Basal insulin glargine (HOE 901) versus NPH insulin in patients with type 1 diabetes on multiple daily insulin regimens. U.S. Insulin Glargine (HOE 901) Type 1 Diabetes Investigator Group

OBJECTIVE

Insulin glargine (HOE 901, 21(A)-Gly-30(B)a-L-Arg-30(B)b-L-Arg human insulin) is a novel recombinant analog of human insulin with a shift in the isoelectric point producing a retarded absorption rate and an increased duration of action that closely mimics normal basal insulin secretion. It recently received approval from the Food and Drug Administration. The aim of this study was to evaluate 2 formulations of insulin glargine for safety and efficacy in the treatment of patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a 4-week trial, 256 patients with type 1 diabetes received either NPH insulin or insulin glargine containing 30 microg/ml zinc (insulin glargine[30]) or 80 microg/ml zinc (insulin glargine[80]). Insulin glargine was given subcutaneously once daily at bedtime. NPH insulin was given either once daily (at bedtime) or twice daily (before breakfast and at bedtime), according to the patient's prestudy regimen. The initial doses of insulin glargine and NPH were based on the previous NPH total daily dose.

RESULTS

At study end point, insulin glargine-pooled groups had significantly lower fasting plasma glucose (FPG) levels than the NPH insulin group, with adjusted mean FPG levels reduced by 2.2 mmol/l (P = 0.0001). Insulin glargine was superior to NPH insulin in reducing FPG levels in patients who had previously received NPH insulin twice daily but not in patients who had previously received NPH once daily. FPG levels were more stable in patients using insulin glargine than in patients using NPH insulin. A subset of patients (n = 71) underwent hourly overnight plasma glucose measurements. Insulin glargine patients exhibited lower FPG levels after 5:00 A.M.; the difference was significant by 8:00 A.M. The adjusted mean FPG for insulin glargine[30] was 7.8 mmol/l; for insulin glargine[80], 7.3 mmol/l; and for NPH, 10.7 mmol/l. Both formulations of insulin glargine were well tolerated, similar to NPH insulin.

CONCLUSIONS

Basal insulin glargine administered once daily for 4 weeks as part of a basal-bolus multiple daily insulin regimen was safe and more effective in lowering fasting plasma glucose levels than NPH in patients with type 1 diabetes.

The Village AIDS Day Treatment Program: a model of interdisciplinary and interdependent care

This article describes the Village AIDS Day Treatment Program, a program for people living with HIV/AIDS that provides health care by using a full range of interdependent services. Opened in 1988, this program was the first of its kind in the country. It has provided leadership in developing a model of care that addresses the full spectrum of health care--promotion, prevention, maintenance, and treatment. Along with describing the program and its services, this article includes the program's history and its influencing philosophies.

Decreased seroprevalence for Toxoplasma gondii in Seventh Day Adventists in Maryland

Despite its widespread prevalence, uncertainties remain about the relative contribution of various routes of transmission to the overall rate of infection with Toxoplasma gondii, particularly in developed countries. To explore the hypothesis that meat consumption is an important risk factor for infection, a cross-sectional seroprevalence study was performed on healthy adults in one region in the state of Maryland. The population included Seventh Day Adventists who as a group follow a diet containing no meat, and control community volunteers who were not Seventh Day Adventists. Thirty-one percent of the population had serologic evidence of T. gondii infection. People with T. gondii infection were older (49 versus 42 years old; P < 0.01, by t-test) and less likely to be Seventh Day Adventists (24% versus 50%; P < 0.01, by chi-square test) than people without T. gondii infection. When adjustments were made for age and gender through multiple logistic regression, Seventh Day Adventists had a significantly decreased risk of T. gondii infection (odds ratio = 0.21, 95% confidence interval = 0.09-0.46, P = 0.0001) compared with the controls. While the basis for this effect remains to be determined, one possible protective factor is the general adherence of Seventh Day Adventists to a diet that does not contain meat.

Diagnostic marker cooperative study for the diagnosis of myocardial infarction

BACKGROUND

Millions of patients present annually with chest pain, but only 10% to 15% have myocardial infarction. Lack of diagnostic sensitivity and specificity of clinical and conventional markers prevents or delays treatment and leads to unnecessary costly admissions. Comparative data are lacking on the new markers, yet using all of them is inappropriate and expensive.

METHODS AND RESULTS

The Diagnostic Marker Cooperative Study was a prospective, multicenter, double-blind study with consecutive enrollment of patients with chest pain presenting to the emergency department. Diagnostic sensitivity and specificity and frequency of increase in patients with unstable angina were determined for creatine kinase-MB (CK-MB) subforms, myoglobin, total CK-MB (activity and mass), and troponin T and I on the basis of frequent serial sampling for </=24 hours. Of 955 patients with chest pain, 119 (12.5%) had infarction identified by use of CK-MB mass, and 203 (21%) had unstable angina. CK-MB subforms were most sensitive and specific (91% and 89%) within 6 hours of onset, followed by myoglobin (78% and 89%). For late diagnosis, total CK-MB activity (derived from subforms) was the most sensitive and specific (96% and 98%) at 10 hours from onset, followed by troponin I (96% and 93%), but not until 18 hours, and troponin T (87% and 93% at 10 hours). In unstable angina, CK-MB subforms were increased in 29.5%, myoglobin in 23.7%, troponin I in 19.7%, and troponin T in 14.8%. All markers were increased in 99 patients. With each marker as the diagnostic standard, CK-MB subforms and myoglobin remained the most sensitive for early diagnosis.

CONCLUSIONS

The CK-MB subform assay alone or in combination with a troponin reliably triages patients with chest pain and should lead to improved therapy and reduced cost.

Giant fibrovascular polyp of the esophagus

Giant fibrovascular polyps (FVP) are the most common intraluminal tumors of the esophagus. The case of a second, nonrecurrent FVP is presented. A thorough review of the literature was conducted to provide an informative discussion on this benign but potentially life-threatening neoplasm.

The importance of orofacial myofunctional therapy in pediatric dentistry: reports of two cases

It is essential that the practitioner determine the factors that are etiologically operative in oral myofunctional therapy in order to establish effective methods of intervention. Of these methods, cephalometrics and facial analysis are especially valuable in revealing and differentiating open-bite syndrome. We indicated two cases treated with only the theory of myofunctional therapy and evaluated with cephalometric radiographs and intraoral photos. This is the first report to evaluate for treatment change of myofunctional therapy with cephalometric radiographs.

PGG-glucan, a soluble beta-(1,3)-glucan, enhances the oxidative burst response, microbicidal activity, and activates an NF-kappa B-like factor in human PMN: evidence for a glycosphingolipid beta-(1,3)-glucan receptor

PGG-Glucan, a soluble beta-(1,6)-branched beta-(1,3)-linked glucose homopolymer derived from the cell wall of the yeast Saccharomyces cerevisiae, is an immunomodulator which enhances leukocyte anti-infective activity and enhances myeloid and megakaryocyte progenitor proliferation. Incubation of human whole blood with PGG-Glucan significantly enhanced the oxidative burst response of subsequently isolated blood leukocytes to both soluble and particulate activators in a dose-dependent manner, and increased leukocyte microbicidal activity. No evidence for inflammatory cytokine production was obtained under these conditions. Electrophoretic mobility shift assays demonstrated that PGG-Glucan induced the activation of an NF-kappaB-like nuclear transcription factor in purified human neutrophils. The binding of 3H-PGG-Glucan to human leukocyte membranes was specific, concentration-dependent, saturable, and high affinity (Kd approximately 6 nM). A monoclonal antibody specific to the glycosphingolipid lactosylceramide was able to inhibit activation of the NF-kappaB-like factor by PGG-Glucan, and ligand binding data, including polysaccharide specificity, suggested that the PGG-Glucan binding moiety was lactosylceramide. These results indicate that PGG-Glucan enhances neutrophil anti-microbial functions and that interaction between this beta-glucan and human neutrophils is mediated by the glycosphingolipid lactosylceramide present at the cell surface.

Electromagnetic interference from a muscle stimulation device causing discharge of an implantable cardioverter defibrillator: epicardial bipolar and endocardial bipolar sensing circuits are compared

This case report is about two patients with two different types of ICDs who underwent electrical muscle stimulation (EMS) therapy. In one patient with an ICD that has epicardial screw-in bipolar sensing leads, electromagnetic interference (EMI) from the EMS device caused the delivery of an inappropriate ICD discharge. In a second patient with an ICD with endocardial true bipolar sensing, there was no evidence of EMI during the EMS therapy despite all of our attempts to reproduce it. The sensing circuits in the two different ICDs are compared.

Helium-oxygen improves Clinical Asthma Scores in children with acute bronchiolitis

OBJECTIVE

To determine the efficacy of a helium-oxygen mixture in children admitted to the pediatric intensive care unit with acute respiratory syncytial virus (RSV) bronchiolitis.

DESIGN

Randomized, double-blind, controlled, crossover study and nonrandomized, prospective study.

SETTING

A pediatric intensive care unit in a university hospital.

PATIENTS

Nonintubated children with signs of acute lower respiratory tract infection and a positive rapid immunoassay for RSV admitted to the pediatric intensive care unit.

INTERVENTIONS

Treatment with either helium-oxygen or air-oxygen was administered in random order for 20 mins. Nonrandomized patients received helium-oxygen as initial therapy.

MEASUREMENTS AND MAIN RESULTS

Clinical Asthma Score, respiratory rate, heart rate, and pulse oximetry oxygen saturation values were recorded at baseline (before randomization) and at the end of each 20-min treatment period (helium-oxygen or air-oxygen). Nonrandomized patients were studied 20 mins into helium-oxygen delivery. Eighteen patients were studied, 13 of whom were randomized. Five children with severe bronchiolitis (Clinical Asthma Score of > or =6) were initially given helium-oxygen and scored at 20 mins. Mean Clinical Asthma Score was 3.04 (range 1 to 7.5) in the 13 randomized patients and 4.25 (range 1 to 9) in the 18 patients overall. Clinical Asthma Score decreased in the 13 randomized patients (mean 0.46, p < .05) and in the 18 patients overall (mean 1.23, p < .01) during helium-oxygen delivery. In randomized patients with Clinical Asthma Scores of <6 (n = 12), a positive correlation (rs = .72) was observed between the Clinical Asthma Score at baseline and the change in Clinical Asthma Score during helium-oxygen administration (p = .009). Respiratory rate and heart rate decreased during helium-oxygen treatment but were not statistically significant. No complications occurred during helium-oxygen delivery.

CONCLUSIONS

Inhaled helium-oxygen improves the overall respiratory status of children with acute RSV lower respiratory tract infection. In patients with mild-to-moderate bronchiolitis (Clinical Asthma Scores of <6), the beneficial effects of helium-oxygen were most pronounced in children with the greatest degree of respiratory compromise.

The Apache III prognostic system: customized mortality predictions for Spanish ICU patients

OBJECTIVE

To customize the Acute Physiology and Chronic Health Evaluation (APACHE) III mortality equation for Spanish admissions to the intensive care unit (ICU) and evaluate its discrimination and calibration.

DESIGN

Prospective multicenter inception cohort study.

SETTING

86 ICUs located in all regions of Spain.

PATIENTS

10,929 adult patients selected by a systematic sampling method. All types of critical care patients were included, including coronary bypass patients, but excluding those with burn injury, those admitted for pacemaker implants, patients under 16 years of age, and patients with length of ICU stay < 6 h.

MEASUREMENTS AND RESULTS

Data collection in the first 24 h after patient admission included: APACHE III score, treatment location prior to ICU admission, and main ICU admission diagnosis. Using these variables, a model for predicting hospital mortality was constructed, adapted to Spain, and its discriminating ability was assessed by the area below the ROC curve, which was 0.83. The model was validated using the jacknife method and the area below the receiver operating characteristic (ROC) curve for the cross-validated predictions was 0.82. The percentage of patients correctly classified at 0.50 risk of death was 82.3%. Model calibration was evaluated by analysis of the agreement between the observed and cross-validated predicted mortality using the Hosmer-Lemeshow test, which gave a value of (H) 12.27, with no statistical significance, i.e., good calibration.

CONCLUSIONS

We have customized the APACHE III mortality prediction system for the Spanish population. This adapted model has demonstrated the requisite validation, calibration, and discrimination for its use among Spanish critical care patients.

Hypnotic technique for sedation of patients during upper gastrointestinal endoscopy

A method of sedation of patients undergoing upper gastrointestinal endoscopy is described. This technique employs a variety of elements, including "pacing and leading," metaphors, use of physiological reactions to deepen the relaxation, imagery, and post hypnotic suggestions. It is a simple and effective method which does not require any preparation. It spares the need for a pharmacological sedation and obviates the possible hazards of such a sedation. The author has successfully used this technique to sedate more than 200 patients undergoing upper gastrointestinal endoscopy. The duration of examinations performed this way compares with that using conventional pharmacological sedation. However, unlike the case of pharmacological sedation, no further monitoring is needed after the completion of the examination and the patients can leave the clinic immediately to resume their activities.

Mastectomy without malignancy after carcinoma diagnosed by large-core stereotactic breast biopsy

Mammary carcinoma diagnosed by large-core stereotactic biopsy (LCSBB) is often followed by definitive surgery. We report on positive (malignant) LCSBB followed by definitive surgery that failed to demonstrate malignancy. Between January 1993 and August 1996, 206 women in our institution underwent LCSBB. Carcinoma was diagnosed in 45 patients (22%) of the 206 (ductal carcinoma in situ (DCIS), n = 12; invasive carcinoma, n = 33). Twenty-nine of the 45 patients subsequently underwent mastectomy, and 8 of 45 underwent lumpectomy. In 34 (92%) of these 37 patients, carcinoma was demonstrated at follow-up surgery, but in 3 patients (8%), mastectomy failed to reveal carcinoma. The characteristics of these three patients are as follows: Patient 1 was a 58-year-old woman with a nonpalpable 6- to 8-mm nodule revealed by a screening mammogram. Three of 8 LCSBBs showed colloid carcinoma, but histologic examination of 50 paraffin blocks and radiographic examination of the mastectomy sample failed to reveal carcinoma. Patient 2 was a 64-year-old woman with a nonpalpable 6- to 9-mm nodule revealed by mammogram. Six of 12 LCSBBs showed tubular carcinoma, but histologic examination of 30 paraffin blocks from her mastectomy sample failed to reveal carcinoma. Patient 3 was a 72-year-old woman with a history of DCIS. She had undergone a lumpectomy and radiotherapy, and she had suspicious ipsilateral microcalcifications. Two of 8 LCSBBs showed comedo DCIS, but histologic examination of 26 paraffin blocks and radiographic examination of the mastectomy sample failed to reveal carcinoma. Possible explanations for a mastectomy without malignancy after carcinoma was diagnosed by LCSBB include removal of the entire lesion by LCSBB, inflammatory response obliterating remaining tumor, false-positive core biopsy result, patient misidentification, inadequate sampling of the surgical specimen, and failure to remove the tumor. We outline a series of steps for the pathologists to follow when confronted with such a case.

Esophagitis is a major cause of upper gastrointestinal hemorrhage in the elderly

BACKGROUND

The risk of death in patients presenting with upper gastrointestinal (UGI) hemorrhage increases with age. Our aims were to define the background characteristics, causes, course, and outcome in patients aged > or = 80 years admitted to hospital because of acute UGI bleeding (n = 115) in relation to patients aged 60-69 years admitted for the same reason (n = 133).

METHODS

A prospective, longitudinal study with a nested case-control analysis was carried out.

RESULTS

In the elderly patients there was a female preponderance and a significantly higher prevalence of atherosclerotic cardiovascular disease. By contrast, use of tobacco and alcohol, diabetes mellitus, and chronic liver disease were significantly commoner in the controls. The use of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, anticoagulants, and corticosteroids was similar in the two groups. Esophagitis was the cause of bleeding in 21.1% of the elderly, as compared with 3.3% in the controls. The relative risk of developing esophagitis in the elderly was increased and was independent of gender, smoking, alcohol consumption, use of NSAIDs, aspirin, or corticosteroids, diabetes mellitus, atherosclerotic cardiovascular disease and liver disease. (Adjusted odds ratio, 18.1; P = 0.0002). The rates of persistent or recurrent bleeding and emergency surgery to control bleeding were similar. However, the mortality in the elderly was higher (13 versus 6.1%; P = 0.09).

CONCLUSIONS

Age > or = 80 years is an independent determinant of esophagitis, a major cause of UGI bleeding in the elderly.

Kinetics and dynamics of single oral doses of sirolimus in sixteen renal transplant recipients

Sirolimus is a new immunosuppressive drug that has been evaluated in animal experiments. The current study was conducted on humans with reformulated sirolimus in doses from 3 mg/m2 to 15 mg/m2. Sixteen renal transplant recipients were included in this phase I study to determine the safety, tolerance, and preliminary pharmacokinetics of increasing single doses of orally administered sirolimus. All 16 patients had stable renal graft function after a renal transplant at least 6 months before the study. Basal immunosuppression consisted of cyclosporine and prednisolone (n = 10) or cyclosporine, azathioprine, and prednisolone (n = 6). Four groups (I, 3 mg/m2; II, 5 mg/m2; III, 10 mg/m2; IV, 15 mg/m2) of four patients were assigned randomly to receive sirolimus (n = 3) or placebo (n = 1). Among the 12 patients who received sirolimus, five had mild transient study events such as headache, nausea, mild dizziness, hypoglycemia, epistaxis, and decrease in platelets. No serious adverse events occurred and no nephrotoxic effects could be related to the single dose administration of sirolimus. The only study event that was judged as probably related to sirolimus was the single case of thrombocytopenia. The other events were evaluated as possibly related. Thrombocytopenia occurred at the highest dose level (15 mg/m2 sirolimus). In two of the patients in the placebo group, slight elevations of liver enzymes and serum amylase were seen. Blood and plasma sirolimus concentrations were analyzed by an electrospray-high performance liquid/mass spectrophotometric (ESP-HPLC/MS) method Sirolimus showed an extensive red blood cell distribution with a mean blood/ plasma ratio of 49.1. The elimination half-life ranged from 43.8 to 86.5 hours (mean 56.9 hours). The Cmax and the area under the concentration versus time curves (AUC) correlated reasonably with doses from 3 to 15 mg/m2. The oral dose clearance ranged from 42 to 339 ml/h.kg. No clinically significant differences were seen in the trough concentrations of cyclosporine or the AUCs before and after the administration of sirolimus. Administration of single oral doses of sirolimus from 3 to 15 mg/m2 was safe and well tolerated in stable renal transplant recipients. Thrombocytopenia may be the dose-limiting toxicity. Additional phase II and phase III clinical trials will define the immunosuppressive efficacy of sirolimus.

Successful surgical removal of an asymptomatic optic nerve hemangioblastoma in von Hippel-Lindau disease

An asymptomatic patient with a family history of von Hippel-Lindau disease carried the abnormal gene for this disease. An imaging survey that consisted of computed tomography, magnetic resonance imaging, and cerebral angiography revealed an optic nerve hemangioblastoma. The potential for visual loss in the future was the indication for microsurgical intervention. This was the first asymptomatic optic nerve hemangioblastoma to be imaged and the first to be successfully removed without any permanent neurological deficits or vision loss.

Consequences of sexual decisions: the perceptions of rural adolescents

The purpose of this study was to examine the content of adolescent thinking about the consequences of choosing abstinence, sexual intercourse with a condom, and unprotected intercourse. Consequences for the relationship and for each partner's thoughts and feelings were explored. Participants were 116 high school students living in a rural area of a midwestern state; their average age was 16 years. They completed a series of open-ended questions about possible outcomes to a scenario involving sexual decision making. Content analysis of responses revealed that about half of the participants associated abstinence with positive consequences; however, it was also associated with insecurity and the possibility of losing the relationship. Sexual intercourse with a condom was viewed as an indication of caring and responsibility and was associated with positive outcomes for the relationship. Identified consequences of unprotected intercourse were almost entirely negative. Some differences in perceived consequences were influenced by the gender of the partner. Integration of these findings into programs designed to prevent sexual risk-taking is discussed.