if at eighth grade is the average education we're dealing with, it can be sometimes a barrier to to get our patients up to speed with what they need to be doing to use it, and then some psychosocial barriers to discuss Here, cognitive would be, as it says here, distorted thoughts and or negative beliefs that hinder behavior change. And within the prison, there's sometimes this invisible line between us and the the patients or the inmates, where they may not trust even though we're health professionals and we're really there to help them and look out for their best interests. They because we're on the the custody side, or the, you know, other side of this line, they may not trust us completely with what we're trying to do for them. And in one case, I can even give you an example. I had a patient that I was using a CGM sensor, a continuous glucose monitor sensor, which we're about to talk about in a second, and that's just a little it's about the size of a quarter that gets put on the back of an arm. Well, I'm pretty sure that patient thought that I was actually putting a microphone or some other tracking device on him, because he continued to return it to me twice after only maybe, like, 12 hours saying it fell off, which is highly unlikely. So, you know, that was a barrier we face with that patient, and also coping skills, as it says here, stress management and problem solving. You know, I would argue that our patients, for the most case, do not have good stress management problem solving skills, hence why they're they're in our prisons, and so it may not be. It may be a barrier for them to be able to manage this technology when there are things that need to be troubleshot or, you know, interruptions for whatever reason. CAPT. Chad Garrett 24:36 Next slide, I don't Speaker 2 24:39 just want to talk about the challenges, because I think there is a lot of great opportunities, and I really appreciate the corrections environment that we have. It's a great environment to do healthcare when you get right down to it. And so there are some beneficial aspects, and I want to talk about them quick. So provision of medicine and supplies, you know, there is no cost for our supplies or medicine to the patient. So. Whereas in the community, that's obviously a big barrier and something that often leads to them discontinuing their use where, here, as long as we can provide them with it, there's there's no reason they shouldn't continue with it, and we have oversight of how it's how it's supplied to them, that we can track everything. So just like with medicines, we can see when they get their refills. The same thing with their supplies, they're supposed to be using a continuous glucose sensor, we can tell whether or not they're actually using it and getting the new devices from us. Diet and food provision oversight here again, just like the medicines you know, they have three meals a day provided to them, plus ability to purchase more stuff through commissary, so there is no food insecurity, and things are provided to them at consistent times, so as long as they're eating most meals at the food service menu, we can, we can have a pretty consistent, you know, flow for when the calories and carbohydrates are going into their body, and there's oversight to it as well. Like I mentioned with commissary, we have the ability to actually watch and monitor everything that they're purchasing on their own, and so we're in the community. I'm sure there's a lot of providers that would love to be able to see the grocery list of their the grocery list of their patients. Well, here in the DOP, we have that ability, so it's something we should take advantage of and access to care I mentioned that before, is a challenge, but it also is a benefit, if you ask me, although it may, on the short term, be something that we have difficulty doing, we know that they're within our walls somewhere, and so it may take a little longer to get to them, but we can find them. It's not like in the community where there's times where providers will see a patient and they're skeptical about whether or not that patient will even come back to a future appointment. But with us, we can. We can always track them down and get access to them again. It may take a while, but we can find them. And then the recreation programs that we have, that we have a lot of professionals, recreation professionals and programs that are available to assist our patients. I like to say that all of our patients have a free gym membership, and because there's no cost, you know, really, all they need is the motivation to take advantage of it, and they have plenty of time. Next slide, okay, so let's talk about continuous glucose monitoring. I referred to this a little bit before, but we're going to talk about that in detail some more now. So go ahead to the next slide. Continuous glucose monitors. If you look in the upper right of the screen, for those who aren't familiar with it, the sensor consists of a transmitter, and it has this tiny little filament that it has marked on that picture as the glucose sensor. That little filament, whenever the applicator applies it to the person's skin, it gets deposited just below the surface of the skin into the interstitial fluid. And it's that sensor that picks up on the changes in the glucose levels the interstitial fluid. And as you see in the lower picture there, that sensor usually communicates with a reader, and that was what I was mentioning before, where a lot of devices now are using a smartphone as the reader, but thankfully, there are a couple options that allow us to use just a dedicated reader that can't communicate. On the left, there's two different types of CGMS or continuous glucose monitors. There's a personal style and a professional style, and you'll see the different manufacturers that are currently available there. There's a lot more personal options right now than there are professional the difference between the two is a personal CGM allows the patient to see real time, how their sugar is changing. It'll often include a lot of different alarms that can be set to notify the patient of whether the sugar is rapidly falling or perhaps gone below a threshold, or even rising or above a threshold. Compare that with a professional model. The professional model, the patient cannot has no idea what's going on. They have the sensor placed. The sensor is working behind the scenes, but they're not receiving any communication until they would go back to the doctor or the provider, and then the reader could be scanned to get the data, but the data is not provided to the patient in real time. In that one Unknown Speaker 28:48 next slide, to give you an idea of where Speaker 2 28:53 you might want to choose a professional device versus a personal device, here's some criteria that we might suggest, really when you look at the personal device, the biggest thing I would emphasize there is the safety concerns with not having so if you have a patient that is exceptionally brittle or prone to having lows that are significant, that would be where you would want to go with that personal device, that way they have the ability to receive those alarms and to have the information Real Time to them. So type one patients, somebody that's on an insulin pump, or somebody that's difficult to stabilize their dosing, and you'd want this to be somebody that's actively engaged in care. Compare that with the professional device. Again, the professional one doesn't provide them the information. So you would really use this where you just want to get a general idea of what's going on. Perhaps you have a new patient, you're just trying to get a feel for where their glucose is going. Usually this would be somebody who's type two, because, again, you don't have those significant low concerns. And so just you know when you want to assess. And the nice thing about the professional device too, is you might have a patient that really doesn't understand what their diet or activity does to their blood sugars. And. You put this device on and then scan it and review it later, they can actually see on a graph where their blood sugar goes in response to those activities. Unknown Speaker 30:07 Next slide. Okay with all that. If Speaker 2 30:11 you still remember our patient, his name is dt, we're going to go back to him now. So again, he's a 48 year old male with diabetes. CAPT. Chad Garrett 30:17 Go to the next slide. Speaker 2 30:20 This is where I was referred or he was referred to me by Commander Bell guards. And that happens fairly often. We'll have a patient like him who has very erratic blood sugar levels, and they want to refer him to me just because I can do a little closer management of him. You know, a lot of times a physician can only see a patient maybe every six months, two months at best, but I can see him every week or two weeks, if need be. So he comes to me, and during my very first encounter, we decide to put on one of these professional continuous glucose monitors. And the reason we're going with a professional one is, again, because he has type two diabetes. He's a new patient to me, so I just really want to get an idea of where his blood glucose is going. What I do during that visit is I give him a patient information sheet. In this case, it was the pre style libre pro model, but this patient information sheet would just tell him a little bit about the sensor, how he's supposed to care for it, and things he needs to be concerned with. But I also make them sign an agreement. It is an instruction agreement form that I developed that basically holds them accountable, saying that they're not going to tamper with the sensor, and that if it happens to fall off, they're going to return it to health services immediately, and that if they fail to do so, that I can hold him accountable. And I would recommend that if you're considering doing this, because I have had several patients tell me that they lost their sensor and they have no idea where it went. And because I have this form on file, I can, at least, you know, hold them a little bit accountable for that action. CAPT. Chad Garrett 31:40 Next slide Speaker 2 31:44 to apply the sensor. This is just a general you know, it would be specific to the device that you're using, but this is just some general guidance to show you that it does usually go on the back of the arm. And there is an applicator that you have to usually use to apply the sensor with. And it's usually just a swift forward motion, you'll hear a click, and then, as you pull the applicator away, the sensor should be attached, and you just want to just push on it a little bit, but make sure it is adhered very well. CAPT. Chad Garrett 32:10 Next slide Speaker 2 32:13 to activate the sensor again. Each if you're going to use the sensor, you would need a reader to go with it. And on each reader, there is a menu that will help you to activate the sensor. In this case, that says, Start new sensor. And so after using that function, you just hold it over the sensor. Usually here beep, and then, in this case, you would have to wait two minutes, and then you scan it again, and it'll verify that, yes, that sensor is active. And the case of this sensor, it's active for 14 days. Unknown Speaker 32:40 Next slide. Speaker 2 32:43 So after again with a professional device, the patient doesn't know what's what's happening with the sugar, but in this case, the patient wore it for 14 days, and when he came to me, then we were able to use the reader to scan all the data, and then and plugging it into the computer, we can download this CGM report, and this is what the CGM the first page of it would look like, and we're going to talk about the three different sections here in more detail. So go ahead to the next slide. The first the top section is called glucose statistics and time and range. So we're going to break down a little bit of what I look at when I look at this part of the report. So if you want to hit your button, the first thing to highlight there is where it says that this sensor was active for 14 days. That's good. You want at least 10 days really, to get a reliable representation of what's going on. And there's studies that indicate that after 14 days of monitoring, that that's that correlates well with a three month average of what's going on with the patient's glucose. So certainly, if the sensor was supposed to last 14 days, that lasted 14 days, that's a good sign. Go to the next one. The next thing I would look at here is this, this bar graph on the right. And specifically what's highlighted here is this target range. So you'll see, on the left there's the goal ranges that we're supposed to hit. And when it comes to the target range, which would be 70 to 180 milligrams per deciliter, we want to be in this range as much as possible, but the goal is to be greater than 70% and so you can see for our patient, dt, he's only in our target range 42% of the time. And then to look at a little bit more, he's also above that range 33% of the time, and then very much above that range 24% of the time. So clearly he has some significant highs going on here that we need to address next. The next thing I would look at here, it says average glucose. So the average glucose, it correlates well with the A 1c and that's what you see. Actually, below that, there's a value called the glucose management indicator, GMI. This was formerly called the estimated a 1c and so that 204 does correlate well with an A 1c of 8.2% in this case, CAPT. Chad Garrett 34:46 go ahead and hit the button two more times. I think Speaker 2 34:51 so that would be, again, if you wanted to estimate the a 1c based on that where. And then the last thing that I think is, and one of the most important things on this part of the chart is this glucose variability. So you'll see there in the smaller print that the goal would be to keep this less than 36% this is an estimate of just how variable the person whose blood sugars are. And so if you're above 36% that shows that you have a lot of variability, that you have a lot of highs, a lot of lows, that you're not consistent like we want it to be. And given the patient's blood glucose log that we reviewed before, that's not surprising. Next the middle section of this continuous glucose report. This is the ambulatory glucose profile. And I think this is maybe the most important part of it to me. What you're seeing here is you have the perhaps darker blue section that goes from 75% to 25% if you look to the right, that would be your interquartile range. And so that dark blue band that you see is where 50% of all the blood glucose values lie. Basically what this sensor did was it took every day's worth of blood sugars and it overlaid it onto 124 hour period that we can look at. And what the goal is is to keep this curve as narrow and as flat as possible. You see on that chart the target range 70 to 180 it would be wonderful if this entire curve stayed really flat and inside those two green bands, of course, with this patient doesn't but what you're looking at here to identify areas of opportunity is you want to see areas where the bands are excessively wide. And so as I look at this, I see the 3pm time frame where that seems to really widen out at that time. So this is an area of exceptionally high glucose variability. And so this is where you we'd want to talk with the patient about, you know, what is your diet going on at that time? Are you exercising at that time? What is it about that time of day that makes your sugars exceptionally variable? Another thing to look at here that the very lowest dotted line that says 5% keep in mind that there are still values that are below that dotted line. And so where that line touches the 70 milligram per deciliter green band, like it does around 9am that would indicate that there's a concerns for hypoglycemia at that time of day. So there will be another area I would focus on with this patient that you know, why at 9am are we going low? Is that based on your activity, or are you not eating breakfast? But that's a concern for hypoglycemia. Is it something you want to look at as well? And what I like to do with this graph is I like to mark right on it while I'm sitting with the patient reviewing it, I like to say, Okay, what time do you eat breakfast? And I'll make a line there. How about lunch, dinner, bedtime, any snacks? When do you exercise? When do you take your medicines, or when you get your insulin? You know Mark right on that graph the different activities and the times that they occur that would affect his blood glucose. And then ask him what he sees. And I think a lot of cases, you'll actually have the patient really buy into the care plan, because they're themselves, seeing what, what is, what they're doing all day long that's affecting their sugar and how they might be able to improve it. So that would encourage you to, you know, this is a wonderful tool to get patient buy into the care plan, to use it that way. Next slide. And then finally, the last part of the report. This breaks it out by day, what each blood glucose looked like. And so the nice thing about this is you can compare, perhaps weekends or certain special days compared to other days. And so as I look at this, I would look especially at Monday, the ninth. You know, that was a day where he was hyperglycemic the entire day, and so we would perhaps look at the eMAR or the medication administration record to see, was this a day that you missed your insulin altogether, you know, or ask him, What was it about that day? Was that a day where they were serving ice cream or something that you indulged or, you know, this will allow you to pick out days where there were, for some reason, they weren't the norm, and, again, identify those, those activities that lead to those, those hyperglycemic, or perhaps hypoglycemic times Next slide. So now that we've reviewed the first sensor use of this patient, again, I'll remind you that his name is dt, and he's 48 years old, but he's had diabetes for 26 years. Again, there's this problem list as current medications. We're going to go to another poll here, and I'm going to ask you what you would do at this time. Speaker 2 39:14 So there's four options that just come up in the pool. We can either A, stop metformin and inpagliflozin, B, order A, C peptide Lab C, increase insulin glargine to 50 units each morning. Or D, add scheduled, regular insulin, 10 units three times daily with meals. I'll let Captain Garrett go ahead and monitor the responses. CAPT. Chad Garrett 39:39 Okay, you guys want to go ahead and mark those answers. We have got a lot of deep thinking going on, and we've got a pretty wide spread going on right this second. You. I give it about another 10 seconds or so, it looks like majority of folks are picking B and C, with some folks picking a and d, but B is in the number one spot, C's in the number two spot, the other two are tied. Good. Speaker 2 40:33 Well, again, like commander Val guardson said before, we were kind of hoping to get a smattering of responses and and again, I would say that you're just as long as you have a clinical reason to back up your decision. I think you could argue for any one of those four. But the choice that we were going for, and what I would pick in this case, would be B C peptide, which it sounds like most people did pick, and the reason behind that is, well, okay, and so in this case, we did run a C peptide, and it came back at less than 0.1 at a normal range is point eight to 3.85, so C peptide is non existent, and what C peptide is, and one reason we would run that is, when your body makes insulin, it actually makes it as this pro insulin compound you see on the left where there are two identical insulin molecules that are connected with this green bridge, And that green bridge is what is called C peptide, or connecting peptide. So when your body makes insulin, it has to cleave that C peptide off to activate it. And then if we check for C peptide, that'll give us a good marker of whether or not our body is making any insulin of its own. If you happen to get insulin injected, it would not have any C peptide because that's not part of the injection. So in this case, we can see this patient is not making any insulin, and the reason that's significant is we probably have misdiagnosed this patient as a type two diabetes case when he's actually type one. If you go to the next slide, some things to keep in mind, especially when you have a patient like this who seems to be exceptionally sensitive and all over the place with his blood glucose levels, there are about 40% of adults who are misdiagnosed with type two diabetes when they actually have type one. Now, type one, for those who are unfamiliar, is a condition where your body's immune system attacked your pancreas and killed its ability to make its own insulin functionally make them insulin dependent right from the beginning. And beginning, and to screen for type one diabetes, normally, you would look for these auto antibody, auto antibodies, and there's four of them listed there. These are what you're going to see when your immune system is active against your pancreas. But in a patient like this, who was diagnosed, if you recall, like 22 years ago, most of these antibodies are no longer detectable. That you're only going to find these whenever the active immune function and dysfunction, I guess, would be, is occurring. And so for your typical patient, the C peptide would be your most reliable test to check for this. And the AA or that the latest ADA guidelines actually added this aa bbcc acronym to help you identify patients that you might want to consider this differential diagnosis and when they have a young age for their onset of their diabetes. As you recall, this patient was, I think, 22 or 26 perhaps, if there's other autoimmunity going on again, that would be an indicator that perhaps they have an immune system that's attacking their pancreas, if they have a low BMI, less than 25 kilograms per meter squared, which is typical of a type one patient, if they have backgrounds of other family with type one, if they're have trouble meeting their blood glucose control, like this patient does, and if they perhaps have other comorbidities, or some other type of Known virus comorbidity that's known to be associated with type one, that would be a consideration. So AA, bbcc is a good thing to remember when you're trying to decide whether or not you should check to see if patient is type one. Unknown Speaker 43:50 Next slide. So now that we have a little better Speaker 2 43:55 picture of why this patient's having trouble controlling his blood glucose, I did issue him a personal continuous glucose monitor sensor. Again, that was typically the type of person we would give one of those two as a type one patient. But despite that, we were still, after three months, unable to get him to better control. He would still have some lows that were uncontrollable, some other highs. A lot of it had to do with the fact that he doesn't have control over when he injects insulin in relation to when he eats his meals. Unfortunately, that's just one of the ways our bop system works, is that we have to give insulin at insulin lines. And so because of that, I really felt as though an insulin pump might be advantageous for this patient, not something I had a ton of experience with. And so that's where I decided to refer him to Commander Bell guards, and who has more experience with insulin pumps, and Unknown Speaker 44:43 he's going to talk about that Speaker 1 44:46 now. Yeah, thanks, Commander swagger. Alright, so I'm going to finish off here with a focus on the insulin pump and management of our now correctly diagnosed type one patient. I think one thing I just wanted to highlight for those you know are in diabetes. Management, we get questions about this a lot. You know, what? About these non insulin therapies for type one? So I have this on the slide, just because I think these are common questions we encounter. So, you know, Metformin is appropriate to use for a patient with type one, if they show that insulin resistance really, the evidence just has document or demonstrated that it's just not generally effective at lowering anyone sees, but I've, I've seen patients where it's been effective for especially when we see signs of resistance. Sglt, twos, I would say there's more evidence with regards to avoiding use for these in type ones, and they've been excluded from a lot of the studies because there is that risk of you glycemic DKA, when taken for a patient who does have a type one diagnosis, especially if their insulin is not super stable and their blood sugars are very variable. That's really when they're at the highest risk. Though, the newer evidence is now showing us, as we learned last week, for those who attended, that CKD and heart failure amongst as well as heart disease itself, there's great benefits with the use of an sglt Two and so generally speaking, I would say, you know, most of the time we're, we're referring to our specialists to get their recommendations for these comorbid conditions, for patients with type one diabetes, and then monitoring very closely. And we've seen several patients with type one diabetes use them for these comorbid conditions with success with close monitoring. But I think generally I would, I would steer away from it if you can, just from the safety perspective, as more data until more data becomes available. And then lastly, the GLP one agonist. I know these are, as Captain Garrett alluded to earlier, the best commercial music out there. So these are good options to consider. There's really nothing inherently built within the way the mechanism of these drugs work, which where they wouldn't work for a patient with type one diabetes, there may be some limited value with regards to the blood sugar management associated with them, but they definitely should and still do help with patients with type one diabetes for weight reduction options as well as the risk of our ascbd, though, there isn't really A lot of direct evidence, a lot of the type one patients, again, were either not reported or excluded from some of these studies. So just wanted to bring that in to make sure I address that, because we do get that question quite a bit. And so then we'll look a little bit, very quickly, through some of the options for insulin dosing strategies. So you've got, you know, you're obviously your basal bolus, subcutaneous insulin options, syringes, pens. I'm sure that many of us are familiar with those. I did categorize the patch, mechanical patch delivery under this category, and I'll bring those up briefly on the next slide. And then what we're here for today, more is some of the technology with the newer insulin pumps, as well as some of that capacity that they have. So just a brief kind of overview. So we're on the same page. We talk about subcutaneous basal bolus insulin dosing. So that would usually consist of a long acne insulin, which you can see as the red straight line at the bottom, and that's usually intended to be there to help control fastening blood sugars overnight between meals, and then when a patient eats, you would need to typically give them some sort of perennial or mealtime insulin. So your breakfast is your blue, lunch is your orange, and then dinner is your green, in this example. And so those obviously are there to help prevent the spike after the meal, to help prevent those big jumps on the blood sugars. As I mentioned earlier, there's these mechanical patches. There's two on the market, the Vigo and the secure simplicity. Both of these actually are there's no technology associated with them with regards to any connectability with with anything, and they're controlled simply by clicking on the device itself. There are slight differences between the two. The Vigo does provide some basal insulin option within the system itself, but also has the click option. It does have to for perennial insulin. It does have to be replaced every day. The seeker, simplicity, on the other hand, is just a perennial only insulin patch, and so you can load the insulin within it. Every time the patient clicks the button, they do get two units of rapid acting insulin, and then they also would have to take a separate shot for their basal insulin. Some of the nice things about these in our settings, obviously, is some of the flexibility around meal time. So if you you know work in a situation where maybe it's hard to get the patient their insulin around the time of their meal, there are some potential flexibility that's built into these, and that might be something to consider. And then the newer insulin pumps. You can see there's a lot of them, and they continue to grow. And I can envision they continue. We'll continue to see advances with technology, and it really has changed the game for management of our patients with type one diabetes. In interest of time, I won't go through this and as much detail, but this is just kind of gives you a picture of what the traditional insulin pump would look like. And so you can these pumps would be programmed, either by the, you know, by the patient, or often by the provider. Then a chronologist would would sort of program this based off the patient's needs. And you can see this blue dotted line that's kind of straight across. Would mimic kind of what a basal insulin dose would be. And you can set the pump to just give a straight basal rate 20 for the same dose for 24 hours. But the nice thing with the in. And pump. But you can also adjust that so if you know your patient tends to run low overnight, you can actually give them, like 10% less from that basal rate overnight, and then when they get that Don phenom phenomenon in the morning, you can increase that basal rate to kind of capture that. You can kind of see that trend, trend in that pattern throughout the day. You can see the adjustments in the basal rates that you can pre program for that patient. And then you can also then give it more variable and adjusted prandial insulin doses. So you still the patient can put their carb counts in the amount of carbs they're going to eat. And you can set up the variable carb ratio so that when the patient, you know, puts that carbon on that pump, will calculate how much insulin to give them for that meal. You can also then put in your blood sugars, and it will adjust, give them an adjustment dose. And so this is all done. A lot of it's still manually done, and it's programmed, and you have to adjust the patients regularly with this. So it's traditionally pretty labor intensive. There was a lot of education needed, and it was really kind of a complex system. And so it was really reserved for very kind of small subset of patients with some of the newer insulin technology. It's really kind of changed the game. So this is kind of a very simplified version of what an automated system, automated insulin delivery system, would look like. So you can on this graph here, you'll see the solid gray line is the blood sugar, and then the green line, lines that go vertical are the insulin dose that's given. So this is all done sort of in the background, automatically. So you can see, as the blood sugar starts to rise in the morning, the insulin will also begin to rise as well. And if it reaches a certain threshold, it'll actually enter kind of a correctional phase, and so it'll increase the insulin even further to help pull those blood sugars back down. And you can see that happen as we get that little hump around 10am patient may do a little exercise, they can put their pump in exercise mode, which will actually increase the the goal or target that the pump is trying to keep the blood sugars at, which, as you can see, what that then does is the patient's sugar starts to drop, the insulin also drops with it. So the insulin eventually gets turned off completely, in this example, during that lower phase after the exercise. But as the sugar starts to rise after the exercise, the insulin will kick itself back on and start releasing. And then as the patient eats, you can see there's a rise on the blood sugars. And if it reaches a real kind of rapid rise that usually that's a male detection technology, some of the newer insulin pumps will actually further kind of increase the rate of the insulin being given to help pull those sugars down more quickly, so not completely hands free. There's you still have to add glucose or, sorry, you still have to add carbs into most of the new pumps. But a lot of this is really kind of done automatically in the background. You set the pump for the goal, target blood sugar as a single blood sugar goal, and the pump with the connection to the continuous glucose monitor will basically just do its best to keep it at that range as much as possible. There's a few pump options that are currently available on the market. I group them here as kind of the tubed in the tubeless options. These are all. They all have smart, connected or automatic systems sort of built into them. Some of the older versions of these are kind of your more traditional pumps. The newest versions all have the abilities to connect to the continuous glucose monitoring systems, and each of them have some some kind of nuanced or unique differences between them. But I think, you know, just highlighted here, you can see the the four on the left do require that tube, essentially to be connected to the patient that also then connects to the device itself, which will hold the insulin to be delivered, the OmniPod on the right there, the tubo option, you can see the insulin gets loaded in this little patch that's in front of this Little Reader or cell phone on this example, that patch can then be applied to the patient, and then it's controlled via Bluetooth or Wi Fi Speaker 1 53:38 with the With the device of the receiver, when considering, kind of, you know, our situation. Obviously, we've got a lot of things to think about. And when we were beginning our process of evaluating both the continuous glucose monitoring and the insulin pumps, we definitely started with the CGMS. You know, they were more simple to kind of think through. What are the challenges associated with them? And so we started with them, you know, over two years ago, I would say more robustly throughout the agency, and we're just now starting learning enough, I think, from the technology side to implement some more insulin pump starts as well, but it is obviously big, so we need to review the products, make sure that they're safe. Evaluate is kind of what commander swagger mentioned earlier with regards to custody concerns. You know, make sure there's no undo communication that we're not aware that the patients might be able to have access to when they have these devices. So a lot of things go into this. Within our structure, we do require National Review at our at the Bureau wide level, it goes to our group that does sort of a Technology Review for all of our health product, health care products. They clear it, and then it goes to our Information Technology Group, which then do sort of a final, sort of review of all of the specs related to these products to make sure that they're okay. Then once it's cleared, there, it then becomes available locally for sites to see the clearance. And then local sites can then work with their local its to order the products. Education is really important, as I mentioned, some of this technology. Is becoming, maybe not more less complicated, right? It's more complicated, but it's more user friendly and so but the important, it's really important for employees to be aware of some of the nuanced challenges that can come with any of these technologies. So you can envision a patient who's on an insulin pump that suddenly stops working in the middle of the night. If you know individuals that are there working don't know what to do with it, potentially, that can become a major problem for that patient certified pump training. So every the FDA does require every new patient who starts on an insulin pump get training, and that has become a bit of a challenge for us, just because it does require, you know, a coordination of getting the individual into our institution to train the patient or having to send them out, which can become costly. So something we were definitely considering ways to maybe manage more internally, with getting some of our pharmacists, as well as our other health professionals trained to be certified pump trainers in house. I did mention a little bit earlier about some of the dosing flexibility with the patch pumps, which you know, is a little less technology, so maybe easier to use with less requirements for review. But, you know, having a full automated insulin delivery device adds a ton of dosing flexibility, and so we really liked that opportunity as well. As you know, the technology becoming sort of the mainstay or the standard of care, especially for patients with complicated type one diabetes. In the community, want to make sure to have that available for our patients. Follow up is really important. So we've talked about this a lot with regards to the importance of having a good team structure make sure the patients have the resources that they need and the follow up so that they're not they don't fall through the cracks. We've seen that happen right? Like there's patients that just slip through, maybe miss supplies, miss an insulin order for the pump device, and that causes major problems. So we needed to make sure that these patients were kind of hyper aware of them, to make sure that we're not losing some important pieces to the follow up with these patients. And we kind of already talked about funding challenges, and that becomes a problem and continues to be an issue for us. I'm sure no one else has that problem, probably just a bureau problem, but something we were always fighting through. So I'm going to skip over this slide, just because I think we've kind of addressed some of these things already the patients that we use them for, I will say, you know, obviously the complicated type one is really the target for our insulin pump usage right now, as we continue to see some of the impact of these and we're hoping to continue to grow this so that we can use them more globally, especially for any patient with type one diabetes to start. But these are kind of some of the metrics that we use, not metrics, but some of the criteria that we maybe use to think about which patients should get an insulin pump. I'm not you know, we've hopefully identified the impact of the pharmacist within the team based care throughout this series. Want to kind of definitely finish that off with this, because we've seen this work well with an insulin pump. We have one institution in our agency right now, who's done a really good job at getting pumps started on patients. And they have an, actually a diabetes practice committee that they've established at their institution that includes all the different disciplines you see listed here. And they actually review once a month all patients that are considering for a pump, and they kind of do a thorough review and evaluating the patient and what their major needs are, and really, kind of get them set up for success to actually start the pump. This is their step process for how they get the pump started for their patients. So a month before, they really kind of make start the kind of interactive, intensive interaction with the patient, with regards to getting them ready for the pump. About two weeks before they start the pump, they get it ordered, make sure it's in, have all the supplies, then they, you know, get the pump placed with the certified pump trainer. And then after they do that, post intensive, really kind of close follow up, three and four, seven and 14 days, they make sure to follow that patient. And then they have ongoing monthly group meetings as well as ongoing individual meetings, at least monthly or more often as needed. Alright, so finishing and tying this all together, we've got our patient as we remember him. This is actually his most recent CGM report, and if you recall the very first one that commander swagger showed us, and I'll just point out the target in range was not much different here than it was on that one, but he's actually starting to show some lows. So we did see the highs kind of go away, which is great, but they kind of shifted into the low space, and he has even more variability. Percentage of his 53.6% on this one, I think it was down at 37% before. So now that we have him correctly diagnosed, he's actually behaving a lot like a complicated type one patient. And so I would definitely heavily consider using an insulin pump for this patient. So I'll just say for our six month follow up with him, as is typical when we first started him, he did have a few challenges with with the tubing changes with the pump he was using, as well as learning the carb counting, which is always can be a tricky thing for patients. And then he's also his history of just, you know, having low blood sugars overnight, just helping him to feel comfortable and trust the pump itself was something that we had to work through. But we've dropped the a 1c so you remember that first a 1c was at 10.4 we've lowered him down to 7.6 on his most recent one after the the pump started. And most importantly in my mind is that in the previous two months, he hadn't had any hypoglycemia that required a health services assistance. And that's really kind of the primary focus of our use of technologies. From this. Safety standpoint, I know we are out of time, so I do appreciate you sticking through with us today. You know, hopefully, all of these presentations, we really brought in the importance and value of a pharmacist and care that can be provided, and really leaning into that pharmacist time and knowledge base, you know, and diabetes technology is something that we've seen pharmacy work really well with and we, you know, recommend, if you don't have a pharmacist, to really kind of put them on this and let them kind of take this and move with it. If it's something you're not using. I think is all we have for today, I will put our contact information up here for those I do see a lot of my bop friends on the call. Thanks for sticking through with us, those that are on and I would encourage you, if you're not using locally, to reach out to me, because we'd love to get you using it. But again, we're happy to take suggestions and questions at any point. Christopher Smith, NPA 1:00:50 Commanders, we did have one question, if you want to give a quick moment to address it, Speaker 1 1:00:56 sure will be op patients released from the BOP so to Roc or home with the CGM? If so, how often does the equipment need to be changed replaced, and what is the cost of the CGM for a BLP institution versus out in the community? That's a really good question. So what we tend to do is we make sure that any patient does release from our facility, does go with the supplies and the product that they were given. We typically will send them with at least a month, up to three months, if we can for CGM sensors, with regards to the cost for compared to the community, I don't think it's much different, to be honest with you. We buy our, at least our CGM devices directly from the manufacturer, which is not too far off of what the federal scheduled pricing is, and I think at least with insurance, from what I've been told, it's not terribly different for most patients in the community, with regards to an insulin pump, that's more variable, so some of the pumps are provided through a pharmacy benefit on the outside, and some are provided through a medical benefit. So that can actually vary quite a bit. We're still kind of working through the nuance of that. We haven't really built any like consistent funding structure from our side. That's kind of a little bit more, I guess, nuance that we're still trying to work through. But hope that answered the question, and I do appreciate it. CAPT. Chad Garrett 1:02:13 All right. Thank you very much. Thank you. And just like that, we have reached the final frame in our nine part mosaic of medical mastery, short, sharp and scintillatingly shrewd as we close the curtain on the clinical prayer series, I offer my sincere gratitude for your sustained curiosity, clinical commitment and generous participation, whether you joined us for one session, our old nine, your presence has helped elevate the discourse and drive forward a vision of correctional care that is evidence informed enthusiastically, enthusiastically driven and exquisitely practical. So a standing ovation goes out to each of our phenomenal presenters, nine series worth of sharp minds and sharper insights, from antibiotic stewardship to substance use disorder and today our grand finale on diabetes technology, I want to thank you for how you generously shared your wisdom, your time, your deep dedication to Correctional Health Innovation, your contributions have not only enlightened our minds, but expanded our possibilities before we officially sign off, please take a moment to complete the post core survey. Your feedback is the compass that guides our future offerings, helping us craft content that remains as relevant as it is rigorous. So as we say for our well to this series, let's keep the momentum moving and the mindset maturing. May your next patient encounter be infused with a new Pearl, may your next case colored with some nuance, and your next challenge met with confidence. Thank you for your time tenacity and your title is pursued it better. But as this door shuts, we open a new one. I would like to invite you all to our upcoming series mastering fungal infections and corrections. We have teamed up with CDC, Nic and the BOP once again to offer this informative three part series, remember, the world of fungal infections is far more complex and consequential than athletes foot and ringworm in the correctional setting, where environmental controls and Patient comorbidities collide, these stealthy spores can spiral into serious health threats. So again, join us for a compelling new clinical series curated in partnership with the Centers for Disease Control and Prevention The Federal Bureau of Prisons, and it's designed specifically for correctional clinicians and custodial healthcare teams. You. Who should attend? Well, any state, federal, local, a tribal correctional jurisdiction with an interest in Correctional Health Care, or if you just got an interest in infectious fungal diseases. So stay tuned for more information and links to register for that and with that, I say thank you and goodbye you. Transcribed by https://otter.ai