The association between renal function and structural parameters: a pig study

Background

The study examines differences regarding quality of life (QoL), mental health and illness beliefs between in-centre haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD/PD) patients. Differences are examined between patients who recently commenced treatment compared to patients on long term treatment.

Methods

144 End-Stage Renal Disease (ESRD) patients were recruited from three treatment units, of which 135 provided full data on the variables studied. Patients consisted of: a) 77 in-centre haemodialysis (HD) and 58 continuous ambulatory peritoneal dialysis (CAPD/PD) patients, all currently being treated by dialysis for varied length of time. Patients were compared for differences after being grouped into those who recently commenced treatment (< 4 years) and those on long term treatment (> 4 years). Next, cases were selected as to form two equivalent groups of HD and CAPD/PD patients in terms of length of treatment and sociodemographic variables. The groups consisted of: a) 41 in-centre haemodialysis (HD) and b) 48 continuous ambulatory peritoneal dialysis (CAPD/PD) patients, fitting the selection criteria of recent commencement of treatment and similar sociodemographic characteristics. Patient-reported assessments included: WHOQOL-BREF, GHQ-28 and the MHLC, which is a health locus of control inventory.

Results

Differences in mean scores were mainly observed in the HD patients with > 4 years of treatment, providing lower mean scores in the QoL domains of physical health, social relationships and environment, as well as in overall mental health. Differences in CAPD/PD groups, between those in early and those in later years of treatment, were not found to be large and significant. Concerning the analysis on equivalent groups derived from selection of cases, HD patients indicated significantly lower mean scores in the QoL domain of environment and higher scores in the GHQ-28 subscales of anxiety/insomnia and severe depression, indicating more symptoms in these areas of mental health. With regards to illness beliefs, HD patients who recently commenced treatment provided higher mean scores in the dimension of internal health locus of control, while CAPD/PD patients on long term treatment indicated higher mean scores in the dimension of chance. Regarding differences in health beliefs between equivalent groups of HD and CAPD/PD patients, HD patients focused more on the dimension of internal health locus of control.

Conclusion

The results provide evidence that patients in HD treatment modality, particularly those with many years of treatment, were experiencing a more compromised QoL in comparison to CAPD/PD patients.     

Is Implementation of the Care Transitions Intervention Associated with Cost Avoidance After Hospital Discharge?

BACKGROUND

Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.

OBJECTIVE

To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).

DESIGN

A quasi-experimental cohort study using consecutive convenience sampling.

PATIENTS

Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.

INTERVENTION

The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.

MAIN MEASURES

We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.

KEY RESULTS

Compared to matched internal controls (N?=?321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P?=?0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.

CONCLUSIONS

This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.     

Socioeconomic and Other Predictors of Colonoscopy Preparation Quality

Background

Suboptimal bowel preparation prior to colonoscopy is a common occurrence, with a deleterious impact on colonoscopy effectiveness. Established risk factors for suboptimal bowel preparation have been proposed, but social factors, such as socioeconomic status and marital status, have not been investigated.

Aims

The aim of this study was to evaluate sociodemographic factors, including insurance status and marital status, as predictive of suboptimal preparation.

Methods

We analyzed a database of 12,430 consecutive colonoscopies during a 28-month period at Columbia University Medical Center. We collected the following variables: age, gender, indication for colonoscopy, location (inpatient vs. outpatient), race, marital status, and Medicaid status. Preparation quality was recorded and dichotomized as optimal or suboptimal. We employed multivariate regression to determine independent risk factors for suboptimal bowel preparation.

Results

Among the 10,921 examinations in which bowel preparation was recorded, suboptimal preparation occurred in 34% of Medicaid patients versus 18% of non-Medicaid patients (P < 0.0001); this remained significant in the multivariate analysis (odds ratio (OR) 1.84, 95% CI 1.61–2.11). Married patients had decreased rates of suboptimal preparation (OR 0.89, 95% CI 0.80–0.98). Other variables associated with suboptimal preparation included increased age (OR per 10 years 1.09, 95% CI 1.05–1.14), male gender (OR 1.44, 95% CI 1.31–1.59), inpatient status (OR 1.51, 95% CI 1.26–1.80), and later time of day (OR 1.89, 95% CI 1.71–2.09).

Conclusions

Unmarried status and Medicaid status are predictive of suboptimal bowel preparation. Future studies are warranted to identify how these social conditions predict bowel preparation quality and to implement interventions to optimize bowel preparation in vulnerable populations.     

Evaluation of unplanned dialysis as a predictor of mortality in elderly dialysis patients: a retrospective data analysis

Background

Increasing numbers of elderly patients are undergoing long-term dialysis. However, the role of dialysis in survival and quality of life is unclear, and poor outcomes may be associated with comorbidities rather than with age only. The initiation of unplanned dialysis in elderly patients with chronic kidney disease (CKD) has been reported to be associated with poor survival. We evaluated patient and practice factors associated with poor survival.

Methods

We performed a retrospective analysis of 90 consecutive elderly patients (≥75 years) with CKD initiated on long-term dialysis at our renal unit between October 2010 and February 2014. Six patients were excluded; data from 84 remaining patients (≥75 years) with end-stage renal disease undergoing planned or unplanned dialysis were analyzed. Patients were followed up until death or January 2015. Patient factors such as age at initiation of dialysis and comorbidities (i.e., diabetes mellitus, ischemic heart disease [IHD], peripheral vascular disease, cancer, chronic obstructive pulmonary disease, and cognitive dysfunction) were analyzed. Practice factors such as planned or unplanned initiation of dialysis were compared in relation to survival outcomes. “Unplanned dialysis” was defined as a patient with known CKD stage 4 or 5 who had not been evaluated by a nephrologist in the 3 months before dialysis initiation.

Results

The average age at dialysis initiation was 81.5?±?4.5 years), serum albumin level was 24.8?±?6 g/L, body mass index was 22.5?±?4.8 kg/m², and glycated hemoglobin A1c level was 6.3?±?1.3. Overall, 51 (61%) and 33 (39%) patients underwent unplanned and planned dialysis, respectively. On univariate analysis, the presence of IHD, peripheral vascular disease, ≥3 comorbidities, and unplanned initiation of dialysis were significantly related to death. On multivariate analysis, unplanned start of dialysis, ischemic heart diseases and peripheral vascular disease remained significant. Survival rates at 3 and 12 months were 38.6% vs. 90.9% and 14.4% vs. 73.6% for unplanned vs. planned dialysis, respectively (p?<?0.001). Unplanned dialysis was significantly associated with greater mortality.

Conclusions

In elderly dialysis patients, unplanned start of dialysis was associated with poor survival. Patient characteristics such as associated peripheral vascular disease and IHD were associated with poor survival.

     

Relationship of exercise volume to improvements of quality of life with supervised exercise training in patients with type 2 diabetes in a randomised controlled trial: the Italian Diabetes and Exercise Study (IDES)

Aims/hypothesis

A positive impact of exercise intervention programmes on quality of life (QoL) may be important for long-term patient compliance to exercise recommendations. We have previously shown that QoL improves significantly with supervised exercise, whereas it worsens with counselling alone, in patients with type 2 diabetes from the Italian Diabetes and Exercise Study (IDES). Here, we report data on the relationship between changes in QoL and volume of physical activity/exercise in these individuals.

Methods

This multicentre parallel randomised controlled, open-label, trial enrolled sedentary patients with type 2 diabetes (n?=?606 of 691 eligible) in 22 outpatient diabetes clinics. Patients were randomised by centre, age and diabetes treatment using a permuted-block design to twice-a-week supervised aerobic and resistance training plus exercise counselling (exercise group) versus counselling alone (control group) for 12?months. Health-related QoL was assessed by the 36-Item Short Form (SF-36) Health Survey.

Results

In the exercise group (n?=?268 of 303 randomised), there was a trend for increasing QoL with increasing exercise volume, with significant improvement of the physical component summary (PCS) measure only above 17.5 metabolic equivalents h^?1?week^?1 and a clear volume-relationship for the mental component summary (MCS) measure. A relationship with volume of physical activity also was observed in the control group (n?=?260 of 303 randomised), despite overall deterioration of all scores. Independent correlates of improvements in both PCS and MCS were exercise volume, study arm and, inversely, baseline score.

Conclusions/interpretation

This large trial shows a relationship between changes in physical and mental health-related QoL measures and volume of physical activity/exercise, with supervised exercise training also providing volume-independent benefits.

Trial registration:

ISRCTN-04252749

Funding:

The study was funded by Lifescan SrL, Novo Nordisk Ltd, Bristol Myers Squibb Italy, Technogym SpA and Cosmed SrL.     

Exercise Capacity Affects Quality of Life in Patients with Pulmonary Hypertension

Background

The objective of this prospective study was to evaluate the impact of exercise capacity, mental disorders, and hemodynamics on quality-of-life (QoL) parameters in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH).

Methods

Sixty-three patients with invasively diagnosed PAH (n = 48) or CTEPH (n = 15) underwent a broad panel of assessments, including cardiopulmonary exercise testing (CPET), 6-minute walking distance (6-MWD), World Health Organization functional class (WHO-FC), and assessment of hemodynamics. QoL was evaluated by the 36-item Medical Outcome Study Short Form Health Survey Questionnaire (SF-36). Exercise capacity, hemodynamics, age, gender, and mental disorders (anxiety and depression) were assessed for association with QoL subscores by uni- and multivariate regression analyses.

Results

Exercise capacity, WHO-FC, oxygen therapy, symptoms of right heart failure, right atrial pressure, and mental disorders were significantly associated with QoL (p < 0.05). In the stepwise backward selection multivariate analysis, depression remained an independent parameter in seven of eight subscales of the SF-36. Furthermore, peak oxygen uptake (peakVO₂) during CPET, 6-MWD, anxiety, long-term oxygen therapy, right heart failure, and age remained independent factors for QoL. Hemodynamic parameters at rest did not independently correlate with any domain of the SF-36 QoL subscores.

Conclusions

Mental disorders, exercise capacity, long-term oxygen therapy, right heart failure, and age play important role in the quality of life in patients with PAH and CTEPH.     

Impact of late anorectal dysfunction on quality of life after pelvic radiotherapy

Purpose

Anorectal dysfunction is common after pelvic radiotherapy. This study aims to explore the relationship of subjective and objective anorectal function with quality of life (QoL) and their relative impact in patients irradiated for prostate cancer.

Methods

Patients underwent anal manometry, rectal barostat measurement, and completed validated questionnaires, at least 1 year after prostate radiotherapy (range 1–7 years). QoL was measured by the Fecal Incontinence Quality of Life scale (FIQL) and the Expanded Prostate Cancer Index Composite Bowel domain (EPICB)-bother subscale. Severity of symptoms was rated by the EPICB function subscale.

Results

Anorectal function was evaluated in 85 men. Sixty-three percent suffered from one or more anorectal symptoms. Correlations of individual symptoms ranged from r?=?0.23 to r?=?0.53 with FIQL domains and from r?=?0.36 to r?=?0.73 with EPICB bother scores. They were strongest for fecal incontinence and urgency. Correlations of anal sphincter pressures, rectal capacity, and sensory thresholds ranged from r?=?0.00 to r?=?0.42 with FIQL domains and from r?=?0.15 to r?=?0.31 with EPICB bother scores. Anal resting pressure correlated most strongly. Standardized regression coefficients for QoL outcomes were largest for incontinence, urgency, and anal resting pressure. Regression models with subjective parameters explained a larger amount (range 26–92 %) of variation in QoL outcome than objective parameters (range 10–22 %).

Conclusions

Fecal incontinence and rectal urgency are the symptoms with the largest influence on QoL. Impaired anal resting pressure is the objective function parameter with the largest influence. Therefore, sparing the structures responsible for an adequate fecal continence is important in radiotherapy planning.     

Understanding Transitions in Care from Hospital to Homeless Shelter: a Mixed-Methods, Community-Based Participatory Approach

BACKGROUND

Coordinated transitions from hospital to shelter for homeless patients may improve outcomes, yet patient-centered data to guide interventions are lacking.

OBJECTIVES

To understand patients?? experiences of transitions from hospital to a homeless shelter, and determine aspects of these experiences associated with perceived quality of these transitions.

DESIGNS

Mixed methods with a community-based participatory research approach, in partnership with personnel and clients from a homeless shelter.

PARTICIPANTS

Ninety-eight homeless individuals at a shelter who reported at least one acute care visit to an area hospital in the last year.

APPROACH

Using semi-structured interviews, we collected quantitative and qualitative data about transitions in care from the hospital to the shelter. We analyzed qualitative data using the constant comparative method to determine patients?? perspectives on the discharge experience, and we analyzed quantitative data using frequency analysis to determine factors associated with poor outcomes from patients?? perspective.

KEY RESULTS

Using qualitative analysis, we found homeless participants with a recent acute care visit perceived an overall lack of coordination between the hospital and shelter at the time of discharge. They also described how expectations of suboptimal coordination exacerbate delays in seeking care, and made three recommendations for improvement: 1) Hospital providers should consider housing a health concern; 2) Hospital and shelter providers should communicate during discharge planning; 3) Discharge planning should include safe transportation. In quantitative analysis of recent hospital experiences, 44?% of participants reported that housing status was assessed and 42?% reported that transportation was discussed. Twenty-seven percent reported discharge occurred after dark; 11?% reported staying on the streets with no shelter on the first night after discharge.

CONCLUSIONS

Homeless patients in our community perceived suboptimal coordination in transitions of care from the hospital to the shelter. These patients recommended improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter.     

Cost analysis of adult�Cadult living donor liver transplantation in Tokyo University Hospital

Background and purpose

Living donor liver transplantation (LDLT) is now a well established treatment modality for end-stage liver diseases, but the financial aspects of LDLT have not yet been fully investigated. The purpose of this study was to determine the overall direct cost of adult?Cadult LDLT in Japan and to identify the factors associated with the high cost.

Materials and methods

The direct cost of initial admission for LDLT was determined in a retrospective analysis of data from hospital charts and databases. The records for 100 consecutive adults who underwent LDLT from January 2004 to February 2006 at our center were reviewed, and clinical and financial data of all recipients and donors were analyzed.

Results

The median direct total cost for LDLT was $82,017 (range $51,189?C438,295). Of this, the median cost for donors was $15,011 (range $12,354?C23,251). A multivariate stepwise logistic regression model for overall cost of transplantation revealed that donor age [odds ratio (OR)?=?1.1, p?=?0.02], acute renal failure (OR?=?24, p?=?0.007), and posttransplant plasma exchange (OR?=?72, p?=?0.01) were associated with higher cost. When the models were repeated with preoperative patient and donor factors alone, donor age (OR 1.1, p?=?0.008) and model for end stage liver disease score (OR 1.2, p?=?0.003) were associated with higher cost.

Conclusions

Donor age, acute renal failure, and posttransplant plasma exchange were independent risk factors for the high cost of LDLT in Japan.     

Efficacy and quality of life 2 years after treatment for faecal incontinence with injectable bulking agents

Background

Stabilized non-animal hyaluronic acid/dextranomer (NASHA^® Dx) gel as injectable bulking therapy has been shown to decrease symptoms of faecal incontinence, but the durability of treatment and effects and influence on quality of life (QoL) is not known. The aim of this study was to assess the effects on continence and QoL and to evaluate the relationship between QoL and efficacy up to 2 years after treatment.

Methods

Thirty-four patients (5 males, mean age 61, range 34–80) were injected with 4 × 1 ml NASHA Dx in the submucosal layer. The patients were followed for 2 years with registration of incontinence episodes, bowel function and QoL questionnaires.

Results

Twenty-six patients reported sustained improvement after 24 months. The median number of incontinence episodes before treatment was 22 and decreased to 10 at 12 months (P = 0.0004) and to 7 at 24 months (P = 0.0026). The corresponding Miller incontinence scores were 14, 11 (P = 0.0078) and 10.5 (P = 0.0003), respectively. There was a clear correlation between the decrease in the number of leak episodes and the increase in the SF-36 Physical Function score but only patients with more than 75 % improvement in the number of incontinence episodes had a significant improvement in QoL at 24 months.

Conclusions

Anorectal injection of NASHA Dx gel induces improvement of incontinence symptoms for at least 2 years. The treatment has a potential to improve QoL. A 75 % decrease in incontinence episodes may be a more accurate threshold to indicate a successful incontinence treatment than the more commonly used 50 %.     

Potential Savings Associated with Drug Substitution in Medicare Part D: The Translating Research into Action for Diabetes (TRIAD) Study

BACKGROUND

Drug substitution is a promising approach to reducing medication costs.

OBJECTIVE

To calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs.

DESIGN

Cross-sectional, simulation analysis.

PARTICIPANTS

Low-income subsidy (LIS) beneficiaries (n?=?145,056) and non low-income subsidy (non-LIS) beneficiaries (n?=?1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution.

MEASUREMENTS

Using administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy.

RESULTS

Overall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries.

CONCLUSIONS

Our findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.     

Oxpentifylline versus placebo in the treatment of erythropoietin-resistant anaemia: a randomized controlled trial

Background

Concern lingers that dialysis therapy at for-profit (versus not-for-profit) hemodialysis facilities in the United States may be associated with higher mortality, even though 4 of every 5 contemporary dialysis patients receive therapy in such a setting.

Methods

Our primary objective was to compare the mortality hazards of patients initiating hemodialysis at for-profit and not-for-profit centers in the United States between 1998 and 2003. For-profit status of dialysis facilities was determined after subjects received 6 months of dialysis therapy, and mean follow-up was 1.7 years.

Results

Of the study population (N = 205,076), 79.9% were dialyzed in for-profit facilities after 6 months of dialysis therapy. Dialysis at for-profit facilities was associated with higher urea reduction ratios, hemoglobin levels (including levels above 12 and 13 g/dL [120 and 130 g/L]), epoetin doses, and use of intravenous iron, and less use of blood transfusions and lower proportions of patients on the transplant waiting-list (P < 0.05). Patients dialyzed at for-profit and at not-for-profit facilities had similar mortality risks (adjusted hazards ratio 1.02, 95% CI 0.99–1.06, P = 0.143).

Conclusion

While hemodialysis treatment at for-profit and not-for-profit dialysis facilities is associated with different patterns of clinical benchmark achievement, mortality rates are similar.     

Effects of sleep disordered breathing on functional capacity and quality of life in chronic kidney disease Egyptian patients

Purpose

We assessed the prevalence of sleep disordered breathing (SDB) and investigated its effects on the muscle functional capacity and quality of life (QoL) among chronic kidney disease (CKD) Egyptian patients, either maintained or not maintained on hemodialysis (HD).

Methods

The study population comprised 100 CKD patients who were divided into patients maintained on HD (n?=?60; M/F?=?28:32) and patients not maintained on HD (n?=?40; M/F?=?24:16). Patients were observed overnight using the pulse-oximetry technique and further subdivided into patients with SDB and patients without SDB, according to their calculated oxygen desaturation index (cutoff 5). All patients were subjected also to estimation of Kt/V ratio (which is a measure for the efficiency of HD), body-composition analysis, biochemical analysis, muscle functional capacity, and QoL measurements using standard methods and questionnaires, respectively.

Results

Primary outcomes were intergroup differences regarding physical capacity and muscle performance, QoL, and body-composition measurements. CKD patients in general, either maintained on HD or not, suffer from SDB, and the levels of urea and creatinine may increase the incidence of SDB in CKD patients not maintained on HD. CKD patients maintained on HD with SDB had poorer functional capacity, physical performance, and muscle composition, in comparison with those without SDB.

Conclusions

Overall, SDB appears to partly contribute to the total diminished functional capacity of HD patients. Thus, CKD patients maintained on HD with SDB had significantly lower sleep quality and QoL as compared to those not maintained on HD with or without SDB.     

Socioeconomic impact on device-associated infections in limited-resource neonatal intensive care units: findings of the INICC

Purpose

To evaluate the impact of country socioeconomic status and hospital type on device-associated healthcare-associated infections (DA-HAIs) in neonatal intensive care units (NICUs).

Methods

Data were collected on DA-HAIs from September 2003 to February 2010 on 13,251 patients in 30 NICUs in 15 countries. DA-HAIs were defined using criteria formulated by the Centers for Disease Control and Prevention. Country socioeconomic status was defined using World Bank criteria.

Results

Central-line-associated bloodstream infection (CLA-BSI) rates in NICU patients were significantly lower in private than academic hospitals (10.8 vs. 14.3 CLA-BSI per 1,000 catheter-days; p < 0.03), but not different in public and academic hospitals (14.6 vs. 14.3 CLA-BSI per 1,000 catheter-days; p = 0.86). NICU patient CLA-BSI rates were significantly higher in low-income countries than in lower-middle-income countries or upper-middle-income countries [37.0 vs. 11.9 (p < 0.02) vs. 17.6 (p < 0.05) CLA-BSIs per 1,000 catheter-days, respectively]. Ventilator-associated-pneumonia (VAP) rates in NICU patients were significantly higher in academic hospitals than in private or public hospitals [13.2 vs. 2.4 (p < 0.001) vs. 4.9 (p < 0.001) VAPs per 1,000 ventilator days, respectively]. Lower-middle-income countries had significantly higher VAP rates than low-income countries (11.8 vs. 3.8 per 1,000 ventilator-days; p < 0.001), but VAP rates were not different in low-income countries and upper-middle-income countries (3.8 vs. 6.7 per 1,000 ventilator-days; p = 0.57). When examined by hospital type, overall crude mortality for NICU patients without DA-HAIs was significantly higher in academic and public hospitals than in private hospitals (5.8 vs. 12.5%; p < 0.001). In contrast, NICU patient mortality among those with DA-HAIs was not different regardless of hospital type or country socioeconomic level.

Conclusions

Hospital type and country socioeconomic level influence DA-HAI rates and overall mortality in developing countries.     

An assessment of the impact of type 2 diabetes on the quality of life based on age at diabetes diagnosis

Aims

This study aimed to determine whether Korean adults diagnosed with type 2 diabetes before the age of 40 have a different perception of the impact of diabetes on their quality of life (QoL) compared with that of patients diagnosed at an older age.

Methods

A total of 236 patients were investigated in this cross-sectional study. The patients were classified into two groups based on their age at diagnosis: early type 2 diabetes (age at diagnosis <40 years) and typical type 2 diabetes (age at diagnosis ≥40 years). The QoL was assessed using the latest version of the audit of diabetes-dependent quality of life (ADDQoL).

Results

The average weighted impact (AWI) of diabetes on QoL was significantly lower in adults with early type 2 diabetes than those diagnosed later. Patients with early type 2 diabetes reported a greater negative impact of diabetes on specific life domains “close personal relationship,” “sex life,” “self-confidence,” “motivation to achieve things,” “feelings about the future,” “freedom to eat,” and “freedom to drink” than patients with typical type 2 diabetes. In multivariate analysis adjusted for demographic and medical variables, a diagnosis of diabetes before the age of 40 was significantly associated with a lower ADDQoL AWI score [OR 3.60 (95 % CI: 1.12–11.55), P < 0.05].

Conclusions

Younger age at type 2 diabetes diagnosis is significantly associated with a poor diabetes-related QoL.     

Lower cardiorespiratory fitness contributes to increased insulin resistance and fasting glycaemia in middle-aged South Asian compared with European men living in the UK

Aims/hypothesis

This study aimed to determine the extent to which increased insulin resistance and fasting glycaemia in South Asian men, compared with white European men, living in the UK, was due to lower cardiorespiratory fitness (maximal oxygen uptake [ V ˙ O 2 max $ \dot{V}{\mathrm{O}}_{2 \max } $ ]) and physical activity.

Methods

One hundred South Asian and 100 age- and BMI-matched European men without diagnosed diabetes, aged 40–70 years, had fasted blood taken for measurement of glucose concentration, HOMA-estimated insulin resistance (HOMA_IR), plus other risk factors, and underwent assessment of physical activity (using accelerometry), V ˙ O 2 max $ \dot{V}{\mathrm{O}}_{2 \max } $ , body size and composition, and demographic and other lifestyle factors. For 13 South Asian and one European man, HbA_1c levels were >6.5% (>48 mmol/mol), indicating potential undiagnosed diabetes; these men were excluded from the analyses. Linear regression models were used to determine the extent to which body size and composition, fitness and physical activity variables explained differences in HOMA_IR and fasting glucose between South Asian and European men.

Results

HOMA_IR and fasting glucose were 67% (p?<?0.001) and 3% (p?<?0.018) higher, respectively, in South Asians than Europeans. Lower V ˙ O 2 max $ \dot{V}{\mathrm{O}}_{2 \max } $ , lower physical activity and greater total adiposity in South Asians individually explained 68% (95% CI 45%, 91%), 29% (11%, 46%) and 52% (30%, 80%), respectively, and together explained 83% (50%, 119%) (all p?<?0.001) of the ethnic difference in HOMA_IR. Lower V ˙ O 2 max $ \dot{V}{\mathrm{O}}_{2 \max } $ and greater total adiposity, respectively, explained 61% (9%, 111%) and 39% (9%, 76%) (combined effect 63% [8%, 115%]; all p?<?0.05) of the ethnic difference in fasting glucose.

Conclusions/interpretation

Lower cardiorespiratory fitness is a key factor associated with the excess insulin resistance and fasting glycaemia in middle-aged South Asian, compared with European, men living in the UK.     

Financial Incentives for Home-Based Health Monitoring: A Randomized Controlled Trial

BACKGROUND

Home wireless device monitoring could play an important role in improving the health of patients with poorly controlled chronic diseases, but daily engagement rates among these patients may be low.

OBJECTIVE

To test the effectiveness of two different magnitudes of financial incentives for improving adherence to remote-monitoring regimens among patients with poorly controlled diabetes.

DESIGN

Randomized, controlled trial. (Clinicaltrials.gov Identifier: NCT01282957).

PARTICIPANTS

Seventy-five patients with a hemoglobin A1c greater than or equal to 7.5 % recruited from a Primary Care Medical Home practice at the University of Pennsylvania Health System.

INTERVENTIONS

Twelve weeks of daily home-monitoring of blood glucose, blood pressure, and weight (control group; n?=?28); a lottery incentive with expected daily value of $2.80 (n?=?26) for daily monitoring; and a lottery incentive with expected daily value of $1.40 (n?=?21) for daily monitoring.

MAIN MEASURES

Daily use of three home-monitoring devices during the three-month intervention (primary outcome) and during the three-month follow-up period and change in A1c over the intervention period (secondary outcomes).

KEY RESULTS

Incentive arm participants used devices on a higher proportion of days relative to control (81 % low incentive vs. 58 %, P?=?0.007; 77 % high incentive vs. 58 %, P?=?0.02) during the three-month intervention period. There was no difference in adherence between the two incentive arms (P?=?0.58). When incentives were removed, adherence in the high incentive arm declined while remaining relatively high in the low incentive arm. In month 6, the low incentive arm had an adherence rate of 62 % compared to 35 % in the high incentive arm (P?=?0.015) and 27 % in the control group (P?=?0.002).

CONCLUSIONS

A daily lottery incentive worth $1.40 per day improved monitoring rates relative to control and had significantly better efficacy once incentives were removed than a higher incentive.     

Quality of life of patients after low anterior, intersphincteric, and abdominoperineal resection for rectal cancer—a matched-pair analysis

Purpose

Limits for sphincter preservation in rectal cancer have been expanded under the assumption that patients with a permanent colostomy have worse quality of life (QoL). Incontinence and painful defecation are common problems; therefore, this study compares functional outcome and QoL after sphincter-sparing intersphincteric resection (ISR), low anterior resection (LAR), and abdominoperineal resection (APR) for rectal cancer.

Methods

From a prospective database, three matched groups of patients after surgery for rectal cancer between 1999 and 2009 were extracted. Median follow-up was 59 months. Of 131 patients receiving a questionnaire, 95 % could be analyzed further. Generic and disease-specific validated QoL (European Organization for Research and Treatment in Cancer QLQ-C30, CR38) and Wexner incontinence score were used.

Results

Global QoL was comparable between the groups. Physical functioning was significantly better after sphincter preservation surgery than APR (p?<?0.05). Symptom scores for diarrhea (DIA) and constipation (CON) were higher after sphincter-preserving surgery (ISR: DIA 45.4, CON 20.2; LAR: DIA 34.1, CON 25.2) compared to APR (DIA 16.6, CON 12.0) (p?<?0.05 and <0.01, respectively). Disease-specific QoL assessment showed significantly worse QoL regarding to male sexual function after APR (80.8) than after ISR (53.6) (p?<?0.005). Regarding defecation, the ISR group showed significantly higher symptom scores than patients after LAR (p?<?0.05). Wexner scores were significantly higher after ISR (12.9) than after LAR (9.5) (p?<?0.005).