Insulin-sensitizing antihyperglycaemic medications are associated with better outcome in patients with diabetes undergoing cardiac stress testing

Background: There are several treatment modalities available for diabetes; however, the effects of the different medications on coronary artery disease are less understood. The purpose of this study was to evaluate the correlation of insulin‐sensitizing therapy with the outcome of stress myocardial perfusion testing and to compare it with conventional therapy. Methods: Of 417 patients referred to stress testing for evaluation of chest pain, 222 were identified as being treated with conventional therapy only (insulin and insulin secretagogues) and 195 as being treated with insulin sensitizers (metformin and thiazolidinediones (TZD)). Multivariate logistic regression models were used to correct for confounding factors and to determine the independent relation between treatment type and stress‐test outcome. Results: Ischaemia, infarction and the composite outcome were less frequent in the insulin‐sensitizer group than in the conventional therapy group (odds ratio (OR) = 0.39, P = 0.025; OR = 0.32, P = 0.021 and OR = 0.38, P = 0.009, respectively). The subgroup analysis showed that treatment with metformin (n = 125) compared with conventional therapy was associated with less infarction or the composite outcome of ischaemia and/or ischaemia (OR = 0.18 (95% confidence interval (CI): 0.05–0.66), P = 0.010; OR = 0.34 (95%CI: 0.15–0.80), P = 0.014, respectively). Treatment with TZD (n = 43) was associated with a trend to less frequent ischaemia (OR = 0.18 (95%CI: 0.03–1.01), P = 0.051). Conclusion: The addition of insulin‐sensitizing medications to the conventional diabetes therapy or their sole use was associated with decreased coronary artery disease or its severity in patients with diabetes as determined by stress myocardial perfusion study. Randomized prospective trials will be necessary to prove this benefit.     

Vasodepressor cough syncope masked by sleep apnea-induced asystole

Vasodepressor Cough Syncope. Cough syncope is classified among the neural-reflex "situational" faints, but whether the clinical consequences in affected individuals result from reflex triggered bradyarrhythmia or vasodepressor-induced hypotension, or both, is often unknown. In this report we describe findings in a patient with a clinical history consistent with cough syncope, and in whom documented multiple asystolic spells were at first believed to be responsible for symptoms. However, pacemaker therapy initiated at an outside facility failed to suppress symptoms, and subsequent referral for more detailed autonomic study revealed the asystole to be due to sleep apnea, whereas cough-induced vasodepressor hypotension was the basis of syncope in this individual; the latter provided a pathophysiologic target for prevention of recurring symptoms. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1024-1027, September 2012).     

Exercise motivation in rectal cancer patients during and after neoadjuvant chemoradiotherapy

Purpose

Aerobic exercise is safe and feasible for rectal cancer patients during and after neoadjuvant chemoradiotherapy (NACRT), but their motivation to perform such exercise is unknown. Here, we explore the motivational outcomes, perceived benefits and harms, and perceived barriers to exercise during and after NACRT.

Methods

Rectal cancer patients (n = 18) participated in supervised aerobic exercise during NACRT followed by unsupervised exercise after NACRT. Using the theory of planned behavior, we assessed perceived benefits, harms, enjoyment, support, difficulty, and barriers for exercise both during and after NACRT.

Results

Patients reported that exercise during NACRT was more enjoyable (p = 0.003) and less difficult (p = 0.037) than initially anticipated. The most common perceived benefits of exercise during NACRT were cardiovascular endurance (75 %), quality of life (75 %), and self-esteem (65 %). After NACRT, the most common perceived benefits were physical functioning (93 %), cardiovascular endurance (86 %), and quality of life (79 %). The most common perceived harms of exercise during NACRT were fatigue (31 %), diarrhea (31 %), and skin irritation (24 %). After NACRT, the most common perceived harms were fatigue (21 %) and hand-foot-syndrome (15 %). Side effects from NACRT were the most common exercise barrier during NACRT (88 %) whereas lack of motivation was the most common barrier after NACRT (79 %).

Conclusions

Rectal cancer patients reported aerobic exercise during NACRT to be more enjoyable and less difficult than anticipated despite significant barriers. This positive motivational response may facilitate recruitment and adherence in future interventions. Moreover, rectal cancer patients identified potential benefits and harms that should be closely monitored in future interventions.

     

Recognizing difficult trade-offs: values and treatment preferences for end-of-life care in a multi-site survey of adult patients in family practices

Background

Decisions about care options and the use of life-sustaining treatments should be informed by a person’s values and treatment preferences. The objective of this study was to examine the consistency of ratings of the importance of the values statements and the association between values statement ratings and the patient’s expressed treatment preference.

Methods

We conducted a multi-site survey in 20 family practices. Patients aged 50 and older self-completed a questionnaire assessing the importance of eight values (rated 1 to 10), and indicated their preference for use of life-sustaining treatment (5 options). We compared correlations among values to a priori hypotheses based on whether the value related to prolonging or shortening life, and examined expected relationships between importance of values and the preference option for life-sustaining treatment.

Results

Eight hundred ten patients participated (92% response rate). Of 24 a priori predicted correlations among values statements, 14 were statistically significant but nearly all were negligible in their magnitude and some were in the opposite direction than expected. For example, the correlation between importance of being comfortable and suffering as little as possible and the importance of living as long as possible should have been inversely correlated but was positively correlated (r?=?0.08, p?=?0.03). Correlations between importance of values items and preference were negligible, ranging from 0.03 to 0.13.

Conclusions

Patients may not recognize that trade-offs in what is most important may be needed when considering the use of treatments. In the context of preparation for decision-making during serious illness, decision aids that highlight these trade-offs and connect values to preferences more directly may be more helpful than those that do not.

     

Effect of trauma on serum insulin levels in rabbits

Summary Serum insulin levels were measured following the infusion of glucose orally, and intraduodenally after exposing the duodenum by surgery. Oral administration of glucose produced a marked rise in insulin levels whereas intraduodenal infusion of glucose in operated animals was not associated with any increase in serum insulin level. Reserpine treatment of animals prior to the operation and the intraduodenal administration of glucose, did not abolish this failure of insulin level to rise following the intraduodenal infusion of glucose. These findings suggest that the failure of serum insulin levels to increase following the intraduodenal infusion of glucose in operated animals was not due solely to enhanced release of catecholamines.

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Die Einwirkung eines Traumas auf den Seruminsulin-Gehalt beim Kaninchen

Zusammenfassung Der Seruminsulinspiegel wurde im Anschluß an eine orale Glucoseinfusion und an eine intraduodenale Infusion nach chirurgischer Vorverlagerung des Duodenums gemessen. Orale Glucosegabe erzeugte einen deutlichen Anstieg des Insulinspiegels, während intraduodenale Glucoseinfusionen bei den operierten Tieren nicht von einem Anstieg des Seruminsulinspiegels gefolgt war. Reserpinbehandlung der Tiere vor der Operation und der intraduodenalen Glucosegabe verhinderte den mangelnden Anstieg des Insulinspiegels nach der intraduodenalen Glucoseinfusion nicht. Aus dem fehlenden Anstieg des Seruminsulinspiegels nach intraduodenaler Glucoseinfusion bei den operierten Tieren ist nicht zu schließen, daß dies allein einer erhöhten Freisetzung von Katecholaminen zuzuschreiben ist.

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Effet du traumatisme sur les taux d'insuline sérique chez les lapins

Résumé Les taux d'insuline sérique ont été mesurés après l'infusion de glucose par voie buccale, et intraduodénale après exposition du duodénum chirurgicalement. L'administration orale de glucose produit une augmentation marquée du taux de l'insuline, tandis que l'infusion intraduodénale de glucose chez les animaux opérés n'est associée à aucune élévation du taux de l'insuline sérique. Le traitement à la réserpine chez les animaux avant l'opération et l'administration intraduodénale de glucose n'ont pas aboli l'incapacité du taux de l'insuline à augmenter après infusion intraduodénale du glucose. Ces résultats suggèrent que le fait que le taux d'insuline sérique n'augmente pas après infusion intraduodénale de glucose chez les animaux opérés n'est pas dû uniquement à une libération accrue de catécholamines.