Comorbidity and patient-reported quality of care: an evaluation of the primary care based German disease management program for type 2 diabetes

Aims  

Previous evaluations of the German disease management program (DMP) for type 2 diabetes show that this approach curbs drug and hospital costs, may reduce mortality and improve quality of diabetes care. Otherwise until now there have been no evaluations which analyse the impact of comorbidity (COMORB) on the effectiveness of German DMP to strengthen patient-reported quality of care. Therefore, the study aimed to assess and compare the impact of comorbidity on patient-reported quality of care for patients participating in DMP and in routine care (RC).     

Neurodegeneration,gliosis, and resolution of haemorrhage in neovascular age-related macular degeneration,a clinicopathologic correlation

BackgroundTo analyse cellular and spatiotemporal factors of neurodegeneration and gliosis in a patient with submacular haemorrhage (SMH) secondary to type 1 macular neovascularization in neovascular age-related macular degeneration (nAMD).MethodsThis is a case study and clinicopathologic correlation of an 84-year-old white man with nAMD treated with antiangiogenic drugs and photodynamic therapy during a 6-year follow-up. Eyes were recovered for histology 8.23 h after death. In vivo multimodal imaging including optical coherence tomography (OCT) and en face modalities was compared with ex vivo OCT and high-resolution histologic images, using a custom image registration procedure. SMH components were defined (intraretinal, subretinal, sub-retinal pigment epithelium (RPE), and dehemoglobinized blood). Neurodegenerative changes in each of these areas were described. One anonymous donor eye with haemorrhagic nAMD was also reviewed as a comparator.ResultsBy in vivo OCT, progressive resolution of the haemorrhage and gradual transformation of sub-RPE fluid to fibrous hyperreflective tissue, progressive macular atrophy, and variation in external limiting membrane (ELM) visibility were observed. Histology showed intense photoreceptor loss with preservation and self-adhesion of macular Müller glia resulting in ELM condensation. The comparator eye exhibited shed cone inner segments among subretinal erythrocytes.ConclusionThis is the most detailed clinicopathologic correlation of nAMD with SMH resolution to date, and the first in the OCT era. Our results reveal profound macular neurodegeneration and gliosis, signified by condensed ELM, soon after haemorrhage begins. Intensified OCT reflectivity of the ELM, an important retinal barrier, has potential as a biomarker for severe photoreceptor loss and gliosis.Subject terms: Macular degeneration, Retina, Macular degeneration, Retina     

European ancestry and cutaneous melanoma in Southern Brazil

Background  Similar to other countries, incidence and mortality rates for cutaneous melanoma (CM) are increasing in Brazil. Resulting from centuries of ethnic mixture, the skin of the Brazilian population presents all phototypes, being progressively lighter following the increase of the latitude toward the South, where the highest incidence of melanoma is observed. Studies from the United States and Argentina in whites suggest that European ancestry could represent an important risk factor for CM in those regions.
Methods  Questionnaires from a case-control study involving 119 melanoma patients and 177 controls were reviewed for age, gender, phototype, sun exposure, photoprotection and ancestry. The patients reported the countries of ancestry of their grandparents. Data were tabulated and converted into scores that would reflect the proportion of ancestry for each country in individuals.
Results  Patients with German and Italian ancestry presented higher risk for CM [odds ratio (OR), 3.5; 95% confidence interval (95% CI), 1.8–6.7 and OR, 9.7; 95% CI, 3.9–24.2, respectively]. Conversely, Brazilian indigenous ancestry showed a protective effect for the development of the disease, with an OR of 0.16 (95% CI, 0.04–0.7).
Conclusions  Some European ancestries, especially German and Italian, seem to be associated to a higher risk of CM in this sample from Southern Brazil. On the other hand, Brazilian indigenous ancestry presented as a protection factor against developing the tumour.

Conflicts of interest

None declared     

Ascending myelopathy in the early stage of spinal cord injury.

A 30-year-old healthy woman was involved in a road traffic accident. She sustained a fracture dislocation of T11/12 with a complete Frankel A paraplegia below T11. She had no associated injuries. High Dose Methylprednisolone was administered according to the NASCIS III protocol (48 h) together with low molecular weight Heparin and gastroprotected medication. Complete transection of the spinal cord and an anterior haematoma from T11 to T12 were confirmed on X rays, CT's and MRI scans. Posterior surgical stabilisation was performed using Isola instrumentation, starting 8 h post injury. Her post surgical period was uneventful except for some episodes of low blood pressure (85/60 mmHg) from which she had no symptoms. On the 12th post operative day, while in the physiotherapy department, she complained of right scapular pain. This occurred every time she was sat up and was associated with paraesthesia of both upper limbs. Two days later she deteriorated neurologically and her level ascended initially to T8 and then to T3. MRI of the spine with and without gadolinium showed spinal cord oedema between C3 and T1. There was no evidence of haemorrhage or syringomyelia. The authors discussed this case making different hypotheses. They are mainly the following: (1) Gradually ascending ischaemia due to a vascular disorder; (2) Double spinal trauma; (3) Ischaemia related to repeated hypotensive episodes; (4) Low grade intramedullary tumour; and (5) Thrombus of the Radicularis Magna artery. The case has been recognised as being very rare and interesting. In the conclusions, the presenting author stresses the importance of adopting MRI-compatible instrumentation for the surgical stabilisation of the spine, and careful monitoring of blood pressure during the acute phase of spinal cord injury. Dr Aito agrees with Mr El Masry about the opportunity of forming a group of clinicians in order to discuss protocols to cope with this devastating complication.     

Delayed language development due to infantile thiamine deficiency

The aim of this study was to investigate the language development of 20 children who had been exposed to thiamine (vitamin B₁) deficiency in infancy due to feeding with soy-based formula that was accidentally deficient of thiamine. In this case–control study, 20 children (12 males, eight females; mean age 31.8mo [SD 4.1], range 24–39mo) who were fed thiamine-deficient formula in infancy were compared with 20 children (12 males, eight females; mean age 32.2mo [SD 3.9], range 25–39mo) fed with other milk sources and matched for age, sex, and maternal education. Receptive and expressive language development was assessed with the Preschool Language Scale, 3rd edition. Other assessments included mental development (Bayley Scales of Infant Development, 2nd edition), evaluation for autistic spectrum disorders, and neurological examination . Motor development was compared by age at independent walking. The study and control groups differed significantly in the expressive communication ( p <0.001) and auditory comprehension language subscales ( p <0.001), the Mental Developmental Index score ( p <0.001), and age at independent walking ( p =0.001). A significant correlation was found between the receptive language score and age at independent walking, i.e. poorer language associated with later walking ( r =–0.601, p =0.005). The conclusion was that thiamine deficiency in infancy could affect language development in childhood.