Treatment satisfaction after commencement of insulin in Type 2 diabetes

Fifty patients with Type 2 diabetes were recruited for a study assessing treatment satisfaction and well-being, following commencement on insulin during routine clinical care. A month after starting insulin, participants completed a Diabetes Treatment Satisfaction Questionnaire (DTSQ) and a Well-being Questionnaire. At seven months, the same questionnaires and clinical measurements were repeated and, in addition, patients completed a Diabetes Treatment Satisfaction Questionnaire (change) (DTSQc). Mean HbA1c decreased from 9.69 to 8.26% (P < 0.001), and the lipid profile showed a corresponding improvement. BMI increased from 30.9 to 32.0 kgm(-2) (P < 0.001). Perceived frequency of hyperglycaemia decreased (P = 0.021), correlating with the change in HbA1c (r = 0.399, P = 0.006). The DTSQc showed improvements at seven months in scores for treatment satisfaction, convenience, flexibility, understanding of diabetes, willingness to recommend the treatment to others, and satisfaction to continue current treatment (all P < 0.001). There was no relationship between weight gain, HbA1c and total or subscale scores. In summary, after seven months of insulin treatment, patients reported positive changes in their perception of treatment satisfaction. These findings, in conjunction with the known health benefits of improved glycaemic control, should encourage practitioners to consider insulin early in the management of Type 2 diabetes.     

Dehydroepiandrosterone supplementation in women with adrenal failure: impact on twenty-four hour GH secretion and IGF-related parameters

OBJECTIVE: In women, GH secretion is strongly influenced by oestrogen status, whereas the role of androgens is unclear. We, therefore, examined GH secretory dynamics during low vs. normalized androgen levels in women with adrenal failure. PATIENTS: Ten females with adrenal failure (AF), mean age of 42 years (range 22-54 years). DESIGN: The effects of 8 days of oral dehydroepiandrosterone (DHEA; 50 mg/day) were studied in a double-blind placebo-controlled, cross-over design. A control group of healthy women was studied once without any treatment. MEASUREMENTS: Before and after each treatment period, blood was sampled for measurement of androgens, IGF-I, IGFBP-3 and GHBP. A 24-h GH profile with measurements every 20 min was performed at the end of each period. RESULTS: DHEA supplementation normalized the mean circulating levels of testosterone and androgen precursors. The secretory pattern of GH was unaltered during DHEA [placebo vs. DHEA; half-life 22.83 +/- 1.24 vs. 21.45 +/- 1.19 (min), P = 0.429; pulse frequency 9.9 +/- 0.7 vs. 10.5 +/- 0.5 (/24 h), P = 0.502; total production rate 62.27 +/- 13.44 vs. 52.61 +/- 7.06 (microg/l/day), P = 0.317]. Subgroup analysis, however, indicated that DHEA treatment increased GH secretion in patients not receiving oestrogen (n = 5), whereas the opposite was observed among patients receiving exogenous oestrogen derivatives (n = 5). Compared to the control group (CON), GH half-life was longer in AF (half-life CON: 16.48 +/- 0.91, P = 0.001). The additional features of GH secretion were similar. Unexpectedly, the levels of IGF-I, IGFBP-3 and GHBP were elevated in the patients as compared to controls, without significant effects of DHEA [AF vs. CON. IGF-I: 186 +/- 20 vs. 144 +/- 7 (microg/l), P = 0.04; IGFBP-3: 5196 +/- 224 vs. 3687 +/- 212 (microg/l), P = 0.001; GHBP: 2.27 +/- 0.25 vs. 1.41 +/- 0.13 (nmol/l), P = 0.002]. CONCLUSION: (1) Short-term DHEA administration in women with adrenal failure normalizes the circulating levels of androgens without uniformly affecting the GH-IGF axis; (2) The observation that exogenous oestradiol may mask a stimulatory effect of DHEA on GH secretion merits future investigation.     

Asthma concepts in the new millennium: update in asthma pathophysiology.

This article reviewed current concepts of airway inflammation with a special emphasis on the epithelium, smooth muscle dysfunction, and airway remodeling. An alternative therapy on the importance of the airway microenvironment or epithelial mesenchymal trophic unit, myofibroblast activation, and role of growth factors was addressed. Future therapeutic strategies may involve these targets and a synergistic approach in preventing remodeling in selected asthmatic patients.     

Identification of successful catheter ablation sites in patients with ventricular tachycardia based on electrogram characteristics during sinus rhythm

BACKGROUND: Zones of slow conduction facilitate reentry, the major mechanism of ventricular tachycardia (VT) after myocardial infarction (MI). Identification of these zones during sinus rhythm (SR) is desirable for radiofrequency (RF) catheter ablation of VT. Local conduction velocity may correlate with electrogram duration. OBJECTIVES: The purpose of this study was to revise the definition of normal electrogram characteristics and to reevaluate the significance of low-amplitude, long-duration electrograms recorded during SR to select RF catheter ablation sites in patients with VT. METHODS: Electroanatomic mapping was performed during SR in 10 control patients with normal left ventricles (LVs) and in 10 patients with stable VT after MI. From the controls, reference values for electrogram amplitude, duration (first peak to last peak distance), and fragmentation (positive deflection) were derived. In patients after MI, areas with signals exceeding these values were annotated and related to successful ablation sites. RESULTS: Ninety-five percent of normal LV electrograms were > or =1.0 mV and < or =28 ms (range 5-39 ms) and all had < or =4 deflections. Based on these results, cutoff values were set at 1 mV, four deflections, and 40 ms. In infarcted hearts, 653 electrograms (44%) were <1.0 mV and of these, 303 were > or =40 ms with >4 deflections and restricted to circumscribed areas. Twenty-seven of 28 targeted VTs remained noninducible after RF catheter ablation within these areas, resulting in 86% sensitivity and 94% specificity for low-amplitude, long-duration electrograms predicting successful ablation sites. CONCLUSION: Identification of successful RF target areas during SR in patients with VT is feasible with high sensitivity and specificity using a mapping strategy based on voltage and duration criteria.     

Childhood asthma: reasons for diagnostic delay and facilitation of early diagnosis--a qualitative study.

BACKGROUND: Children with undiagnosed asthmatic symptoms account for much illness and hospitalisation. The aim of the study was to identify reasons for diagnostic delay in childhood asthma and to develop tools for early diagnosis. METHODS: A qualitative study, using semi-structured interviews with the parents of 30 children with asthma aged 2-15 years, combined with 15 GP interviews. FINDINGS: Asthma symptoms for most of the children started during their first year. The typical symptom pattern reported by parents consisted of insidious recurrent or continuous respiratory symptoms, particularly bad at night, often lasting several weeks or months, provoked or aggravated by common colds or foggy weather. In describing the symptoms, parents focussed on coughing and sputum production. As in other studies, the children's asthmatic diagnosis was obscured by excessive diagnostic emphasis on respiratory infections. The reasons for diagnostic delay seemed to be, typically, that doctors did not pay enough attention to the history of recurrent cough and unspecified respiratory symptoms, just as the parents' use of lay and onomatopoeic terms and metaphors for wheezing seemed to be misinterpreted. Furthermore some doctors relied more on the present symptoms and physical examination, although asthmatic patients may have normal auscultation on examination. Several doctors did not expect asthma in infancy. CONCLUSIONS: The underlying reason for diagnostic delay could be that a former diagnostic definition of asthma, focussing on severe and dramatic cases, was still used by doctors. However, adapting to a new diagnostic concept for asthma, which highlights a history of periodic or chronic cough, wheeze and/or breathing difficulties and the typical asthma pattern in toddlers as shown in this study, may enable earlier diagnosis and treatment.     

Drug-induced long QT syndrome in injection drug users receiving methadone: high frequency in hospitalized patients and risk factors

BACKGROUND: Drug-induced long QT syndrome is a serious adverse drug reaction. Methadone prolongs the QT interval in vitro in a dose-dependent manner. In the inpatient setting, the frequency of QT interval prolongation with methadone treatment, its dose dependence, and the importance of cofactors such as drug-drug interactions remain unknown. METHODS: We performed a systematic, retrospective study comparing active or former intravenous drug users receiving methadone and those not receiving methadone among all patients hospitalized over a 5-year period in a tertiary care hospital. A total of 167 patients receiving methadone fulfilled the inclusion criteria and were compared with a control group of 80 injection drug users not receiving methadone. In addition to methadone dose, 15 demographic, biological, and pharmacological variables were considered as potential risk factors for QT prolongation. RESULTS: Among 167 methadone maintenance patients, the prevalence of QTc prolongation to 0.50 second((1/2)) or longer was 16.2% compared with 0% in 80 control subjects. Six patients (3.6%) in the methadone group presented torsades de pointes. QTc length was weakly but significantly associated with methadone daily dose (Spearman rank correlation coefficient, 0.20; P<.01). Multivariate regression analysis allowed attribution of 31.8% of QTc variability to methadone dose, cytochrome P-450 3A4 drug-drug interactions, hypokalemia, and altered liver function. CONCLUSIONS: QT interval prolongation in methadone maintenance patients hospitalized in a tertiary care center is a frequent finding. Methadone dose, presence of cytochrome P-450 3A4 inhibitors, potassium level, and liver function contribute to QT prolongation. Long QT syndrome can occur with low doses of methadone.     

Bone oedema predicts erosive progression on wrist MRI in early RA--a 2-yr observational MRI and NC scintigraphy study

OBJECTIVES: To investigate if disease assessment by contrast-enhanced dynamic and static magnetic resonance imaging (MRI) and quantitative nanocolloid (NC) scintigraphy gives useful additional information in early rheumatoid arthritis (RA). METHODS: Twenty-seven patients with early RA (disease duration < or =12 months) were followed up for 1 yr and 24 of them for 2 yrs with contrast-enhanced MRI and NC scintigraphy of the wrist joint. Synovial inflammation was assessed by measuring time-dependent enhancement rates (E-rate) from dynamic MRI scans and technetium(99m)-labelled nanocolloid ((99m)Tc-NC) uptake from scintigraphy scans. Synovial membrane hypertrophy, bone oedema and erosions were semiquantitatively scored according to the Outcome Measures in Rheumatology Clinical Trials RA-MRI scoring system from static MR images. Response to the treatment was evaluated based on whether or not > or = 50% improvement was achieved in the tender and swollen joint scores and the Health Assessment Questionnaire score, with normal C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) levels. Progression of the erosion score on wrist MRI was evaluated as the outcome. RESULTS: The baseline MRI bone oedema score (rho= 0.67), MRI synovitis score (rho= 0.57), ESR (rho= 0.56), CRP (rho= 0.48), E-rate (rho= 0.47) and (99m)Tc-NC uptake (rho= 0.45) were related with the change in the MRI erosion score from baseline to 2 yrs (rho= Spearman's correlation). In the multivariate logistic regression model, the bone marrow oedema score was the only baseline variable that predicted erosive progression at 2 yrs' follow-up (OR 4.2, 95% CI 1.3-13.8). The median (interquartile range) change in the erosion score from baseline to 2 yrs was 0 (0, 0) and 4 (2, 5) in the patients with (n= 9) and without (n= 15) a persistent clinical response over the 2 yrs, respectively (P= 0.001). The non-responders who presented with erosive progression from 1 yr to 2 yrs had higher MRI synovitis scores, bone oedema scores, E-rate and (99m)Tc-NC uptake at 1-yr follow-up than the non-responders without progressive bone damage. CONCLUSION: The degree of local synovial inflammation at baseline, evaluated by dynamic and static MRI and quantitative NC scintigraphy, is closely related to the progression of wrist joint erosions during the first 2 yrs of the disease. Furthermore, at follow-up, if no persistent clinical response is achieved, these imaging methods may help to predict future erosiveness and help in clinical therapeutic decision making.     

Endobiliary brush biopsy: Intra- and interobserver variation in cytological evaluation of brushings from bile duct strictures

OBJECTIVE: Obtaining cytological specimens by wire-guided endobiliary brushing at the time of endoscopic retrograde cholangiopancreatography (ERCP) is a convenient way to reach a diagnosis. Sensitivity for malignant disease is generally around 50% and specificity around 100%. The present study was designed to assess the reproducibility of the cytological examination. MATERIAL AND METHODS: Samples were obtained from 55 consecutive patients with biliary duct strictures that eventually turned out to be caused by malignant disease in 41 patients (73%). The cytology specimens were evaluated twice in different random order with an interval of at least 4 months by two pathologists blinded to the final diagnoses. Suitability for diagnosis (suitable, suboptimal or unsuitable) and cytologic diagnosis (benign, atypical, suspicious for malignancy and malignant cells) were registered. Kappa analysis was applied. RESULTS: Regarding suitability for diagnosis, the two observers reproduced their findings in 84% (kappa 0.76) and 87% (0.59) (p>0.05), while the interobserver variations on the two occasions were 76% and 78% (kappa 0.49 and 0.58, respectively) (p>0.05). Five percent of samples were rated as inadequate for diagnosis in at least one reading; 18% were suboptimal and 62-82% were suitable. The observers reproduced their cytological diagnosis in 77% and 71% (weighted kappa 0.83 and 0.75) (p>0.05), and agreed on the cytological diagnosis in 65% and 73% (weighted kappa 0.65 and 0.75) (p>0.05). CONCLUSIONS: The intra- and interobserver agreement in cytological evaluation of endobiliary brushings from bile duct strictures is generally good. The rates of inadequate and suboptimal samples can probably be reduced by modifications of the brush design.