Glycemic excursion minimization in the management of type 2 diabetes: a novel intervention tested in a randomized clinical trial

INTRODUCTION

This study of adults with type 2 diabetes employed a non-inferiority hypothesis to investigate whether an innovative lifestyle focused on minimizing postnutrient blood glucose (BG) excursions (glycemic excursion minimization (GEM)) would be equivalent or superior to conventional weight loss (WL) therapy in regard to reducing HbA1c, and superior to WL when investigating physical, behavioral and psychological secondary outcomes. The impact of BG feedback on GEM efficacy was also investigated.

RESEARCH DESIGN AND METHODS

178 adults with type 2 diabetes for ≤10 years, HbA1c ≥6.8%, and not using insulin were randomized to WL (n=40) or one of three versions of GEM. Didactic (GEM-D, n=39) taught participants to choose low-glycemic load foods, reduce sedentary time and increase moderate routine physical activity. GEM-S (n=51) received GEM-D and systematically measured BG before and after meals and physical activity to educate and motivate food and activity choices. GEM-C (n=48) received GEM-D with continuous glucose monitoring feedback. All participants received 6 hours of group training and BG and activity monitors. Before and 3 months after treatment, participants were assessed for HbA1c, lipids, weight, routine physical activity, nutrition, depression, diabetes empowerment and distress.

RESULTS

GEM versions did not differ in primary or secondary outcomes, so they were combined for analyses. While WL reduced body mass index (BMI) (p=0.005), GEM demonstrated a greater reduction in HbA1c (p=0.005), BMI (p=0.013), carbohydrate intake (p=0.001), BG response to a glucose challenge (p=0.02), and cardiovascular risk (p=0.003). Only GEM participants significantly improved diabetes empowerment, diabetes distress, depressive symptoms, steps/day, and active hours and reduced calories/day. Neither intervention had negative side effects.

CONCLUSIONS

GEM is an effective alternative to WL with respect to physical, behavioral and psychosocial outcomes.

TRIAL REGISTRATION NUMBER

NCT03196895.

Effects of Fostamatinib on the Pharmacokinetics of Oral Contraceptive, Warfarin, and the Statins Rosuvastatin and Simvastatin: Results From Phase I Clinical Studies

BACKGROUND AND OBJECTIVES

Fostamatinib is a spleen tyrosine kinase inhibitor that has been investigated as therapy for rheumatoid arthritis and immune thrombocytopenic purpura. The present studies assessed the potential for pharmacokinetic interaction between fostamatinib and the commonly prescribed medications oral contraceptive (OC), warfarin, and statins (rosuvastatin, simvastatin) in healthy subjects.

METHODS

The OC study was a crossover study over two 28-day treatment periods (Microgynon(®) 30 plus placebo or fostamatinib). Concentrations of OC constituents (ethinyl estradiol/levonorgestrel) were measured. Effects on warfarin pharmacokinetics and pharmacodynamics were assessed (21-day study). Warfarin was administered on days 1 and 14, fostamatinib on days 8-20. The statin study was a two-period, fixed-sequence study of the effects of fostamatinib on exposure to rosuvastatin or simvastatin (single doses). Safety was assessed throughout.

RESULTS

Fostamatinib co-administration with OC increased exposure to ethinyl estradiol [area under the plasma concentration-time curve at steady state (AUCss) 28% [confidence interval (CI 90%) 21-36]; maximum plasma concentration (Cmax) at steady state (Cmax,ss) 34% (CI 26-43)], but not levonorgestrel (AUCss 5%; Cmax,ss -3%), while exposure to luteinizing hormone and follicle-stimulating hormone decreased (≈ 20%). Fostamatinib did not affect the pharmacokinetics/pharmacodynamics of warfarin to a clinically relevant extent, but caused an upward trend in AUC for both R- and S-warfarin [18% (CI 13-23) and 13% (CI 7-19)]. Fostamatinib increased rosuvastatin AUC by 96% (CI 78-115) and Cmax by 88% (CI 69-110), and increased simvastatin acid AUC by 74% (CI 50-102) and Cmax by 83% (CI 57-113).

CONCLUSION

Fostamatinib exhibits drug-drug interactions when co-administered with OC, simvastatin, or rosuvastatin, with the AUC of statins almost doubling. Fostamatinib did not exhibit a clinically relevant DDI on warfarin.

The daily management of athletes with diabetes

The unique demands of exercise and competition can predispose diabetic athletes to harmful complications. A basic understanding of glucose metabolism during exercise, nutritional adequacy, blood glucose control, medications, and management of on-field complications is important for medical personnel who care for diabetic athletes on a daily basis. Diabetic athletes are best managed by "individualized"" preventive and treatment algorithms that should be developed by a team of medical professionals including the athletic trainer, sports nutritionist, and physician.

The detection of depression by patient self-report in women with gynecologic cancer

We examined the utility of patient self-report forms in identifying those gynecologic oncology patients who would be diagnosed by an experienced consultation-liaison psychiatrist as suffering from major depression. Sixty-five women with gynecologic tumors were evaluated by a consultation-liaison psychiatrist, using standardized (DSM-III) criteria. Each patient also completed a Carroll Rating Scale for Depression (CRS). The CRS demonstrated sensitivity and specificity of 87 percent and 58 percent, respectively. Used as a screening instrument to rule out depression, the CRS yielded a negative predictive value of 94 percent. We identified a priori forty items from the CRS which should not be influenced by the non-psychiatric biologic effects of gynecologic tumors, and compared the performance of this non-cancer related symptoms subscale (NCSG) to that of the CRS. The NCSG did not significantly outperform the CRS; its sensitivity and specificity were 87 percent and 62 percent, respectively. Because our study population was relatively homogeneous (i.e., non-ovarian gynecologic oncology patients without severe debilitation who were not receiving chemotherapy, radiation therapy, or other invasive procedures), the findings should not be generalized to other oncologic populations at this time. Our results suggest that patient self-report forms can be effective screening devices for identifying those non-ovarian, gynecologic oncology patients who should then be carefully evaluated for coexisting clinical depression.

Understanding the experience: patients' perceptions of postmyocardial infarction teaching

It is a widely accepted belief among healthcare professionals that patient education for survivors of myocardial infarction (MI) is valuable. Patients benefit by learning about their disease, reducing their risk factors and modifying their lifestyle. Although these assumptions have been studied, the viewpoint of the consumer has not been elucidated. This study sought to determine patients' experience with an in-hospital, post-MI teaching program, the meaning attached to the teaching experience and the overall perceptions of the program. A qualitative focus group method was used to answer the study's questions. The findings suggest that patients valued the teaching experience and found it helped them establish new meaning in their lives. Not only was the teaching content valuable, but so were other factors crucial to their recovery from MI. Healthcare professionals can utilize these findings to develop teaching programs that truly meet the need of consumers.

Writing poetry: a way of knowing nursing

Carper's patterns of knowing expose the relevance and importance of different knowledge to the enterprise of nursing. She noted that the aesthetic pattern enables nurses to know unique perceptive experiences. Poetry captures particular perceptive experiences and reconstructs them into universal wholes. The opportunity for nurses to write poetry can illuminate and legitimate their perceptive experiences which often become worn or hidden in the everyday work world and in other ways of knowing. Expressing nursing experiences through writing poetry generally involves three phases: (a) creating an image of experience, (b) fully articulating the image, and (c) sharing a clear, new meaning of the image. A poem, written to express one author's unique nursing experience, is used to explore the knowledge gained through the process of writing poetry. Writing poetry can help nurses connect with and maintain their personal and professional history. Moreover, writing poetry increases our awareness of the sensibilities of nursing practice and the meanings that these sensibilities add to the depth and design of the discipline.

Grading Journals in Clinical Practice: A Delicate Issue

Offering students opportunities to gain a strong sense of self, a positive professional image, and a chance to articulate their clinical practice is a challenge for nurse educators. Writing journals in clinical placements is one way in which students can create a dialogue with their teacher and reflect upon and explore their clinical experiences in the context in which these experiences occur. However, grading journals according to numerous predetermined criteria can sabotage the benefits and opportunities of writing journals. Judgment and control are two aspects of evaluation and subsequent grading that can sabotage the benefits. Limiting predetermined criteria and not assigning grades to students' journals are two answers to this delicate issue. To function as competent practitioners, nursing students must be able to meet standards of practice; they must achieve a strong sense of self and a positive professional image. Clinical placements offer students the opportunity to explore the experience of clinical nursing and the context in which these experiences unfold. As students acquire skills and explore the practice of nursing, they also face the reality that their instructors will award a judgment of worth to their efforts. This evaluation is necessary to determine whether students have met the required standards. Evaluation and subsequent grades, therefore, must be an integral part of the students' clinical experience. Writing journals is often used as a method of exploring experiences in clinical nursing. Journals are also used as a method of clinical evaluation. Assigning a grade to student journals has a detrimental effect on the purpose of the assignment. An emphasis on exploring the purpose of writing journals and an analysis of the impact that grading has on this exercise will expose the incompatibility between writing and grading journals.

Silicone controversy: a survey of women with breast cancer and silicone implants

BACKGROUND

During the past 3 years, there has been a highly publicized debate concerning the potential medical complications of silicone breast implants. There have been no studies that have addressed the effect of this controversy on women with a history of breast cancer who have undergone breast reconstruction with silicone implants.

PURPOSE

This study was undertaken to understand the concerns of such women regarding their breast reconstructions and to assess what impact the silicone implant controversy had on them.

METHODS

One hundred seventy-four randomly selected women who had undergone reconstructive surgery with silicone implants subsequent to mastectomy for treatment of breast cancer were interviewed by telephone from February through May 1992. (A moratorium on use of silicone breast implants, imposed by the Food and Drug Administration, extended from January through April 1992.) These women, a subset of 359 mastectomy/reconstruction patients of one university-based plastic surgeon, had their first permanent prostheses placed between 1985 and 1990. The interview included questions designed to elicit information about women's experiences with reconstruction and reactions to the controversy.

RESULTS

All study participants were aware of the controversy surrounding silicone implants. Seventy-six percent stated that breast reconstruction helped them cope with cancer, and only 16% had regrets about reconstruction. Many respondents had misconceptions about the nature of possible complications from silicone implants. Fifty-five percent were worried about the implants, yet only 13% considered having them removed as a result of the controversy. Only 27% indicated they would be completely likely to choose silicone implants again. The majority of women were unwilling to accept substantial risks of complications from implants, but there was variability in the level of risk that respondents would tolerate.

CONCLUSIONS

A majority of women who have had breast reconstruction using silicone implants after treatment of breast cancer believe that implants helped them cope with the cancer. However, a sizeable proportion of such women are worried about possible medical complications that may develop as a consequence of silicone breast implants. Many would likely not choose these implants today.

IMPLICATIONS

The true risks associated with silicone implants will ultimately be known. In the meantime, health care providers need to address patients' concerns about these implants. Information and guidance regarding the potential benefits and risks of breast implant devices should be provided to women with breast cancer who are considering treatment options.

Treatment of depression in cancer patients is associated with better life adaptation: a pilot study

Major depression occurs in a significant number of cancer patients, and there is evidence that cancer patients with depression do not receive adequate antidepressant treatment. In an uncontrolled pilot study, the authors assess the degree of depression and the quality of life after the initiation of antidepressant medication treatment in 12 depressed cancer patients who received adequate antidepressant drugs and in 10 depressed cancer patients who received inadequate antidepressant treatment. These preliminary findings suggest that cancer patients with major depression benefit from antidepressant medication treatment and may experience an improved psychosocial adjustment to cancer. Controlled clinical trials will be necessary to verify these preliminary findings.

Depression in women treated for gynecological cancer: clinical and neuroendocrine assessment

To determine the prevalence of major depression in cancer patients and assess the usefulness of the dexamethasone suppression test (DST) and the thyrotropin-releasing hormone (TRH) stimulation test for diagnosing major depression in these patients, the authors studied 83 women hospitalized for gynecological cancer. Nineteen (23%) had major depression according to DSM-III criteria. The sensitivity and specificity of the DST were 40% and 88%, respectively. No relationship between DST and TRH test results was found. These findings indicate a high prevalence of depression in cancer patients, but further research on these tests in cancer patients is needed; their routine use with cancer patients is premature at this time.