The effectiveness of adding cognitive behavioural therapy aimed at changing lifestyle to managed diabetes care for patients with type 2 diabetes: design of a randomised controlled trial

Background  

In patients with type 2 diabetes, the risk for cardiovascular disease is substantial. To achieve a more favourable risk profile, lifestyle changes on diet, physical activity and smoking status are needed. This will involve changes in behaviour, which is difficult to achieve. Cognitive behavioural therapies focussing on self-management have been shown to be effective. We have developed an intervention combining techniques of Motivational Interviewing (MI) and Problem Solving Treatment (PST). The aim of our study is to investigate if adding a combined behavioural intervention to managed care, is effective in achieving changes in lifestyle and cardiovascular risk profile.     

Prevalent vertebral deformities predict mortality and hospitalization in older women with low bone mass. Fracture Intervention Trial Research Group

OBJECTIVES: To determine the relationship between prevalent vertebral deformities and the risk of mortality and hospitalization in older women with low bone mass. DESIGN: A prospective cohort study. SETTING: Eleven clinical centers in the United States. PARTICIPANTS: A total of 6459 community-dwelling women with low bone mass aged 55 to 81 participated in the Fracture Intervention Trial (FIT), a multicenter clinical trial of alendronate that enrolled women into one of two study arms based solely on the presence or absence of existing radiographic vertebral deformities. There were 2027 women with at least one vertebral deformity enrolled in the vertebral fracture arm of FIT and followed prospectively for an average of 2.9 years, whereas 4432 women with no vertebral deformity were enrolled in the clinical fracture arm of FIT and followed prospectively for an average of 4.2 years. MEASUREMENTS: Determination of prevalent vertebral deformities on baseline lateral thoracic and lumbar spine radiographs was made at the coordinating center using a combination of radiographic morphometry by digitization and semiquantitative radiologic interpretation. Deaths were confirmed by obtaining copies of original death certificates of all participants who died. Episodes of hospitalization were captured through adverse event reporting; hospitalizations resulting solely from adverse events containing the words "fracture" or "trauma" were excluded from the analyses. RESULTS: During the follow-up period, 122 women died, and 1676 women were hospitalized on at least one occasion for reasons not related solely to fracture. Compared with women without prevalent vertebral deformities, those women with prevalent deformities had higher risks of mortality (age- and treatment assignment-adjusted relative risk 1.60, 95% confidence interval (CI), 1.10-2.32) and hospitalization (age- and treatment assignment-adjusted relative risk 1.18, 95% CI, 1.06-1.31). In addition, further adjustment for other factors, including smoking status, physical activity, hypertension, coronary heart disease, obstructive lung disease, any fracture since the age of 50, health status, total hip BMD, and body mass index did not alter the association between prevalent vertebral deformities and risk of mortality substantially (multivariate relative risk 1.49, 95% CI, 1.05-2.21). Adjustment for all these factors and diabetes also did not change the relationship between prevalent vertebral deformities and hospitalization (multivariate relative risk 1.14, 95% CI, 1.02-1.27). Rates of mortality and hospitalization increased with increasing number of prevalent vertebral deformities (tests for trend P < .01). CONCLUSIONS: Prevalent vertebral deformities in older women with low bone mass are associated with increased risks of mortality and hospitalization. Only a portion of this increased risk was explained by other known predictors of these outcomes.     

Methotrexate-induced erythema multiforme

The folic acid antagonist, methotrexate, has many applications in the treatment of neoplastic disease. While methotrexate produces several well-recognized toxic effects, cutaneous reactions are rare. A patient who developed classical erythema multiforme while receiving low-dose methotrexate as treatment of nonmetastatic gestational trophoblastic neoplasia is presented. Erythema multiforme has been associated with a variety of pharmacologic agents. It typically presents as a pruritic papular dermatitis of the extensor surfaces of the extremities and may require multiple skin biopsies to establish the diagnosis. Spontaneous reversal usually occurs with discontinuation of therapy. Patients developing erythema multiforme related to antineoplastic agents should be switched to an alternate regimen.     

Autopsies of sudden infant death syndrome—classification and epidemiology

An enquiry into sudden infant death syndrome (SIDS) in 1987 furnished us with detailed epidemiological data for 281 cases that underwent a thorough post-mortem examination. This analysis uses these data to evaluate the role the autopsy plays in explaining sudden death. The cases were classified into three diagnostic groups: explained causes of death (group 1), unexplained deaths with anomalies (group 2), and no anomaly (group 3). These 281 cases show the three essential features that characterize SIDS: over-representation of males, increased deaths during the second and third months of life, and increased deaths during winter. The autopsy examination revealed that many of these deaths had a medical explanation. Almost half were assigned to group 1. At the time of autopsy, no precise pathology could be diagnosed for 147 deaths; of these, 140 showed histological anomalies. There were only seven sudden deaths for which no abnormal sign was evident at the autopsy. These results are compared with those of similar studies and discussed in connection with three factors: the initial selection of cases, the nature and degree of the investigations, and the possible interpretations of the symptoms uncovered.     

DNA testing for fragile X syndrome in schools for learning difficulties

Fragile X syndrome is the most common inherited cause of mental retardation. Early diagnosis is important not only for appropriate management of individuals but also to identify carriers who are unaware of their high risk of having an affected child. The disorder is associated with a cytogenetically visible fragile site (FRAXA) at Xq27.3, caused by amplification of a (CGG)n repeat sequence within the gene at this locus designated FMR1. Clinical and molecular studies have been undertaken to screen for fragile X syndrome in 154 children with moderate and severe learning difficulties of previously unknown origin. Southern blot analysis of peripheral blood showed the characteristic abnormally large (CGG)n repeat sequence associated with fragile X syndrome in four of the 154 children. The findings were confirmed by cytogenetic observation of the fragile site and by further molecular studies. The families of the affected children were offered genetic counselling and DNA tests to determine their carrier status. These findings show that there are still unrecognised cases of fragile X syndrome. Given the difficulty of making a clinical diagnosis and the implications for families when the diagnosis is missed, screening in high risk populations may be justified. The issues involved in screening all children in special schools for fragile X syndrome are discussed.     

Does age at the start of breast feeding influence infantile diarrhoea morbidity? A case–control study in periurban Guinea–Bissau

Colostrum protects the newborn from intestinal infection by its content of secretory immunoglobulin A and other immediately acting factors. It may also induce maturation of the child's gastrointestinal immune defences, thus contributing to the protection against diarrhoeal disease later in infancy. To test this hypothesis, a case–control study on breast feeding and diarrhoea was carried out in a periurban community in Guinea–Bissau. The child's age at the start of breast feeding was ascertained soon after birth ( n = 279). Subsequent cases of acute diarrhoea ( n = 66) were identified at 3–monthly examinations, and four concurrent controls were randomly selected among attendants. Three separate estimates of association showed that the cases tended to have started breast feeding later after birth than the diarrhoea–free controls, but no single test was statistically significant. Early breast feeding might have consequences for diarrhoeal morbidity after the neonatal period.     

胸腹部联合损伤73例诊治分析

1临床资料 1995-07／2003-12收治胸腹联合伤73（男52，女21）例，年龄3～72（平均47）岁，急诊入院69例，受伤至急诊入院时间为1／3～16h，致伤原因：穿透伤26例，其中刀刺伤23例，枪伤3例，闭合伤47例，其中车祸38例，坠落伤9例，入院时伴休克50例，呼吸急促36例，胸痛29例，腹痛20例，胸腹联合痛14例，昏迷10例，气管移位11例，伤侧呼吸音减弱或消失17例。