Mismatch of Sleep and Work Timing and Risk of Type 2 Diabetes

OBJECTIVE

To examine whether a mismatch between chronotype (i.e., preferred sleep timing) and work schedule is associated with type 2 diabetes risk.

RESEARCH DESIGN AND METHODS

In the Nurses’ Health Study 2, we followed 64,615 women from 2005 to 2011. Newly developed type 2 diabetes was the outcome measure (n = 1,452). A question on diurnal preference ascertained chronotype in 2009; rotating night shift work exposure was assessed regularly since 1989.

RESULTS

Compared with intermediate chronotypes, early chronotypes had a slightly decreased diabetes risk after multivariable adjustment (odds ratio 0.87 [95% CI 0.77–0.98]), whereas no significant association was observed for late chronotypes (1.04 [0.89–1.21]). Among early chronotypes, risk of type 2 diabetes was modestly reduced when working daytime schedules (0.81 [0.63–1.04]) and remained similarly reduced in women working <10 years of rotating night shifts (0.84 [0.72–0.98]). After ≥10 years of shift work exposure, early chronotypes had a nonsignificant elevated diabetes risk (1.15 [0.81–1.63], P_trend = 0.014). By contrast, among late chronotypes, the significantly increased diabetes risk observed among day workers (1.51 [1.13–2.02]) appeared largely attenuated if their work schedules included night shifts (<10 years: 0.93 [0.76–1.13]; ≥10 years: 0.87 [0.56–1.34]; P_trend = 0.14). The interaction between chronotype and shift work exposure was significant (P_interaction = 0.0004). Analyses restricting to incident cases revealed similar patterns.

CONCLUSIONS

In early chronotypes, type 2 diabetes risk increased with increasing duration of shift work exposure, whereas late types had the highest diabetes risk working daytime schedules. These data add to the growing body of evidence that workers could benefit from shift schedules minimizing interference with chronotype-dependent sleep timing.     

Do Circadian Preferences Influence the Sleep Patterns of Night Shift Drivers?

Objective

The objective of this study was to analyze the effect of individual circadian preferences of drivers with fixed night work schedules on sleep patterns.

Subjects and Methods

A total of 123 professional drivers, 32 indifferent preference drivers and 91 morning preference drivers of an intermunicipality and interstate bus transportation company were evaluated. All drivers underwent polysomnographic recordings after their shifts. Furthermore, they filled out a questionnaire that contained sociodemographic and health questions. The Horne and Östberg questionnaire was used to assess the subjects'' morningness-eveningness preference.

Results

The mean age was 42.54 ± 6.98 years and 82 (66.66%) of the drivers had worked for ≥15 years. A significant effect on rapid eye movement (REM) was observed in the morning preference drivers. They showed an increased sleep latency and an REM sleep percentage of 5% of the total REM time. This reveals a significant effect on sleep architecture associated with work time.

Conclusion

The drivers reported that morning preference had a significant effect on their sleep pattern indicating less REM sleep and longer REM sleep latency in the morning preference group. Thus, it is important to evaluate interactions between individual aspects of health and other parameters, such as sleep quality and work organizational factors, to promote night shift workers'' health and well-being.Key Words: Circadian rhythm, Shift work, Sleep     

The Morbidity Rate of Chronic Disease among Chinese Rural Residents: Results from Liuyang Cohort

Objective

To study the health status and explore the putative risk factors of chronic diseases among a Chinese rural population.

Subjects and Methods

Face-to-face interviews were carried out to collect the information of social characteristics, health status and related risk factors of 11,909 families comprised of 49,383 subjects in the rural area of Liuyang, Hunan province during 2007. Chronic disease was diagnosed according to the diagnosis certification from the town clinic or superior level hospital.

Results

The morbidity rate of chronic disease among Liuyang rural residents in 2007 was 19.22s%. The prevalence of the top 10 chronic disorders was as follows: hypertension: 3.65s%; urolithiasis: 1.03s%; chronic obstructive pulmonary disease: 0.92s%; ischemic heart disease: 0.92s%; chronic gastritis: 0.91s%; cerebrovascular disease: 0.71s%; lumbar disk disease: 0.61s%; chronic viral hepatitis: 0.55s%; gallstones: 0.54s%, and diabetes: 0.54s%. Age, gender, educational level, occupation, marital status, type of housing, source of drinking water, smoking, underweight and overweight were factors associated with chronic disease. We also noticed that 14.2s% of the residents were underweight and 29.7s% are still using unsafe sources of drinking water.

Conclusions

The prevalence of chronic disease in Liuyang area was severe both in communicable and noncommunicable chronic disease. Unhealthy lifestyles such as tobacco usage and overweight partially contributed to the high prevalence of chronic disease.Key Words: Chronic disease, Epidemiology, Risk factors, Prevalence rate, Rural residence, China     

A Retrospective Radiographic Study of Coronal-Periapical Status and Root Canal Filling Quality in a Selected Adult Turkish Population

Objective

To investigate the oral health (with regard to the periapical status, quality of root fillings and coronal restorations) in an urban adult Turkish subpopulation using digital panoramic radiographs.

Materials and Methods

One thousand digital panoramic radiographs involving 28,000 teeth were selected from the archive of the Public Oral and Dental Health Center of Isparta. Coronal status (the type of restoration, signs of marginal leakage or decay), root filling quality (length and lateral seal) and periapical status (according to Periapical Index, PAI) were evaluated. Correlations between apical periodontitis (AP) and the quality of root fillings or coronal restorations were statistically analyzed using the χ² test.

Results

Of the 28,000 teeth evaluated, 22,380 (80.0s%) were sound, 4,732 (16.9s%) were missing, 753 (2.6s%) were filled and 135 (0.5s%) were decayed. Of the 753 coronal restorations, 400 (53.1s%) were radiographically acceptable. Of the 23,268 teeth, 601 (2.6s%) were root filled and 247 root fillings were adequate. Ninety-five (15.8s%) root-filled teeth had AP (PAI 3–5). Out of the total, the AP prevalence was 0.4s% in root-filled teeth and 0.8s% in teeth without root fillings. The presence of AP was significantly correlated with inadequate coronal restorations and root canal fillings (p = 0.000).

Conclusion

Tooth type, quality and type of coronal restorations, and length and homogeneity of root fillings significantly affected periapical status.Key Words: Coronal status, Digital panoramic radiography, Periapical index, Periapical status, Root canal filling quality     

Chronotype Is Independently Associated With Glycemic Control in Type 2 Diabetes

OBJECTIVE

To examine whether chronotype and daily caloric distribution are associated with glycemic control in patients with type 2 diabetes independently of sleep disturbances.

RESEARCH DESIGN AND METHODS

Patients with type 2 diabetes had a structured interview and completed questionnaires to collect information on diabetes history and habitual sleep duration, quality, and timing. Shift workers were excluded. A recently validated construct derived from mid-sleep time on weekends was used as an indicator of chronotype. One-day food recall was used to compute the temporal distribution of caloric intake. Hierarchical linear regression analyses controlling for demographic and sleep variables were computed to determine whether chronotype was associated with HbA_1c values and whether this association was mediated by a higher proportion of caloric intake at dinner.

RESULTS

We analyzed 194 completed questionnaires. Multiple regression analyses adjusting for age, sex, race, BMI, insulin use, depressed mood, diabetes complications, and perceived sleep debt found that chronotype was significantly associated with glycemic control (P = 0.001). This association was partially mediated by a greater percentage of total daily calories consumed at dinner.

CONCLUSIONS

Later chronotype and larger dinner were associated with poorer glycemic control in patients with type 2 diabetes independently of sleep disturbances. These results suggest that chronotype may be predictive of disease outcomes and lend further support to the role of the circadian system in metabolic regulation.The circadian system, controlled by the master circadian clock located in the suprachiasmatic nuclei of the hypothalamus, plays a major role in regulating daily rhythms of sleep/wake and various metabolic outputs, such as feeding behavior, peripheral tissue metabolism, and hormone secretions (1–3). Despite having this genetically regulated master circadian clock, humans living in modern industrialized societies with 24-h access to light often engage in behaviors that are inappropriately timed relative to their endogenous circadian rhythms. This mismatch in timing is termed “circadian misalignment” and has been associated with a number of negative health outcomes. Night shift work is an example of severe circadian misalignment, as workers are awake, active, and eating during their circadian night and trying to sleep and fast during their circadian day. Epidemiologic studies reveal that shift work is associated with health problems including peptic ulcer disease, coronary heart disease, and metabolic syndrome, as well as certain types of cancers (4). In controlled laboratory studies, experimentally induced circadian misalignment in healthy human volunteers resulted in impaired glucose tolerance (5,6). In animal experiments, mice fed a high-fat diet during their inactive period gained significantly more weight than mice fed during their active phase, despite consuming the equivalent amount of calories (7). Taken together, these data suggest that severe circadian misalignment involving eating and sleeping at an abnormal circadian time leads to impaired energy metabolism.Many individuals in modern society experience a form of mild circadian misalignment, especially during the work or school week as they follow social rhythms imposed by professional obligation, school schedules, family, and other commitments (8). The degree of misalignment is dependent on the individual’s “chronotype” (8). Chronotype is a construct that captures an individual’s preference for being a “morning” or “evening” person. Late chronotype is typically associated with a greater degree of misalignment between social rhythms and the circadian clock (8). This misalignment phenomenon has been termed “social jetlag,” as it resembles the condition experienced after traveling across time zones (8) and can be observed by comparing the difference in sleep timing between work/school days and free days. In a large population study, larger amounts of social jetlag were recently reported to be associated with higher BMI in overweight individuals (9). In addition, a recent study found that patients with type 2 diabetes had significantly later bedtimes and wake times than participants without diabetes, suggesting that chronotype may play a role in glucose metabolism (10).In addition to chronic circadian misalignment, late chronotypes or “evening types” tend to minimize or skip breakfast (11,12). Therefore, the daily distribution of food intake may be mismatched with circadian-controlled metabolic rhythms. It is well recognized that glucose tolerance is worse in the evening (13), suggesting that eating late may result in adverse metabolic consequences. Indeed, a study of healthy volunteers reported that the amount of calories consumed after 8:00 p.m. predicted a higher BMI after controlling for sleep timing and duration (14), suggesting that the timing of food intake across the waking day is of metabolic relevance.To date, little is known about chronotypic variations in patients with type 2 diabetes and the potential associations with glycemic control. There is abundant evidence that sleep disturbances such as short sleep duration and poor sleep quality are linked to the risk of diabetes and obesity, as well as glycemic control in subjects with type 2 diabetes (15,16), but little is known about the association between chronotype and metabolism independently of these sleep characteristics. The aim of this study was to examine whether chronotype was independently associated with glycemic control in patients with type 2 diabetes. We hypothesized that late chronotype would be associated with worse glycemic control independently of sleep disturbances. Because the distribution of food intake across the day is associated with chronotype, we also examined whether daily caloric distribution contributed to glycemic control. We hypothesized that a greater percentage of daily calories consumed at dinner would be associated with worse glycemic control.     

Occupational Injuries Prone to Infectious Risks amongst Healthcare Personnel in Kuwait: A Retrospective Study

Objective

The study aimed at determining the prevalence of incident occupational exposure to blood and other potentially infectious materials (OPIM) among healthcare personnel (HCP) during 2010 and at evaluating the factors associated with these incidents.

Subjects and Methods

An epidemiological, retrospective, record-based study was conducted. All self-reported incidents of occupational exposure to blood and OPIM among HCP from all healthcare settings of the Kuwait Ministry of Health during 2010 were included.

Results

The total number of the exposed HCP was 249. The prevalence of incident exposure was 0.7s% of the HCP at risk. Their mean age was 32.31 ± 6.98 years. The majority were nurses: 166 (66.7s%), followed by doctors: 35 (14.1s%), technicians: 26 (10.4s%) and housekeeping personnel: 22 (8.8s%). Needle stick injury was the most common type of exposure, in 189 (75.9s%), followed by sharp-object injury, mucous-membrane exposure and contact with nonintact skin. The majority of needle stick exposures, i.e. 177 (93.7s%), were caused by hollow-bore needles. Exposure to blood represented 96.8s%, mostly during drawing blood and the insertion or removal of needles from patients [88 (35.4s%)] and when performing surgical interventions [56 (22.6s%)]. Easily preventable exposures such as injuries related to 2-handed recapping of needles [24 (9.6s%)] and garbage collection [21 (8.4s%)] were reported. Exposures mainly occurred in the inpatient wards [75 (30.1s%)] and operating theaters [56 (22.6s%)]. Among the exposed HCP, 130 (52.2s%) had been fully vaccinated against hepatitis B virus (HBV).

Conclusion

Needle stick injuries are the most common exposure among HCP in Kuwait, and nurses are the most frequently involved HCP category. A good proportion of exposures could be easily prevented. HBV vaccination coverage is incomplete.Key Words: Occupational exposure, Blood-borne viruses, Healthcare personnel, Kuwait     

Characteristics of Symptom Presentation and Risk Factors in Patients with Erosive Esophagitis and Nonerosive Reflux Disease

Objective

The aim of this study was to investigate the effect of gender on symptom presentation and quality of life of patients with erosive esophagitis (EE) and nonerosive reflux disorder (NERD).

Subjects and Methods

Medical records from patients with gastroesophageal reflux disease (GERD) between January and December 2009 were reviewed. The patients were assigned to either the EE or the NERD group. The general demographic data, the modified Chinese GERDQ scores and the Short Form (SF)-36 life quality questionnaire scores of the two groups of patients were compared.

Results

Of the 261 patients, 87 (33.3s%), 86 (33.0s%) and 88 (33.7s%) patients were classified into the EE, the NERD and the control groups, respectively. The patients in the EE group were significantly older (48.94 ± 17.38 vs. 43.34 ± 12.67 years), were predominately male (58.6 vs. 39.5s%), had more frequently hiatal hernia (34.5 vs 17.4s%), had a higher body weight (67.57 ± 15.13 vs. 61.06 ± 11.08 kg) and a higher body mass index (24.09 ± 4.61 vs. 22.68 ± 3.12) than those in the NERD group. The GERD-specific symptom scores and the general life quality scores of the EE and the NERD groups were similar, and both groups had lower life quality scores than the control group did. The female patients with NERD had a higher frequency of GERD symptoms and lower quality of life scores. Gender had no effect on symptom scores or life quality scores in the EE group.

Conclusion

The GERD-specific symptom severity and general quality of life scores of the EE and the NERD patients were similar. Gender had a great influence on symptom presentation and quality of life in patients with NERD, but not in those with EE.Key Words: Erosive esophagitis, Gastroesophageal reflux disease, Gender, Quality of life, Nonerosive reflux disease     

Potassium Abnormalities in Current Clinical Practice: Frequency,Causes, Severity and Management

Objective

We aimed to investigate the prevalence and etiology of potassium abnormalities (hypokalemia and hyperkalemia) and management approaches for hospitalized patients.

Subjects and Methods

Over a 4-month period, all hospitalized patients at Hacettepe University Medical Faculty Hospitals who underwent at least one measurement of serum potassium during hospitalization were included. Data on serum levels of electrolytes, demographic characteristics, cause(s) of hospitalization, medications, etiology of potassium abnormality and treatment approaches were obtained from the hospital records.

Results

Of the 9,045 hospitalized patients, 1,265 (14.0s%) had a serum potassium abnormality; 604 (6.7s%) patients had hypokalemia and 661 (7.30s%) had hyperkalemia. In the hypokalemic patients, the most important reasons were gastrointestinal losses in 555 (91.8s%) patients and renal losses in 252 (41.7s%) patients. The most frequent treatment strategies were correcting the underlying cause and replacing the potassium deficit. Of the 604 hypokalemic patients, 319 (52.8s%) were normokalemic at hospital discharge. The most common reason for hyperkalemia was treatment with renin-angiotensin-aldosterone system blockers in 228 (34.4s%) patients, followed by renal failure in 191 (28.8s%). Two hundred and ninety-eight (45.0s%) patients were followed without any specific treatment. Of the 661 hyperkalemic patients, 324 (49.0s%) were normokalemic at hospital discharge.

Conclusion

This study showed a high prevalence of potassium imbalance among hospitalized patients. Although most of the potassium abnormalities were mild/moderate, approximately half of the patients treated for hypokalemia or hyperkalemia were discharged from the hospital with ongoing dyskalemia.Key Words: Hypokalemia, Hyperkalemia, Potassium     

Utility of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Patients with Fever of Unknown Origin Diagnosed as Lymphoma

Objective

To assess the efficacy of fluorine-18 fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET)/computed tomography (CT) in the diagnosis of patients with fever of unknown origin (FUO), who were finally diagnosed as lymphoma.

Subjects and Methods

A retrospective study was performed in the First Affiliated Hospital, School of Medicine of Zhejiang University, China, from March 2009 to March 2012. The PET/CT images of consecutive patients with FUO were analyzed. Within 1 week of PET/CT scanning, additional histological tests were also performed if clinically needed.

Results

A total of 73 consecutive patients were included. Of these, 34 (47s%) had a PET/CT finding suggestive of the presence of lymphoma and 29 (85s%) had a diagnosis of confirmed lymphoma; 39 (53s%) had a PET/CT result revealing the absence of lymphoma and 4 (10s%) were diagnosed by biopsy as having lymphoma. The most frequent lymphoma diagnosis was peripheral T cell lymphoma (n = 16; 55s%), followed by diffuse large B cell lymphoma (n = 9; 31s%). The accuracy of PET/CT was 88s%.

Conclusion

In this study, PET/CT had high diagnostic accuracy in patients with FUO resulting from lymphoma, which indicated that PET/CT scanning was a valuable diagnostic tool for these groups of patients with FUO.Key Words: Fever of unknown origin, Positron emission tomography, Computed tomography, Diagnosis, Lymphoma     

Long-Term Results of Various Operations for Lumbar Disc Herniation: Analysis of over 39,000 Patients

Objective

To determine the long-term follow-up of the various operations for lumbar disc herniation in a large patient population.

Subjects and Methods

Patients who had operations for lumbar disc herniation (microdiscectomy, endoscopic microdiscectomy and the ‘classical operation’, i.e. laminectomy/laminotomy with discectomy) were collected from the world literature. Patients who had follow-ups for at least 2 years were analyzed relative to the outcome. The outcome was graded by the patients themselves, and the operative groups were compared to one another.

Results

39,048 patients collected from the world literature had had lumbar disc operations for disc herniations. The mean follow-up period was 6.1 years, and 30,809 (78.9s%) patients reported good/excellent results. Microdiscectomy was performed on 3,400 (8.7s%) patients. The mean follow-up was 4.1 years with 2,866 (84.3s%) good/excellent results, while 1,101 (3.6s%) patients had endoscopic microdiscectomy. There, the mean follow-up was 2.9 years with 845 (79.5s%) good/excellent results. The classical operation was performed on 34,547 (88.5s%) patients with a mean follow-up period of 6.3 years, and 27,050 (78.3s%) patients had good/excellent results. These results mirror those with discectomy and the placement of prosthetic discs.

Conclusions

The analysis of 39,048 patients with various operations for lumbar disc herniation revealed the same pattern of long-term results. Patients who had microdiscectomy, endoscopic microdiscectomy or the classical operation (laminectomy/laminotomy with discectomy) all had approximately 79s% good/excellent results. None of the operative procedures gave a different outcome.Key Words: Lumbar disc herniation, Lumbar disc surgery, Long-term follow-up, Lumbar disc operations, Operations for lumbar disc herniation, Results of lumbar disc surgery     

The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients

Introduction

This study hypothesised that a reduction of sound during the night using earplugs could be beneficial in the prevention of intensive care delirium. Two research questions were formulated. First, does the use of earplugs during the night reduce the onset of delirium or confusion in the ICU? Second, does the use of earplugs during the night improve the quality of sleep in the ICU?

Methods

A randomized clinical trial included adult intensive care patients in an intervention group of 69 patients sleeping with earplugs during the night and a control group of 67 patients sleeping without earplugs during the night. The researchers were blinded during data collection. Assignment was performed by an independent nurse researcher using a computer program. Eligible patients had an expected length of stay in the ICU of more than 24 hours, were Dutch- or English-speaking and scored a minimum Glasgow Coma Scale of 10. Delirium was assessed using the validated NEECHAM scale, sleep perception was reported by the patient in response to five questions.

Results

The use of earplugs during the night lowered the incidence of confusion in the studied intensive care patients. A vast improvement was shown by a Hazard Ratio of 0.47 (95% confidence interval (CI) 0.27 to 0.82). Also, patients sleeping with earplugs developed confusion later than the patients sleeping without earplugs. After the first night in the ICU, patients sleeping with earplugs reported a better sleep perception.

Conclusions

Earplugs may be a useful instrument in the prevention of confusion or delirium. The beneficial effects seem to be strongest within 48 hours after admission. The relation between sleep, sound and delirium, however, needs further research.

Trial registration

Current Controlled Trials ISRCTN36198138     

Health Education Materials for Arab Patients: Content and Design Preferences

Objective

To investigate the content and design preferences of printed health education leaflets among Arab patients.

Materials and Methods

A survey questionnaire to 17 subjects (women: n = 8, men: n = 9; age range 17–70 years) and three focus-group discussions (total 16 participants) were used to assess preferences by showing samples of Arabic health education materials. The questionnaire was administered by interviewers. For the focus-group discussions, the sessions were conducted by a trained interviewer, audio recorded and analyzed thematically. The subjects’ educational level was from no formal schooling to university level.

Results

In survey component, all patients preferred photographs over clipart. Typeface (‘font’) preferences were for Simplified Arabic in 8 subjects (47s%) and Mudir MT in 7 (41s%); the 16-point font size was favored by 14 (82s%) patients. In the three focus-group discussions, themes that participants expressed included use of standard Arabic with local dialects, short sentences, and culturally appropriate advice with practical and quantifiable examples.

Conclusions

The participants preferred health education materials to be color trifold brochures illustrated with pictures and not clipart and written in Arabic using the Simplified Arabic font in 16-point size.Key Words: Health education, Arabic world, Patient education handout     

Direct and Transdentinal (Indirect) Antibacterial Activity of Commercially Available Dental Gel Formulations against Streptococcus mutans

Objective

To evaluate the direct and transdentinal (indirect) agar diffusion antibacterial activity of different commercially available antibacterial dental gel formulations against Streptococcus mutans.

Materials and Methods

The commercially available dental gel formulations were Corsodyl® (COG, 1s% chlorhexidine), Cervitec® (CEG, 0.2s% chlorhexidine s+ 0.2s% sodium fluoride), Forever Bright® (FOB, aloe vera), Gengigel® (GEG, 0.2s% hyaluronic acid), 35s% phosphoric acid gel and distilled water (control). Direct agar diffusion was performed by isolating three wells from brain-heart infusion agar plates using sterile glass pipettes attached to a vacuum pump and adding 0.1 ml of the gels to each well. Transdentinal (indirect) agar diffusion was performed by applying gel to 0.2- and 0.5-mm-thick human dentin discs previously etched with phosphoric acid and rinsed with distilled water. Zones formed around the wells and the dentin discs were measured and analyzed using Kruskal-Wallis and Mann-Whitney U tests with Bonferroni correction (p < 0.01).

Results

Direct agar diffusion tests showed significant differences among all gel formulations (p < 0.01) except for COG and CEG (p > 0.01). COG and CEG exhibited higher antibacterial effects compared to FOB and GEG (p < 0.01) in both direct and transdentinal (indirect) testing procedures. GEG did not show any antimicrobial activity in transdentinal (indirect) testing.

Conclusion

Commercially available dental gels inhibited S. mutans, which may indicate their potential as cavity disinfectants.Key Words: Antibacterial dental gels, Streptococcus mutans, Cavity disinfectant, Chlorhexidine, Hyaluronic acid, Aloe vera     

Clinical Factors Associated with Negative Urinary Antigen Tests Implemented for the Diagnosis of Community-Acquired Pneumococcal Pneumonia in Adult Patients

Objective

This study investigated clinical factors associated with negative urinary antigen tests (UAT) implemented for the diagnosis of pneumococcal community-acquired pneumonia (CAP) in adult patients.

Subjects and Methods

We reviewed the medical records of 755 adult patients who completed the UAT in our hospital between 2009 and 2012. Of these, we evaluated 63 patients with bacteriologically confirmed definite pneumococcal CAP (33 were UAT-positive, and 30 were UAT-negative).

Results

There was no significant difference between the UAT-positive and the UAT-negative patients regarding age, dehydration, respiratory failure, orientation, blood pressure (ADROP) score (the CAP severity score proposed by the Japanese Respiratory Society), gender, white blood cell counts, liver/kidney function tests, or urinalysis. However, serum C-reactive protein (CRP) concentrations were 31s% lower in the UAT-negative patients than in the UAT-positive patients (p = 0.02). Furthermore, the prothrombin time-international normalized ratio was 50s% higher in the UAT-negative patients than in the UAT-positive patients, although the difference did not reach statistical significance (p = 0.06). The prevalence of comorbidities was similar in both UAT-positive and UAT-negative patients. However, warfarin had been prescribed in 8 (27s%) of the UAT-negative patients compared to only 1 (3s%) of the UAT-positive patients (odds ratio = 11.6; p = 0.01).

Conclusions

These results suggested that low serum CRP concentrations and the use of warfarin increased the possibility with which false-negative UAT results occurred in these patients with pneumococcal CAP.Key Words: Urinary antigen test, Community-acquired pneumonia, Streptococcus pneumoniae, Anticoagulation therapy     

Inflammatory Morbidity due to Compound Mandibular Body Fractures: Does It Have a Relationship with Treatment Outcome?

Objective

The aim of this study was to evaluate the relationship between the degree of preoperative pain and trismus with the development of complications following the repair of isolated unilateral compound mandibular body fractures using a closed reduction technique.

Subjects and Methods

This was a 7-year prospective study carried out at the Dental and Maxillofacial Surgery Clinic of the University of Calabar Teaching Hospital, Calabar, Nigeria. Of a total of 97 patients, 83 (85.6s%) subjects (66 males, 17 females, ratio 5:1) were preoperatively evaluated for trismus and pain in a blinded manner by a single examiner, and complications were recorded postoperatively. The data obtained were statistically analyzed with EPI Info 2008 software.

Results

Of the 83 patients treated, 13 (15.7s%) developed complications. The fractures were most common in the age range of 21–40 years (n = 45, 54.2s%). The age (p = 0.02) and gender (p = 0.01) distribution of the subjects was significant. The more severe the limitation of mouth opening (p = 0.03) and pain (p = 0.04) before treatment, the more complications developed, and these significantly affected treatment outcome. Impaired mastication and facial asymmetry (n = 17, 41.5s%) were the most common complications.

Conclusion

This study showed that posttrauma pain and trismus due to unilateral mandibular body fractures may be associated with the development of complications. An adequately powered prospective study treating patients at 5 or 7 days is required in order to make the case for later intervention.Key Words: Mandible, Body fracture, Pain, Trismus, Complications     

Clinical Consequences of Untreated Dental Caries Evaluated with the Pulpal Involvement-Roots-Sepsis Index in the Primary Dentition of School Children from the Raipur and Durg Districts,Chhattisgarh State,India

Objective

To evaluate the prevalence of the clinical consequences of untreated dental caries in primary dentition among 6- to 8-year-old children using the prs [pulpal involvement (p), roots (r) and sepsis (s)] index and record the distribution of prs among boys and girls.

Subjects and Methods

The study included a sample of 371 children aged 6–8 years with at least one carious primary molar tooth, who had been randomly selected from schools in the districts of Raipur and Durg, Chhattisgarh State, India. We recorded the presence of decayed, extracted and filled (i.e. def) teeth. The prevalence of the consequences of untreated dental caries was evaluated using the prs index. The data were statistically analyzed to express the prevalence of prs among boys and girls and the distribution of individual prs codes in the sample population.

Results

The prevalence of carious lesions was very high (87s%) and teeth with clinical consequences of untreated dental caries were found in 49.3s% of the children. The prs distribution in children who were 8 years old (40.9s%) was higher than in the 6-year-old children (25.6s%). In the group of 8-year-olds, the occurrence of prs was greater among the boys whereas in the 6- and 7-year-old group, it was greater among the girls.

Conclusion

The prs index is a valuable tool for measuring the clinical consequences of untreated dental caries. It could be useful for epidemiological studies and provide relevant information regarding treatment needs.Key Words: Primary dentition, Dental caries, PRS index     

Partial Sleep Restriction Decreases Insulin Sensitivity in Type 1 Diabetes

OBJECTIVE

Sleep restriction results in decreased insulin sensitivity and glucose tolerance in healthy subjects. We hypothesized that sleep duration is also a determinant of insulin sensitivity in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

We studied seven patients (three men, four women) with type 1 diabetes: mean age 44 ± 7 years, BMI 23.5 ± 0.9 kg/m², and A1C 7.6 ± 0.3%. They were studied once after a night of normal sleep duration and once after a night of only 4 h of sleep. Sleep characteristics were assessed by polysomnography. Insulin sensitivity was measured by hyperinsulinemic euglycemic clamp studies with an infusion of [6,6-²H₂]glucose.

RESULTS

Sleep duration was shorter in the night with sleep restriction than in the unrestricted night (469 ± 8.5 vs. 222 ± 7.1 min, P = 0.02). Sleep restriction did not affect basal levels of glucose, nonesterified fatty acids (NEFAs), or endogenous glucose production. Endogenous glucose production during the hyperinsulinemic clamp was not altered during the night of sleep restriction compared with the night of unrestricted sleep (6.2 ± 0.8 vs. 6.9 ± 0.6 μmol · kg lean body mass⁻¹ · min⁻¹, NS). In contrast, sleep restriction decreased the glucose disposal rate during the clamp (25.5 ± 2.6 vs. 22.0 ± 2.1 μmol · kg lean body mass⁻¹ · min⁻¹, P = 0.04), reflecting decreased peripheral insulin sensitivity. Accordingly, sleep restriction decreased the rate of glucose infusion by ∼21% (P = 0.04). Sleep restriction did not alter plasma NEFA levels during the clamp (143 ± 29 vs. 133 ± 29 μmol/l, NS).

CONCLUSIONS

Partial sleep deprivation during a single night induces peripheral insulin resistance in these seven patients with type 1 diabetes. Therefore, sleep duration is a determinant of insulin sensitivity in patients with type 1 diabetes.Intensive insulin therapy is essential for optimal glucoregulation in type 1 diabetes because the degree and duration of hyperglycemia determine the incidence of complications (1). However, glucoregulation cannot be normalized in patients with type 1 diabetes, as reflected by relatively large intra-individual variations of blood glucose levels. Subtle intra-individual variations in glucoregulation and insulin sensitivity in these patients depend on variations in physiological determinants such as dietary factors and exercise (2,3). In contrast to healthy subjects, however, patients with type 1 diabetes are unable to compensate for these physiological variations, other than by adaptations of the dose of exogenous insulin.Normal glucose homeostasis shows a diurnal pattern with variations in glucose tolerance, in which sleep characteristics play a key role (4). In this respect, sleep duration may be particularly relevant because sleep curtailment is a common aspect of our modern 24-h society (5,6). A reduction in sleep duration impairs glucose tolerance in healthy subjects (7). The effects of reduction of sleep duration on insulin sensitivity have not been studied in patients with type 1 diabetes.We hypothesized that partial sleep restriction decreases insulin sensitivity in patients with type 1 diabetes, which may contribute to intra-individual variations in glucoregulation. Therefore, we compared the effects of a single night of reduced sleep duration with those of a night of normal sleep duration on hepatic and peripheral insulin sensitivity, as assessed by hyperinsulinemic euglycemic clamp studies combined with tracer dilution of [6,6-²H₂]glucose in patients with type 1 diabetes.     

Efficacy and Safety of Lixisenatide Once-Daily Morning or Evening Injections in Type 2 Diabetes Inadequately Controlled on Metformin (GetGoal-M)

OBJECTIVE

To examine the efficacy and safety of lixisenatide (20 μg once daily, administered before the morning or evening meal) as add-on therapy in patients with type 2 diabetes insufficiently controlled with metformin alone.

RESEARCH DESIGN AND METHODS

This was a 24-week, randomized, double-blind, placebo-controlled study in 680 patients with inadequately controlled type 2 diabetes (HbA_1c 7–10% [53−86 mmol/mol]). Patients were randomized to lixisenatide morning (n = 255), lixisenatide evening (n = 255), placebo morning (n = 85), or placebo evening (n = 85) injections.

RESULTS

Lixisenatide morning injection significantly reduced mean HbA_1c versus combined placebo (mean change −0.9% [9.8 mmol/mol] vs. −0.4% [4.4 mmol/mol]; least squares [LS] mean difference vs. placebo −0.5% [5.5 mmol/mol], P < 0.0001). HbA_1c was significantly reduced by lixisenatide evening injection (mean change –0.8% [8.7 mmol/mol] vs. –0.4% [4.4 mmol/mol]; LS mean difference –0.4% [4.4 mmol/mol], P < 0.0001). Lixisenatide morning injection significantly reduced 2-h postprandial glucose versus morning placebo (mean change −5.9 vs. −1.4 mmol/L; LS mean difference −4.5 mmol/L, P < 0.0001). LS mean difference in fasting plasma glucose was significant in both morning (–0.9 mmol/L, P < 0.0001) and evening (–0.6 mmol/L, P = 0.0046) groups versus placebo. Mean body weight decreased to a similar extent in all groups. Rates of adverse events were 69.4% in both lixisenatide groups and 60.0% in the placebo group. Rates for nausea and vomiting were 22.7 and 9.4% for lixisenatide morning and 21.2 and 13.3% for lixisenatide evening versus 7.6 and 2.9% for placebo, respectively. Symptomatic hypoglycemia occurred in 6, 13, and 1 patient for lixisenatide morning, evening, and placebo, respectively, with no severe episodes.

CONCLUSIONS

In patients with type 2 diabetes inadequately controlled on metformin, lixisenatide 20 μg once daily administered in the morning or evening significantly improved glycemic control, with a pronounced postprandial effect, and was well tolerated.Glucagon-like peptide-1 (GLP-1) receptor agonists are subcutaneously injected glucose-lowering agents that are associated with weight loss and have a low propensity to induce hypoglycemia (1,2). The distinct efficacy and safety profile of this class of drugs provides a novel approach for add-on therapy in the event of failure of other antidiabetic agents. The GLP-1 receptor agonists currently available include twice-daily and once-weekly formulations of exenatide and a once-daily formulation of liraglutide, thus providing a broad scope for tailoring therapy to individual patients (3–5).Lixisenatide is a selective once-daily prandial GLP-1 receptor agonist (6–9) that was approved by the European Medicines Agency in February 2013 for the treatment of type 2 diabetes. The 20-µg once-daily dose was previously shown to provide the best balance of glucose-lowering efficacy and gastrointestinal tolerability in patients with type 2 diabetes inadequately controlled with metformin (7). More recently, lixisenatide 20 μg once daily given as monotherapy was shown to significantly improve HbA_1c and provide a pronounced effect on postprandial plasma glucose (PPG) in patients with type 2 diabetes inadequately controlled with lifestyle intervention alone (6).The efficacy and safety of once-daily morning (prebreakfast) administration of lixisenatide (and twice-daily morning/evening dosing in early studies) have been evaluated in previous clinical studies (6,7,9). If once-daily evening dosing is also effective at reducing HbA_1c with similar tolerability, then this would provide patients with increased flexibility to manage their diabetes according to their lifestyle. In the current study (GLP-1 agonist AVE0010 in paTients with type 2 diabetes mellitus for Glycemic cOntrol and sAfety evaLuation with Metformin treatment [GetGoal-M]), we evaluated the efficacy and tolerability of lixisenatide once daily as add-on therapy in patients with type 2 diabetes inadequately controlled on metformin and, in contrast with other studies, included separate treatment arms looking at prebreakfast administration and pre-evening meal administration.     

Can Appropriate Diagnosis and Treatment of Childhood Asthma Reduce Excessive Antibiotic Usage?

Introduction

This study compared the frequency of antibiotic usage and the number of asthma episodes before and after the diagnosis and treatment of pediatric asthma patients who were followed up by specialists.

Subjects and Methods

Included in this study were 334 patients (211 males and 123 females) of 2–16 years of age who were diagnosed with asthma and followed up for at least 1 year in our clinic. The frequency of antibiotic usage and the number of asthma episodes in the year prior to diagnosis and treatment were compared to these same variables after 1 year of follow-up by specialists.

Results

The median age was 84 months (range: 24–192) and 212 (63s%) children were at school or in day care centers. Atopy and a family history of asthma were present in 200 (60s%) of the patients, and 137 (41s%) reported that at least one member of their household smoked. Antibiotics were used a median number of 7 times [interquartile range (IQR) = 6] in the year before the asthma diagnosis, and 2 times (IQR = 3) during the year after treatment (p < 0.001). The mean number of asthma episodes before diagnosis, i.e. 4 (IQR = 8) was reduced to 0 (IQR = 2) in the year after treatment when the patients were followed up by specialists (p < 0.001).

Conclusion

This study shows that appropriate diagnosis and treatment of childhood asthma significantly reduce the frequency of antibiotic usage and the number of asthmatic episodes.Key Words: Childhood, Asthma, Antibiotic usage     

Determinants of Length of Hospitalization due to Acute Odontogenic Maxillofacial Infections: A 2009–2013 Retrospective Analysis

Objectives

To investigate the determinants of the length of hospitalization (LOH) due to acute odontogenic maxillofacial infections (AOMIs) from 2009 to 2013.

Materials and Methods

Dental records of adult patients with AOMIs and related data were retrieved from the Vilnius University''s dental hospital. The LOH was related to several determinants in each of the following domains: outpatient primary care, severity of AOMIs, lifestyle and disease domains. Determinants were also associated with the LOH using multivariate analysis.

Results

A total of 285 patients were hospitalized with AOMIs, of which 166 (58.2s%) were males and 119 (41.8s%) were females. The mean LOH was 8.3 ± 4.9 days. The bivariate analysis did not reveal any statistically significant differences in LOH between patients with AOMIs who received urgent outpatient primary care and those who did not receive such care prior to hospitalization. All AOMI severity-related determinants were associated with the LOH. The LOH was related to coexisting systemic conditions but not to the higher severity of dental or periodontal diseases. Both bivariate and multivariate analyses revealed similar trends, where the most significant determinants of a longer LOH were related to the severity of AOMIs.

Conclusion

The most important determinants regarding longer hospitalization were indicators of infection severity such as an extension of the odontogenic infection and the need for an extraoral incision to drain the infection.Key Words: Length of hospitalization, Odontogenic infections, Determinants