Association of retinopathy severity with cardiovascular and renal outcomes in patients with type 1 diabetes: a multi-state modeling analysis

This study aimed to assess the impact of diabetic retinopathy (DR) severity on the incidence of major adverse cardiac events (MACE) and end-stage renal disease (ESRD) in T1D patients. Patients diagnosed with T1D between 1999 and 2013 were identified from patient-level data of Taiwan’s National Health Insurance Research database. A total of 1135 patients were included and classified into mild DR (n = 454), severe DR (n = 227), or non-DR (n = 454) by using propensity score matching. Multi-state model analyses, an extension of competing risk models with adjustment for transition-specific covariates for prediction of subsequent MACE and ESRD, were performed. MACE and ESRD risks were significantly higher in the severe DR patients; a 2.97-fold (1.73, 5.07) and 12.29-fold (6.50, 23.23) increase in the MACE risk among the severe DR patients compared to the mild DR and DR-free patients, respectively; and, a 5.91-fold (3.50, 9.99) and 82.31-fold (29.07, 233.04) greater ESRD risk of severe DR patients than that of the mild DR and DR-free groups, respectively (p < 0.001). Severity of DR was significantly associated with the late diabetes-related vascular events (i.e., MACE, ESRD) among T1D patients.

The Biomechanical Properties of a High-Tensile Strength Tape for Tendon Graft Fixation Using the Krackow Configuration

Purpose

To compare the biomechanical properties of a high-tensile strength suture with the high-tensile strength tape for tendon graft fixation.

Methods

A total of 24 porcine tendons were used and were randomly divided into 2 groups. Two kinds of suture materials, a braided nonabsorbable high-strength suture (group S) and a high-tensile strength tape (group T), were used to complete 3 pairs of Krackow stitches on the tendons. Each specimen was pretensioned to 100 N for 3 cycles, cyclically loaded from 50 to 200 N for 200 cycles, and finally loaded to failure. Elongation after cyclic loading, ultimate failure load, and the mode of failure were recorded.

Results

The elongation after cyclic loading between group S (26% ± 5%) and group T (24% ± 5%) were not significantly different (P = .378). The ultimate failure loads in group T (400 ± 38 N) were significantly greater than those in group S (358 ± 21 N) (P = .010). All specimens failed because of suture material breakage.

Conclusions

Compared with the braided nonabsorbable high-strength suture, the high-tensile strength tape had similar elongation values after cyclic loading, but significantly greater ultimate failure load in this porcine in vitro biomechanical model.

Clinical Relevance

A secure suture-tendon construct is especially important when a post-tie fixation technique is used because the mitigating construct may potentially lead to graft loosening and affect graft healing.

Using Interconnected Knotless Anchor for Suprapectoral Biceps Tenodesis Could Offer Improved Biomechanical Properties in a Cadaveric Model

PURPOSE

To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis.

METHODS

In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n = 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated.

RESULTS

The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA.

CONCLUSIONS

In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study.

CLINICAL RELEVANCE

The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis.

Testing of non-inferiority and superiority for three-arm clinical studies with multiple experimental treatments

The purpose of a non-inferiority trial is to assert the efficacy of an experimental treatment compared with a reference treatment by showing that the experimental treatment retains a substantial proportion of the efficacy of the reference treatment. Statistical methods have been developed to test multiple experimental treatments in three-arm non-inferiority trials. In this paper, we report the development of procedures that simultaneously test the non-inferiority and the superiority of experimental treatments after the assay sensitivity has been established. The advantage of the proposed test procedures is the additional ability to identify superior treatments while retaining an non-inferiority testing power comparable to that of existing testing procedures. Single-step and stepwise procedures are derived and then compared with each other to determine their relative testing power and testing error in a simulation study. Finally, the suggested procedures are illustrated with two clinical examples.

Application of flow cytometry for evaluating clinical prognosis and histopathological grade of human glioma

OBJECTIVES

Flow cytometry was applied to predict the biological parameters of tumor behavior based on the DNA content distribution of tumors. We used flow cytometry to determine the number of cell cycles for the characterization of intracranial gliomas and its possible prognostic role.

METHODS

Flow cytometric analysis of the DNA content was performed for 37 fresh operative glioma specimens. The expression of Ki-67 in glioma specimens was detected using immunohistochemistry staining. The check points of G2/M-phase fractions, cyclin B, and pCdk1 (Y15) were analyzed using Western immunoblotting.

RESULTS

Compared to low-grade (grade I/II) gliomas, significant differences in the Ki-67, cyclin B, G2/M-phase, and S+G2/M-phase expressions were found in high-grade (grade III/IV) gliomas. Furthermore, receiver operating characteristic (ROC) analysis indicated optimal cutoff points for the G2/M-phase and S+G2/M-phase fractions of 13.47 and 17.26%, respectively, which can be used to differentiate cases with low- and high-grade gliomas. Additionally, both G2/M-phase and S+G2/M-phase fractions had significant association with the expression of Ki-67 in the gliomas. The gliomas were classified by the DNA content. We found that patients with high-grade glioma had worse survival rate than patients with low-grade glioma. Meanwhile, ROC curve analysis gave cutoffs for G2/M-phase of 9.4% and for S+G2/M-phase fractions of 15.04% as best predicting survival. The patients with glioma had poor survival when the levels of G2/M-phase and S+G2/M-phase were more than 9.4 and 15.04%, respectively. In contrast, no significant association between the DNA content of glioma patients and their age, tumor recurrence, and tumor size was found.

DISCUSSION

Our results indicate that flow cytometry analysis for G2/M-phase and S+G2/M-phase fractions can be used for tumor grading for rapidly differentiating low- from high-grade gliomas.

Noninferiority Studies with Multiple New Treatments and Heterogeneous Variances

The objective of a noninferiority (NI) trial is to affirm the efficacy of a new treatment compared with an active control by verifying that the new treatment maintains a considerable portion of the treatment effect of the control. Compensation by benefits other than efficacy is usually the justification for using a new treatment, as long as the loss of efficacy is within an acceptable margin (NI margin) from the standard treatment. A popular approach is to express this margin in terms of the efficacy difference between the new treatment and the active control. Based on this approach and the realization that NI trials often comprise several new treatments, statistical procedures that simultaneously conduct NI tests of several new treatments have been developed. However, these procedures rely on the assumption that the variances of the treatments are homogeneous. In this article, we discuss the undesirable effect of using these procedures on the familywise Type I error rate when the treatment responses have heterogeneous variances. To alleviate this problem, we reveal potential procedures that are more appropriate. Further, a power study is conducted to compare the different procedures to provide guidance on the selection of adequate testing procedures in NI trials. Clinical examples are given for illustrative purposes.

Extension of three-arm non-inferiority studies to trials with multiple new treatments

Non-inferiority (NI) trials are becoming increasingly popular. The main purpose of NI trials is to assert the efficacy of a new treatment compared with an active control by demonstrating that the new treatment maintains a substantial fraction of the treatment effect of the control. Most of the statistical testing procedures in this area have been developed for three-arm NI trials in which a new treatment is compared with an active control in the presence of a placebo. However, NI trials frequently involve comparisons of several new treatments with a control, such as in studies involving different doses of a new drug or different combinations of several new drugs. In seeking an adequate testing procedure for such cases, we use a new approach that modifies existing testing procedures to cover circumstances in which several new treatments are present. We also give methods and algorithms to produce the optimal sample size configuration. In addition, we also discuss the advantages of using different margins for the assay sensitivity test between the active control and the placebo and the NI test between the new treatments and the active control. We illustrate the new approach by using data from a clinical trial.

A preliminary study of a healthy-lifestyle-promoting program for nursing students in Taiwan

This pilot study evaluated the effects of a healthy-lifestyle-promoting program, taught as part of an undergraduate community health nursing course, on the physical fitness and health choices of 42 Taiwanese nursing students. A convenience sample provided quantitative indexes of physical fitness and lifestyle before and after the course. Qualitative data, in the form of student diaries, were also analyzed. The findings indicated a positive change in physical fitness, exercise, and nutrition as a result of the program. Including lifestyle programs in nursing education may help promote the long-term health of future nurses who will serve as positive patient role models.

Androgen receptor gene repeats and indices of obesity in older adults

OBJECTIVE

To examine the relationship between GGN and CAG trinucleotide repeat polymorphisms in the androgen receptor (AR) gene and indices of obesity in older Caucasian adults.

DESIGN

A cross-sectional study.

SUBJECTS

Ninety-nine healthy men (age 51-93 y) and 113 healthy postmenopausal women (age 51-92 y).

MEASUREMENTS

Genotyping the GGN and CAG repeats of the AR gene, and measuring body weight, height and waist and hip circumferences. Waist was measured at the umbilicus (wstumb), iliac crest (wstili), and mid-way between the iliac crest and lowest rib (wstwst). Waist-to-hip ratios (WHRUMB, WHRILI and WHRWST) and body mass index (BMI) were calculated.

RESULTS

Women who were homozygous for a common GGN (17 or 18) and short CAG (</=25) had higher waist and hip circumferences and higher WHRUMB and WHRWST, compared with women without this allele combination. The odds ratios (OR) for the upper 25th percentile of obesity measures were 3.6-5.6-fold higher for wstumb, wstwst, WHRUMB and WHRWST among women with this allele combination. Men who had both a rare GGN (not 17) and short CAG (</=23) had a higher WHRUMB and WHRILI compared with men without this allele combination. The OR related to the upper 10th percentile of obesity measures among men who had this allele combination was 4.7-fold higher for WHRILI.

CONCLUSION

AR GGN and CAG allele combinations are strongly associated with central obesity indices in older adults, particularly in women.

Clients' outcomes of home health nursing in Taiwan

The home health nursing movement is expanding rapidly. Home health nursing agencies (HHNAs) are expected to demonstrate that the care provided does make a difference for the client receiving the services. The purpose of this study was to explore client outcomes from home health nursing. Outcome indicators include: Services utilized (emergency services, re-hospitalization), physiological status (catheter indwelling status, consciousness level, wound severity-number and wound stages) and functional status (reflected by Barthel Index). A prospective research design was used to collect the results. Five hospital-based HHNAs were invited to participate in this research. Clients newly admitted to HHNAs and diagnosed as non-cancer patients were recruited, and the researchers gathered outcome indicators over a six-month period. Data were analyzed using SPSS 8.0 computer software. There were 75 clients in this study. Results showed that most of the clients (64.0%) received service for more than 180 days. The client characteristics were dominated by elderly (66.6% age above 70), female (53.3%) and married (74.7%). The three leading care needs were NG tubing service (84.0%), Foley tubing service (45.3%) and wound care (38.7%). The Kruscal Wallis Test revealed that there was no difference in emergency service frequency and re-hospitalization between clients who received service for more than 180 days and those who received service for less than 180 days. The Wilcoxon Sign rank test showed that within one half-year, catheter indwelling status, functional status, and wound severity were not significantly different, with the exception only of conscious level (p = .001). The results of this study can be viewed as preliminary data to assist in shaping home health nursing services in Taiwan.

[Analysis and separation of chromium(III) oligomers by ion chromatography]

A method of analyzing chromium(III) oligomers in aqueous solution by means of TSK-Gel ion exchange analytical column and diode array detector was developed. The effects of determination conditions, elution and ionic strength on analysis were investigated carefully and the analytical condition was optimized. The samples were separated for 10 min by using TSK-Gel SP-5PW(75 mm x 7.5 mm i.d., 10 microns) as column, 3 mol/L NaClO4-0.03 mol/L HClO4 as mobile phase, and detected at the wavelength of 200 nm. The method was simple, rapid and repeatable. This method was also used to determine the concentration of each fraction under various conditions of preparing chromium(III) oligomers and rendering the optimized preparation parameters.

[Purification of prothrombin in Nitschmann fraction III by membrane radial column ion-exchange liquid chromatography]

A method is described for the purification of human prothrombin complex concentrate (PCC) from Nitschmann fraction III by membrane radial column ion-exchange chromatography, which allows large sample volumes to be processed at low operation pressure. The Nitschmann fraction III (15 g) was mixed with 1,000 mL 0.06 mol/L Tris-HCl(pH 7.5). The centrifuged supernatant(10,000 r/min, 15 min, 20 degrees C) was applied onto a DEAE ion-exchange liquid chromatographic column(XK-16 DEAE fast flow Sepharose and DEAE membrane radical column chromatography) with almost the same excellent separation efficiency. The parameters of sample flow rate, elution flow rate and sample capacity were optimized.

Fasting plasma glucose in screening for diabetes in the Taiwanese population

OBJECTIVE

To reveal the relationship between fasting and 2-h postload plasma glucose and to examine the appropriate fasting glucose cutoff as the primary screening test for diabetes.

RESEARCH DESIGN AND METHODS

We recruited 5,303 subjects from preventive services of the National Cheng Kung University Hospital. Exclusion criteria were age <20 years, pregnancy, known diabetes, and a history of recent surgery, trauma, or illness. All subjects received the 75-g oral glucose tolerance test. The relationship between fasting and 2-h glucose was examined. Sensitivities, specificities, efficiency, and predictive values were assessed at different cutoffs of fasting glucose for prediction of diabetes.

RESULTS

The best fit model for the relationship between fasting and 2-h glucose was fasting glucose = 4.914-0.060 x (2-h glucose) + 0.0144 x (2-h glucose)2. From this model, the fasting glucose was 6.0 mmol/l when 2-h glucose was 11.1 mmol/l. A fasting glucose with 6.25 mmol/l gave the same diabetes prevalence as the World Health Organization 2-h glucose criterion. When 7.8 mmol/l was the fasting glucose cutoff, the sensitivity was 28.5%. Lowering the cutoff from 7.8 to 7.0 mmol/l increased the sensitivity by 11.2% and slightly reduced the specificity and positive predictive value. If the cutoffs were 6.25 and 6.0 mmol/l, the sensitivity increased and the specificity and the positive predictive value decreased accordingly.

CONCLUSIONS

Our results suggest that fasting glucose as a screening criterion for diabetes could be revised downward to 7.0 mmol/l, because the slight reduction of positive predictive value was more than balanced by an apparent increase of sensitivity and insignificant change of specificity.