Comparing Continuous Glucose Monitoring and Blood Glucose Monitoring in Adults With Inadequately Controlled, Insulin-Treated Type 2 Diabetes (Steno2tech Study): A 12-Month, Single-Center, Randomized Controlled Trial

OBJECTIVE

To compare the 12-month effects of continuous glucose monitoring (CGM) versus blood glucose monitoring (BGM) in adults with insulin-treated type 2 diabetes.

RESEARCH DESIGN AND METHODS

This is a single-center, parallel, open-label, randomized controlled trial including adults with inadequately controlled, insulin-treated type 2 diabetes from the outpatient clinic at Steno Diabetes Center Copenhagen, Denmark. Inclusion criteria were ≥18 years of age, insulin-treated type 2 diabetes, and HbA1c ≥7.5% (58 mmol/mol). Participants were randomly assigned (1:1) to 12 months of either CGM or BGM. All participants received a diabetes self-management education course and were followed by their usual health care providers. Primary outcome was between-group differences in change in time in range (TIR) 3.9-10.0 mmol/L, assessed at baseline, after 6 and 12 months by blinded CGM. The prespecified secondary outcomes were differences in change in several other glycemic, metabolic, and participant-reported outcomes.

RESULTS

The 76 participants had a median baseline HbA1c of 8.3 (7.8, 9.1)% (67 [62-76] mmol/mol), and 61.8% were male. Compared with BGM, CGM usage was associated with significantly greater improvements in TIR (between-group difference 15.2%, 95% CI 4.6; 25.9), HbA1c (-0.9%, -1.4; -0.3 [-9.4 mmol/mol, -15.2; -3.5]), total daily insulin dose (-10.6 units/day, -19.9; -1.3), weight (-3.3 kg, -5.5; -1.1), and BMI (-1.1 kg/m2, -1.8; -0.3) and greater self-rated diabetes-related health, well-being, satisfaction, and health behavior.

CONCLUSIONS

In adults with inadequately controlled insulin-treated type 2 diabetes, the 12-month impact of CGM was superior to BGM in improving glucose control and other crucial health parameters. The findings support the use of CGM in the insulin-treated subgroup of type 2 diabetes.

Automated Insulin Delivery in Adults With Type 1 Diabetes and Suboptimal HbA1c During Prior Use of Insulin Pump and Continuous Glucose Monitoring: A Randomized Controlled Trial

BACKGROUND

Automated insulin delivery (AID) systems offer promise in improving glycemic outcomes for individuals with type 1 diabetes. However, data on those who struggle with suboptimal glycemic levels despite insulin pump and continuous glucose monitoring (CGM) are limited. We conducted a randomized controlled trial to assess the effects of an AID system in this population.

METHODS

Participants with hemoglobin A1c (HbA1c) ≥ 58 mmol/mol (7.5%) were allocated 1:1 to 14 weeks of treatment with the MiniMed 780G system (AID) or continuation of usual care (UC). The primary endpoint was change in time in range (TIR: 3·9-10·0 mmol/L) from baseline to week 14. After this trial period, the UC group switched to AID treatment while the AID group continued using the system. Both groups were monitored for a total of 28 weeks.

RESULTS

Forty adults (mean ± SD: age 52 ± 11 years, HbA1c 67 ± 7 mmol/mol [8.3% ± 0.6%], diabetes duration 29 ±13 years) were included. After 14 weeks, TIR increased by 18.7% (95% confidence interval [CI] = 14.5, 22.9%) in the AID group and remained unchanged in the UC group (P < .0001). Hemoglobin A1c decreased by 10.0 mmol/mol (95% CI = 7.0, 13.0 mmol/mol) (0.9% [95% CI = 0.6%, 1.2%]) in the AID group but remained unchanged in the UC group (P < .0001). The glycemic benefits of AID treatment were reproduced after the 14-week extension phase. There were no episodes of severe hypoglycemia or diabetic ketoacidosis during the study.

CONCLUSIONS

For adults with type 1 diabetes not meeting glycemic targets despite use of insulin pump and CGM, transitioning to an AID system confers considerable glycemic benefits.

DiaFocus: A Personal Health Technology for Adaptive Assessment in Long-Term Management of Type 2 Diabetes

Type 2 diabetes (T2D) is a large disease burden worldwide and represents an increasing and complex challenge for all societies. For the individual, T2D is a complex, multi-dimensional, and long-term challenge to manage, and it is challenging to establish and maintain good communication between the patient and healthcare professionals. This article presents DiaFocus, which is a mobile health sensing application for long-term ambulatory management of T2D. DiaFocus supports an adaptive collection of physiological, behavioral, and contextual data in combination with ecological assessments of psycho-social factors. This data is used for improving patient-clinician communication during consultations. DiaFocus is built using a generic data collection framework for mobile and wearable sensing and is highly extensible and customizable. We deployed DiaFocus in a 6-week feasibility study involving 12 patients with T2D. The patients found the DiaFocus approach and system useful and usable for diabetes management. Most patients would use such a system, if available as part of their treatment. Analysis of the collected data shows that mobile sensing is feasible for longitudinal ambulatory assessment of T2D, and helped identify the most appropriate target users being early diagnosed and technically literate T2D patients.

Observation of Microcanonical Atom Number Fluctuations in a Bose-Einstein Condensate

Quantum systems are typically characterized by the inherent fluctuation of their physical observables. Despite this fundamental importance, the investigation of the fluctuations in interacting quantum systems at finite temperature continues to pose considerable theoretical and experimental challenges. Here we report the characterization of atom number fluctuations in weakly interacting Bose-Einstein condensates. Technical fluctuations are mitigated through a combination of nondestructive detection and active stabilization of the cooling sequence. We observe fluctuations reduced by 27% below the canonical expectation for a noninteracting gas, revealing the microcanonical nature of our system. The peak fluctuations have near linear scaling with atom number ΔN_{0,p}^{2}∝N^{1.134} in an experimentally accessible transition region outside the thermodynamic limit. Our experimental results thus set a benchmark for theoretical calculations under typical experimental conditions.

Changes in the lipidome in type 1 diabetes following low carbohydrate diet: Post-hoc analysis of a randomized crossover trial

Aims

Lipid metabolism might be compromised in type 1 diabetes, and the understanding of lipid physiology is critically important. This study aimed to compare the change in plasma lipid concentrations during carbohydrate dietary changes in individuals with type 1 diabetes and identify links to early-stage dyslipidaemia. We hypothesized that (1) the lipidomic profiles after ingesting low or high carbohydrate diet for 12 weeks would be different; and (2) specific annotated lipid species could have significant associations with metabolic outcomes.

Methods

Ten adults with type 1 diabetes (mean ± SD: age 43.6 ± 13.8 years, diabetes duration 24.5 ± 13.4 years, BMI 24.9 ± 2.1 kg/m2, HbA1c 57.6 ± 2.6 mmol/mol) using insulin pumps participated in a randomized 2-period crossover study with a 12-week intervention period of low carbohydrate diet (< 100 g carbohydrates/day) or high carbohydrate diet (> 250 g carbohydrates/day), respectively, separated by a 12-week washout period. A large-scale non-targeted lipidomics was performed with mass spectrometry in fasting plasma samples obtained before and after each diet intervention. Longitudinal lipid levels were analysed using linear mixed-effects models.

Results

In total, 289 lipid species were identified from 14 major lipid classes. Comparing the two diets, 11 lipid species belonging to sphingomyelins, phosphatidylcholines and LPC(O-16:0) were changed. All the 11 lipid species were significantly elevated during low carbohydrate diet. Two lipid species were most differentiated between diets, namely SM(d36:1) (β ± SE: 1.44 ± 0.28, FDR = 0.010) and PC(P-36:4)/PC(O-36:5) (β ± SE: 1.34 ± 0.25, FDR = 0.009) species. Polyunsaturated PC(35:4) was inversely associated with BMI and positively associated with HDL cholesterol (p < .001).

Conclusion

Lipidome-wide outcome analysis of a randomized crossover trial of individuals with type 1 diabetes following a low carbohydrate diet showed an increase in sphingomyelins and phosphatidylcholines which are thought to reduce dyslipidaemia. The polyunsaturated phosphatidylcholine 35:4 was inversely associated with BMI and positively associated with HDL cholesterol (p < .001). Results from this study warrant for more investigation on the long-term effect of single lipid species in type 1 diabetes.

Efficacy of Bolus Calculation and Advanced Carbohydrate Counting in Type 2 Diabetes: A Randomized Clinical Trial

Background: Carbohydrate counting and use of automated bolus calculators (ABCs) can help reduce HbA_1c in type 1 diabetes but only limited evidence exists in type 2 diabetes. We evaluated the efficacy of advanced carbohydrate counting (ACC) and use of an ABC compared with manual insulin bolus calculation (MC) in persons with type 2 diabetes. Materials and Methods: A 24-week open-label, randomized clinical study was conducted in 79 persons with type 2 diabetes treated with basal-bolus insulin (mean age 62.5 ± 9.6 years, HbA_1c 8.7% ± 1.0% [72 ± 11 mmol/mol], diabetes duration 18.7 ± 7.6 years). Participants were randomized 1:1 into two groups: ABC group received training in ACC and use of an ABC; MC group received training in ACC and manual calculation of insulin bolus. Participants wore blinded continuous glucose monitors for 6 days at baseline and at study end. Primary endpoint was change in HbA_1c. Results: After 24 weeks, HbA_1c decreased 0.8% (8.8 mmol/mol) in ABC group and 0.8% (9.0 mmol/mol) in MC group with no between-group difference (P = 0.96) and without increase in time in hypoglycemic range (sensor glucose <3.9 mmol/L). Glycemic variability decreased significantly in both groups, whereas the total insulin dose and body mass index (BMI) remained unchanged during the study. Treatment satisfaction increased significantly in both groups after 24 weeks. Conclusion: ACC is an effective, low-cost tool to reduce HbA_1c and glycemic variability in persons with basal-bolus insulin-treated type 2 diabetes without increase in hypoglycemia or BMI. Similar effects were seen with use of an ABC and with use of manual bolus calculation. Trial registration: ClinicalTrials.gov NCT02887898.

Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasi-experimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls

Background

To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities.

Methods

Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage.

Results

The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s).

Conclusions

Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

Low versus high carbohydrate diet in type 1 diabetes: A 12-week randomized open-label crossover study

AIMS

To compare the effects of a low carbohydrate diet (LCD < 100 g carbohydrate/d) and a high carbohydrate diet (HCD > 250 g carbohydrate/d) on glycaemic control and cardiovascular risk factors in adults with type 1 diabetes.

MATERIALS AND METHODS

In a randomized crossover study with two 12-week intervention arms separated by a 12-week washout, 14 participants using sensor-augmented insulin pumps were included. Individual meal plans meeting the carbohydrate criteria were made for each study participant. Actual carbohydrate intake was entered into the insulin pumps throughout the study.

RESULTS

Ten participants completed the study. Daily carbohydrate intake during the two intervention periods was (mean ± standard deviation) 98 ± 11 g and 246 ± 34 g, respectively. Time spent in the range 3.9-10.0 mmol/L (primary outcome) did not differ between groups (LCD 68.6 ± 8.9% vs. HCD 65.3 ± 6.5%, P = 0.316). However, time spent <3.9 mmol/L was less (1.9 vs. 3.6%, P < 0.001) and glycaemic variability (assessed by coefficient of variation) was lower (32.7 vs. 37.5%, P = 0.013) during LCD. No events of severe hypoglycaemia were reported. Participants lost 2.0 ± 2.1 kg during LCD and gained 2.6 ± 1.8 kg during HCD (P = 0.001). No other cardiovascular risk factors, including fasting levels of lipids and inflammatory markers, were significantly affected.

CONCLUSIONS

Compared with an intake of 250 g of carbohydrate per day, restriction of carbohydrate intake to 100 g per day in adults with type 1 diabetes reduced time spent in hypoglycaemia, glycaemic variability and weight with no effect on cardiovascular risk factors.

Observation of Atom Number Fluctuations in a Bose-Einstein Condensate

Fluctuations are a key property of both classical and quantum systems. While the fluctuations are well understood for many quantum systems at zero temperature, the case of an interacting quantum system at finite temperature still poses numerous challenges. Despite intense theoretical investigations of atom number fluctuations in Bose-Einstein condensates, their amplitude in experimentally relevant interacting systems is still not fully understood. Moreover, technical limitations have prevented their experimental investigation to date. Here we report the observation of these fluctuations. Our experiments are based on a stabilization technique, which allows for the preparation of ultracold thermal clouds at the shot noise level, thereby eliminating numerous technical noise sources. Furthermore, we make use of the correlations established by the evaporative cooling process to precisely determine the fluctuations and the sample temperature. This allows us to observe a telltale signature: the sudden increase in fluctuations of the condensate atom number close to the critical temperature.

Cardiovascular effects of antidiabetic drugs

Type 2 diabetes mellitus is a common and severe chronic metabolic disease, which confers increased risk of cardiovascular disease and mortality. During the last decade a large number of new drugs within the classes dipeptidyl peptidase 4 (DPP-4) inhibitors (DPP-4Is), glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1RAs) and sodium/glucose cotransporter 2 (SGLT-2) inhibitors (SGLT-2Is) have been developed and tested in nine large-scale cardiovascular outcome trials (CVOTs). Here we review the evidence behind antihyperglycemic treatment of patients with type 2 diabetes with a particular focus on compiling and summarizing the evidence of hard clinical endpoints stemming from these large CVOTs.

Mesenchymal stromal cell injection promotes vocal fold scar repair without long-term engraftment

BACKGROUND

Regenerative medicine holds promise for restoring voice in patients with vocal fold scarring. As experimental treatments approach clinical translation, several considerations remain. Our objective was to evaluate efficacy and biocompatibility of four bone marrow mesenchymal stromal cell (BM-MSC) and tunable hyaluronic acid based hydrogel (HyStem-VF) treatments for vocal fold scar using clinically acceptable materials, a preclinical sample size and a dosing comparison.

METHODS

Vocal folds of 84 rabbits were injured and injected with four treatment variations (BM-MSC, HyStem-VF, and BM-MSC in HyStem-VF at two concentrations) 6 weeks later. Efficacy was assessed with rheometry, real-time polymerase chain reaction (RT-PCR) and histology at 2, 4 and 10 weeks following treatment. Lung, liver, kidney, spleen and vocal folds were screened for biocompatibility by a pathologist.

RESULTS AND DISCUSSION

Persistent inflammation was identified in all hydrogel-injected groups. The BM-MSC alone treatment appeared to be the most efficacious and safe, providing an early resolution of viscoelasticity, gene expression consistent with desirable extracellular matrix remodeling (less fibronectin, collagen 1α2, collagen 3, procollagen, transforming growth factor [TGF]β1, alpha smooth muscle actin, interleukin-1β, interleukin-17β and tumor necrosis factor [TNF] than injured controls) and minimal inflammation. Human beta actin expression in BM-MSC-treated vocal folds was minimal after 2 weeks, suggesting that paracrine signaling from the BM-MSCs may have facilitated tissue repair.

Efficacy of basal-bolus insulin regimens in the inpatient management of non-critically ill patients with type 2 diabetes: A systematic review and meta-analysis

Hyperglycemia during hospitalization is associated with increased rates of complications and longer hospital stays. Various insulin regimens are used in the inpatient diabetes management of non-critically ill patients. In this systematic review and meta-analysis, we aimed to assess the efficacy and safety of basal-bolus insulin therapy (BBI) by summarizing evidence from studies of BBI versus sliding scale insulin therapy (SSI) in the management of hospitalized non-critically ill type 2 diabetes patients. We searched MEDLINE, EMBASE, Scopus, and the Cochrane Library for studies comparing BBI therapy with SSI therapy in hospitalized non-critically ill patients with type 2 diabetes. Primary outcome was mean daily blood glucose (BG) during admission. Secondary outcomes were incidence of hypoglycemia and length of hospital stay. Results of included randomized controlled trials (RCT) were pooled and meta-analysed to provide estimates of the efficacy of BBI therapy. Five RCTs and seven observational studies were included in the review. Meta-analysis of RCTs showed significantly lower mean daily BG with BBI than SSI. Mean difference in daily BG between the two regimens ranged from 14 to 29 mg/dl. BBI therapy was associated with increased risk of mild hypoglycemia (BG ≤ 70 mg/dl, RR 5.75; 95% CI 2.79-11.83), (BG ≤ 60 mg/dl, RR 4.21; 95% CI 1.61-11.02) compared with SSI therapy. There was no difference in risk of severe hypoglycemia (BG ≤ 40 mg/dl) and no difference in mean length of stay. In conclusion, basal-bolus insulin in the inpatient diabetes management results in significantly lower mean daily BG than sliding scale insulin but is associated with increased risk of mild hypoglycemia.

Development and evaluation of an "emergency access button" in Danish out-of-hours primary care: a study protocol of a randomized controlled trial

BACKGROUND

Out-of-hours (OOH) health care for acute medical problems is often challenged by long waiting time for callers in need of advice and triage. Allowing patients to bypass the OOH telephone waiting line may increase patient satisfaction and provide them with a feeling of safety. We aimed to develop an "emergency access button" enabling patients to bypass the normal telephone waiting line in out-of-hours primary care (OOH-PC) if they perceive their condition to be critical and to evaluate the effect of introducing the button in terms of patient satisfaction and their feeling of safety.

METHODS

All patients calling the OOH-PC in two different Danish health care regions during three months will be included in this randomized controlled trial. Data will be collected through two questionnaires developed for this study: a pop-up questionnaire on the relevance of bypassing the normal waiting line to be completed by triage professionals after patient contact and a paper/electronic questionnaire on perceived safety and satisfaction with the emergency access button to be completed by the callers. These questionnaires were developed and validated using external and internal expert feedback, focus group interviews and a two-week field test. The study will be conducted over three months with an estimated user-rate of the emergency access button of 3%.

DISCUSSION

We have developed an emergency access button and we now want to investigate whether this new option will influence upon the level of satisfaction and the feeling of safety in the calling patients. Additionally, the study will reveal the assessed relevance of the decision to bypass the line by triage professionals.

TRIAL REGISTRATION

Registered as NCT02572115 at Clinicaltrials.gov on October 5^th 2015.

The Utility of Acute-Phase Proteins in the Assessment of Treatment Response in Dogs With Bacterial Pneumonia

Background

Acute‐phase proteins (APPs) are sensitive markers of inflammation, and serum C‐reactive protein (CRP) recently has been shown to be a useful diagnostic marker in dogs with bacterial pneumonia (BP). In humans with community‐acquired pneumonia, APPs also have great utility as follow‐up markers aiding in the assessment of treatment response.

Objectives

The aim of our study was to investigate the applicability of APPs as markers of treatment response in dogs with BP.

Animals

Nineteen dogs diagnosed with BP and 64 healthy dogs.

Methods

The study was conducted as a prospective longitudinal observational study. Serum CRP, serum amyloid A (SAA), and haptoglobin concentrations were followed during a natural course of BP. Normalization of serum CRP was used to guide the duration of antibiotic treatment (treatment was stopped 5–7 days after CRP normalized) in 8 of 17 dogs surviving to discharge; 9 of 17 dogs were treated according to conventional recommendations.

Results

All measured APPs initially were significantly increased, but the magnitude of increase was not correlated to disease severity. C‐reactive protein and SAA concentrations decreased rapidly after initiation of antimicrobial treatment. When normalization of serum CRP was used to guide the duration of antibiotic treatment, treatment duration was significantly (P = .015) decreased without increasing the number of relapses.

Conclusions and Clinical Importance

Serum CRP and SAA reflected the recovery process well and therefore may be used as markers of treatment response. According to the results, the normalization of serum CRP may be used to guide the duration of antibiotic treatment in dogs with BP.

Swellable Coatings for Hearing Aid Applications

The problem of acoustic feedback in hearing aids could be solved potentially by applying a compliant hydrogel to the outer surface that would conform to the ear canal and block feedback. With this objective, several formulations of hydrogels were developed and their swelling and mechanical properties investigated. Hydrogel formulations were polymerized from hydroxyethyl methacrylate (HEMA) and N-vinyl-pyrrolidone (NVP), with various photo-initiators, crosslinkers, and swelling agents. The hydrogel that swelled most rapidly and yet remained undissolved in water had a monomer composition of 40 mol% HEMA, 60 mol% NVP, with 1 wt% polyethylene glycol dimethacrylate as a crosslinker, and 0.5 wt% 2,2-dimethoxy-2-phenyl-acetophenone as the photo-initiator. The tensile modulus, strength, hardness, and durability of the dry hydrogels were not a strong function of composition. In the swollen state, the mechanical properties were much reduced. The potential use of these materials on hearing aids has been discussed in this article.

Experimental Induction of Muscle Tenderness and Headache in Tension-Type Headache Patients

The aim of the present study was to investigate the impact of static contraction of the shoulder and neck muscles on muscle tenderness and headache in patients with tension-type headache. Twenty patients with frequent episodic tension-type headache and 20 healthy age- and sex-matched controls were examined using a placebo-controlled cross-over design. The subjects performed static contraction of the trapezius muscles (active procedure) or the anterior tibial muscles (placebo procedure) with 10% of maximal force for 30 min. Total tenderness score, local tenderness score and headache intensity were evaluated before and after the static work. Changes in headache intensity were followed for 24 h. Pericranial tenderness increased significantly more in patients than in controls after the active procedure ( P = 0.04). The increase in pericranial tenderness tended to be higher after the active procedure than after the placebo procedure in patients ( P = 0.08) and in controls ( P = 0.07). Sixty per cent of the patients and 20% of the healthy controls developed headache after the active procedure. Fifty per cent of the patients and none of the controls developed headache after the placebo procedure. There was no significant difference in headache development between the active and the placebo procedure in patients or controls. These findings demonstrate that tension-type headache patients are more liable to develop shoulder and neck pain in response to static exercise than healthy controls.

Genotype of galectin 2 (LGALS2) is associated with insulin-glucose profile in the British Women's Heart and Health Study

AIMS/HYPOTHESIS

It has been suggested that the gene encoding lymphotoxin-alpha (LTA) is associated with insulin resistance, and genetic association studies in the LTA region offer some support for this. However, LTA is in linkage disequilibrium with both the HLA gene cluster and the gene encoding TNF-alpha, making inferences about causality difficult. In this study, we used the galectin 2 (LGALS2) genotype, which affects LTA secretion but is located on another chromosome than the HLA gene cluster or TNF, to examine the relationship between the LTA pathway and traits of the metabolic syndrome.

SUBJECTS

A cross-sectional genetic association study was carried out in 3,272 British women of European origin who were aged 60 to 79 years and were randomly selected from the community.

RESULTS

Fasting plasma glucose and serum insulin were statistically significantly associated with LGALS2 rs7291467, with this association being independent of BMI and WHR. The mean difference in fasting insulin per minor allele was -4% (p=0.01 for trend by allele) and the mean per minor allele difference in fasting glucose was -2% (p=0.02 for trend by allele). When women with known diabetes were excluded from the analyses the findings did not differ from those for the whole cohort.

CONCLUSIONS/INTERPRETATION

Our findings for the physically unlinked LGALS2, invite further study of LGALS2 specifically and the LTA pathway generally for their influence on glucose-insulin regulation.

Frequent attenders in general practice care: A literature review with special reference to methodological considerations

OBJECTIVE

To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs).

DESIGN

The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the 'related articles' function in the ISI Citation database and Medline.

SETTING

General practice.

SUBJECTS

Sixty-one articles (54 studies).

MEASURES

The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results.

RESULTS

There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30-50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender.

CONCLUSION

The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies.

The effect of an out-of-hours reform on attendance at casualty wards. The Danish example

OBJECTIVE

A reorganisation of the out-of-hours general practice service in Denmark was launched in January 1992. The biggest changes were in a mandatory telephone triage staffed by GPs and the replacement of small rota systems with county-based health centres. We aimed to analyse the effect of this out-of-hours reform on the number of contacts with the casualty wards.

DESIGN

A register-based ecologic time-trend study of the mean number of annual contacts per inhabitant from 1988 to 1997.

SETTING

The County of Aarhus.

SUBJECTS

All 630000 inhabitants in the county.

MAIN OUTCOME MEASURES

Mean number of annual contacts with casualty wards per inhabitant. Intercepts derived from two regression models.

RESULTS

The mean number of contacts with casualty wards rose significantly during the whole period. Given this constant increase in contact rates, a regression model showed that the increase in the attendance rate with casualty wards after the reform was statistically insignificant.

CONCLUSIONS

The decrease in the total number of contacts with the out-of-hours primary health care after the reform was not met by a corresponding increase in casualty ward contacts. A clear-cut significant increase in the use of casualty wards following the out-of-hours reform could not be demonstrated.

[Are out of hours contacts with physicians necessary? Assessment by physicians on call and by patients]

Patients and GPs were asked about necessity and possible prevention of contacts to the out of hour service. 4187 (83.9%) of the GP questionnaires and 1493 (52.3%) of the patient questionnaires were returned. According to the GPs 25% of the contacts were not necessary and 5% were not necessary according to the patients. Patients and GPs agreed that contacts concerning old people were most necessary. GPs assessed contacts concerning children relatively more necessary. Patients assessed contacts concerning middle-aged relatively more necessary. Frequent users were assessed less necessary according to GPs but more necessary according to the users themselves. Many contacts could have been prevented according to both GPs and patients--especially within the first five hours of the service. Concordance between a patient's and a GPs answer was bad (kappa = 0.0-0.2). Concordance between the GPs answering the phone and the GPs examining the patient was only slightly better (kappa = 0.1-0.3).

Eosinophil markers in seasonal allergic rhinitis. Intranasal fluticasone propionate inhibits local and systemic increases during the pollen season

BACKGROUND

The purpose was to study activation markers of the eosinophil granulocytes in seasonal allergic rhinitis, and the impact of topical steroid therapy thereupon.

METHODS

Sixty-three rhinitis patients with monoallergy to grass were examined before and at peak pollen season. Blood eosinophil count, eosinophil cationic protein (ECP), and eosinophil peroxidase (EPO) in serum and nasal lavage fluid were measured. During the season, patients were randomized to treatment with intranasal fluticasone propionate 0.1 mg o.d. (n=26), 0.2 mg o.d. (n=25), or placebo (n=12). Six healthy persons served as controls.

RESULTS

During the season, all parameters, except nasal lavage ECP, increased in the placebo group (P<0.001-P<0.05). Significant differences were seen between the steroid groups and the placebo group for all parameters (P<0.001-P<0.05). Higher eosinophil count (P<0.05), serum EPO (P<0.02), and nasal lavage EPO (P<0.05) were found in patients before season than in controls. The following winter, 44 patients returned for repeated measurement. Lower levels of nasal lavage EPO were observed for patients than levels at the beginning of the season (P<0.0001).

CONCLUSIONS

Intranasal fluticasone propionate reduced inflammation of the nasal mucosa, demonstrated locally by nasal lavage ECP and EPO, and systemically by blood eosinophils, serum ECP, and serum EPO. EPO seemed more sensitive than ECP as indicator of allergic inflammation. EPO demonstrated some perennial eosinophil activity in hay fever patients, increasing locally during spring.

Out of hours service in Denmark: evaluation five years after reform

OBJECTIVE

Five years after its introduction, to evaluate the 1992 reform in the out of hours service in Denmark.

DESIGN

Comparison of data before and after reform. Data were collected from published reports, Danish national health statistics, and the Danish trade union for general practitioners.

SETTING

Denmark.

MAIN OUTCOME MEASURES

Number of out of hours services; workload of general practitioners; cost of the service; patient satisfaction.

RESULTS

Five years after the reform, the percentage of telephone consultations had almost doubled, to 48%. Consultations in doctors' surgeries were relatively unchanged, but home visits were much reduced, to 18%. The percentage of doctors who worked 5 hours or more out of hours per week dropped from about 70% to about 50%. Overall patient satisfaction in 1995 was high (72%).

CONCLUSION

The organisation of the out of hours service, with a fully trained general practitioner in a telephone triage function, is working satisfactorily. Many calls that previously would have required home visits are now dealt with by telephone or through consultations. The out of hours workload for general practitioners has decreased considerably.

[Prescription of strong analgesics in the out-of-hours general practice in the county of Aarhus]

The article describes the ordination of opioid analgesics in the out-of-hours general practice service to patients with pain due to an illness lasting for more than two days. The physicians working out-of-hours duty and the patient's GP answered a questionnaire. The research includes 227 contacts. The results showed that the main diagnoses were: migraine/headache (33%), angina pectoris (19%) and back-pain (11%). The physicians estimated 33% of the contacts to be "less necessary" or "unnecessary". In 78% of the cases the GPs "agreed" or "almost agreed" with the deputizing doctors' use of opioids. In most of the cases the patients' usual GPs agreed with the treatment prescribed by the deputizing doctors. There seems to be a disagreement between the GPs and the Danish National Board of Health about the principles concerning the use of opioids.

[Use of on-call service by patients with pain in the county of Aarhus]

The aim of the study was to describe the numbers and other characteristics of patients who contacted the general practitioners (GP) out-of-hours on-call service with pain as the most important or major contributing reason for the contact. Data were collected from a questionnaire entered in the GPs' computer system. About 80% of the GPs participated. Over a 14 day period 10,653 contacts were registered, and of these 4718 were analyzed, consisting of 2080 telephone consultations, 1316 consultations and 1322 home visits. The results showed that 30% of the telephone calls, 37% of the consultations and 41% of the home visits concerned a patient with pain problems. Of these contacts concerning pain patients, the physicians estimated that 33% of the consultations and home visits and 55% of the telephone calls were "less necessary" or "unnecessary". It is concluded that pain is a major reason for contacting the GPs' on-call service, and that physicians deem many of these contacts "less necessary" of "unnecessary". Better information to citizens and better education of the physicians might enable some of these contacts to be transferred to normal working hours.

Assessment of the allergic reaction in seasonal rhinitis: acoustic rhinometry is a sensitive and objective method

BACKGROUND

Seasonal allergic rhinitis constitutes an excellent in vivo model of an allergic mucosal inflammatory reaction. This offers the opportunity of studying the fundamentals of allergic inflammation in addition to improvement of knowledge on the basal pathophysiological mechanisms of the disease. So far, monitoring methods of disease activity and treatment efficacy have mainly been based upon subjective assessments, illustrating the impact of introducing reliable objective methods.

OBJECTIVE

To investigate the allergic inflammatory reaction of seasonal rhinitis through different objective methods and evaluate these as indicators of disease activity and treatment efficacy.

METHODS

Functional parameters, i.e. acoustic rhinometry and nasal metacholine challenge, and biological markers, i.e. blood eosinophil count, eosinophil cationic protein in serum (s-ECP) and nasal lavage fluid (n-ECP), were assessed before and at peak pollen season in 27 patients with grass pollen induced rhinitis. Patients were randomized to either nasal corticosteroid or placebo treatment and recorded nasal symptom scores.

RESULTS

Acoustic rhinometry revealed a significant difference in favour of steroid treatment (P < 0.05) comparing nasal volumes before and during season. This difference primarily relied upon a decrease in the placebo group (P = 0.05). A reduction from baseline of s-ECP in the steroid group (P < 0.01) was obtained. N-ECP demonstrated a difference between treatment groups, although not significant. Symptom scores increased in all patients during the pollen season, although this was only significant in the placebo treated patients (P < 0.01). The remaining methods applied did not demonstrate further differences, either within or between treatment groups.

CONCLUSION

Our results demonstrate acoustic rhinometry to be a sensitive and objective method of assessment of nasal obstruction. Furthermore, acoustic rhinometry and s-ECP reflect the impact of nasal steroid therapy on seasonal allergic rhinitis.

The absorption of chlortetracycline following transscrotal instillation for the treatment of primary hydrocele testis

We describe the absorption of chlortetracycline from the emptied hydrocele sac, which was instilled to treat a primary hydrocele of the testis. The study included 7 patients and 2 control subjects who were given 500 mg. chlortetracycline. Plasma concentration was determined at 0, 1/2, 1, 2, 4, 6, 12 and 24 hours after instillation, and in 2 patients plasma levels also were determined at 48 and 72 hours. The area under the plasma concentration-time curve (AUC1) was calculated in each case by using the trapezoidal rule. In the control group the plasma level was determined at 0, 1, 2, 4 and 6 hours after instillation. The area under the plasma concentration-time curve (AUC2) was calculated by the formula AUC2 = Co/Kc. The fraction F of absorption can be expressed as F = AUC1/AUC2; median F = 0.67 (range 0.41 to 0.92). We conclude that chlortetracycline passes readily and almost completely through the tunica vaginalis lining the hydrocele sac.

UVB serum factor: suppression of allergic contact dermatitis in guinea pigs

Serum from guinea pigs exposed to a single high dose of UVB and from controls was injected into the spleen of normal animals 5 days prior to sensitization. When 1.0 ml was transferred 4.5 h after irradiation, immunosuppression was obtained. Transfer of 1.5 ml of serum 2.5 h after irradiation failed to induce immunosuppression. This experimental model in guinea pigs might be valuable in further studies investigating the effect of other modalities of ultraviolet exposure (e.g., PUVA or high-dose UVA) on the release of soluble serum factor(s) inducing immunosuppression in allergic contact dermatitis.

Does sodium cromoglycate have an effect on contact dermatitis?

Sodium cromoglycate was applied to the forearm of 9 subjects with known delayed hypersensitivity, and to the back of 14 dinitrochlorobenzene-sensitized guinea pigs before challenge with the allergen and sodium lauryl sulphate. Sodium cromoglycate did not decrease the intensity of allergic of toxic-irritant reactions in either humans or guinea pigs.

Flare-up reactions and desensitization from oral dosing in chromate-sensitive guinea pigs

Flare-up reactions were induced in potassium dichromate hypersensitive guinea pigs by a single oral dose of 55 mg/kg. This dose is systemically toxic and higher than the dose required to induce the same reactions in humans. A total oral dose of potassium dichromate of 90-115 mg/kg induced immunological unresponsiveness for at least 6 weeks. With limitations, the guinea pig model may be helpful in screening the hyposensitization capacity of different haptens dosed orally.

Effect of vehicle on elicitation of DNCB contact allergy in the guinea pig

22 DNCB sensitized guinea pigs were challenged with varying amounts dissolved in alcohol, acetone and olive oil. DNCB applied in alcohol resulted in almost 100% positive reactions; the test scores correlated to dose. When similar amounts were applied in alcohol and acetone, the former produced a significantly higher degree of positivity. The importance of defining allergen concentration, volume or weight of test substance applied and test area size, when comparing test results in guinea pigs and humans, is emphasized.

Cystic fibrosis serum effect on the short circuit current of rat jejunum

Sera from 100 subjects were tested for the presence of the cystic fibrosis (CF) "factor" utilizing the short circuit current rat jejunum bioassay. Comparing the mean percent decrease in short circuit current, the presumed normal group differs from the homozygous CF group at P = 0.001 and from the heterozygous group at P = 0.05. The two CF genotypes are statistically different at P = 0.004. There is, however, a large overlap among the three groups, which limits the assay's utility as a guide for factor purification as well as clinical use.