Randomized Controlled Study of Metformin and Sitagliptin on Long-term Normoglycemia Remission in African American Patients With Hyperglycemic Crises.

OBJECTIVE: After intensive insulin treatment, many obese African American patients with new-onset diabetic ketoacidosis (DKA) and severe hyperglycemia are able to achieve near-normoglycemia remission. The optimal treatment to prevent hyperglycemic relapses after remission is not known. RESEARCH DESIGN AND METHODS: This prospective, 4-year, placebo-controlled study randomly assigned 48 African American subjects with DKA and severe hyperglycemia to metformin 1,000 mg daily (n = 17), sitagliptin 100 mg daily (n = 16), or placebo (n = 15) after normoglycemia remission. Hyperglycemic relapse was defined as fasting glucose >130 mg/dL (7.2 mmol/L) and HbA1c >7.0% (53 mmol/mol). Oral glucose tolerance tests were conducted at randomization and at 3 months and then every 6 months for a median of 331 days. Oral minimal model and incremental area under the curve for insulin (AUCi) were used to calculate insulin sensitivity (Si) and ß-cell function, respectively. Disposition index (DI) was calculated as a product of Si and incremental AUCi. RESULTS: Relapse-free survival was higher in sitagliptin and metformin (P = 0.015) compared with placebo, and mean time to relapse was significantly prolonged in the metformin and sitagliptin groups compared with the placebo group (480 vs. 305 days, P = 0.004). The probability of relapse was significantly lower for metformin (hazard ratio 0.28 [95% CI 0.10-0.81]) and sitagliptin (0.31 [0.10-0.98]) than for placebo. Subjects who remained in remission had a higher DI (P = 0.02) and incremental AUCi (P < 0.001) than those with hyperglycemia relapse without significant changes in Si. CONCLUSIONS: This study shows that near-normoglycemia remission was similarly prolonged by treatment with sitagliptin and metformin. The prolongation of remission was due to improvement in ß-cell function.

The impact of increased weekend physiotherapy service provision in critical care: a mixed methods study.

BACKGROUND: At the hospital studied, weekend physiotherapy (WEPT) is routinely provided and in 2013 WEPT was increased from one (PRE) to three (POST) physiotherapists (PTs) to cover intensive care and ward patients. AIMS: (1) To evaluate the impact of increased WEPT on patient volumes, treatments provided and conditions treated in critical care and wards; and (2) to understand the PTs' perspectives on the new coverage model. METHODS: A mixed methods design was utilized. The quantitative component consisted of retrospective document reviews of all weekend patients treated January 1-May 5 (PRE) and May 11-December 31 (POST). The qualitative component used a questionnaire to collect staff feedback. PRE-POST comparisons were conducted using χ(2) or Mann-Whitney U tests. RESULTS: Significant (p = 0.00) increases POST were seen in number of patients treated, number of mobility treatments provided and number of post-surgical patients seen in both clinical areas. The majority of survey respondents reported feeling adequately trained, but had concerns regarding the impact of increased WEPT on work-life balance. CONCLUSION: PTs perceived enhanced service was beneficial for continuity of weekday care and improved patient function. Future studies need to focus on measuring the effect of increased weekend provision on outcomes, preventing complications and length of stay.

The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases.

Based on indicators that emerged from The First Physical Therapy Summit on Global Health (2007), the Second Summit (2011) identified themes to inform a global physical therapy action plan to integrate health promotion into practice across the World Confederation for Physical Therapy (WCPT) regions. Working questions were: (1) how well is health promotion implemented within physical therapy practice; and (2) how might this be improved across five target audiences (i.e. physical therapist practitioners, educators, researchers, professional body representatives, and government liaisons/consultants). In structured facilitated sessions, Summit representatives (n = 32) discussed: (1) within WCPT regions, what is working and the challenges; and (2) across WCPT regions, what are potential directions using World Café(TM) methodology. Commonalities outweighed differences with respect to strategies to advance health-focused physical therapy as a clinical competency across regions and within target audiences. Participants agreed that health-focused practice is a professional priority, and a strategic action plan was needed to develop it as a clinical competency. The action plan and recommendations largely paralleled the principles and objectives of the World Health Organization's non-communicable diseases action plan. A third Summit planned for 2015 will provide a mechanism for follow-up to evaluate progress in integrating health-focused physical therapy within the profession.

Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors.

OBJECTIVE: To conduct a bedside study to determine the factors driving insulin noncompliance in inner-city patients with recurrent diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS: We analyzed socioeconomic and psychological factors in 164 adult patients with DKA who were admitted to Grady Hospital between July 2007 and August 2010, including demographics, diabetes treatment, education, and mental illness. The Patient Health Questionnaire-9 and the Short Form-36 surveys were used to screen for depression and assess quality of life. RESULTS: The average number of admissions was 4.5 ± 7 per patient. A total of 73 patients presented with first-time DKA, and 91 presented with recurrent DKA; 96% of patients were African American. Insulin discontinuation was the leading precipitating cause in 68% of patients; other causes were new-onset diabetes (10%), infection (15%), medical illness (4%), and undetermined causes (3%). Among those who stopped insulin, 32% gave no reasons for stopping, 27% reported lack of money to buy insulin, 19% felt sick, 15% were away from their supply, and 5% were stretching insulin. Compared with first-time DKA, those with recurrent episodes had longer duration of diabetes (P < 0.001), were a younger age at the onset of diabetes (P = 0.04), and had higher rates of depression (P = 0.04), alcohol (P = 0.047) and drug (P < 0.001) abuse, and homelessness (P = 0.005). There were no differences in quality-of-life scores, major psychiatric illnesses, or employment between groups. CONCLUSIONS: Poor adherence to insulin therapy is the leading cause of recurrent DKA in inner-city patients. Several behavioral, socioeconomic, psychosocial, and educational factors contribute to poor compliance. The recognition of such factors and the institution of culturally appropriate interventions and education programs might reduce DKA recurrence in minority populations.

Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery.

OBJECTIVE: Hospital hyperglycemia, in individuals with and without diabetes, has been identified as a marker of poor clinical outcome in cardiac surgery patients. However, the impact of perioperative hyperglycemia on clinical outcome in general and noncardiac surgery patients is not known. RESEARCH DESIGN AND METHODS: This was an observational study with the aim of determining the relationship between pre- and postsurgery blood glucose levels and hospital length of stay (LOS), complications, and mortality in 3,184 noncardiac surgery patients consecutively admitted to Emory University Hospital (Atlanta, GA) between 1 January 2007 and 30 June 2007. RESULTS: The overall 30-day mortality was 2.3%, with nonsurvivors having significantly higher blood glucose levels before and after surgery (both P < 0.01) than survivors. Perioperative hyperglycemia was associated with increased hospital and intensive care unit LOS (P < 0.001) as well as higher numbers of postoperative cases of pneumonia (P < 0.001), systemic blood infection (P < 0.001), urinary tract infection (P < 0.001), acute renal failure (P = 0.005), and acute myocardial infarction (P = 0.005). In multivariate analysis (adjusted for age, sex, race, and surgery severity), the risk of death increased in proportion to perioperative glucose levels; however, this association was significant only for patients without a history of diabetes (P = 0.008) compared with patients with known diabetes (P = 0.748). CONCLUSIONS: Perioperative hyperglycemia is associated with increased LOS, hospital complications, and mortality after noncardiac general surgery. Randomized controlled trials are needed to determine whether perioperative diabetes management improves clinical outcome in noncardiac surgery patients.

The cumulative effect of coffee and a mental stress task on heart rate, blood pressure, and mental alertness is similar in caffeine-naïve and caffeine-habituated females.

Most North American workers drink coffee throughout their workday, although the cumulative effect of job stress and coffee is not well known. Research has shown that coffee affects the cardiovascular system and mental alertness primarily through the active ingredient caffeine; however, the dose of caffeine used in these studies is greater than a normal cup of coffee. In addition, these changes have been mostly determined in male caffeine-habituated consumers. Therefore, this study examined the effect of a normal cup of coffee on the cardiovascular and mental alertness response both before and after a mental stress task in 10 caffeine-naïve (23 +/- 5.0 years) and 10 caffeine-habituated (25 +/- 6 years) females. Blood pressure, heart rate, and mental alertness were taken at baseline (before coffee), 50 minutes after finishing coffee and immediately after a 9-minute mental stress task. The volume of coffee ingested for a 15-minute period was 350 mL (12 oz), which is equivalent to 140 mg of caffeine. The combined effect of coffee and mental stress significantly decreased diastolic blood pressure (Delta8 mm Hg) and increased heart rate (Delta6 beats per minute) and mental alertness (Delta67.3%) in caffeine-naïve and caffeine-habituated females, whereas systolic blood pressure (Delta10.3 mm Hg) only increased in the caffeine-naïve participants. Our results indicate that a normal cup of coffee can effect changes in blood pressure and mental alertness and that mental stress may alter the magnitude of change; however, the transient increase in systolic blood pressure after drinking coffee in caffeine-naïve participants requires further investigation.

Faulty proprioceptive information disrupts motor imagery: an experimental study.

QUESTION: Does faulty proprioceptive input disrupt the internal model of the body that the brain uses to control movement? DESIGN: Randomised, within-participant experimental study. PARTICIPANTS: Twenty-two (13 F) healthy adults. INTERVENTION: Participants performed a motor imagery task that involved making left/right judgements of pictured right and left hands in 16 different postures under five conditions involving stimuli being applied to the experimental (L) hand. The five conditions were: vibration (of the wrist extensor tendons to elicit the illusion of wrist flexion), sham (vibration of the ulna styloid), active flexion, passive flexion, and control (no stimulus). OUTCOME MEASURES: Accuracy and response time of the control (R) hand in making left/right judgements of the pictures. RESULTS: Response time during vibration was longer for those who reported the illusion of wrist flexion (n = 18) than for those who did not (p < 0.01) whereas accuracy was unaffected (p = 0.71). In those who reported the illusion, accuracy was unaffected by condition, hand or picture (p > 0.21). Response time during vibration was 910 ms longer (95% CI 730 to 1090) for pictures of the experimental (L) hand (mean 2731 ms, 95% CI 2543 to 2918) than it was for pictures of the control (R) hand (mean 1822 ms, 95% CI 1634 to 2009), and approximately 580 ms longer (95% CI 380 to 785) for pictures of either hand during any other condition (p < 0.025). CONCLUSION: Faulty proprioceptive input disrupted this motor imagery task, which suggests it can disrupt the model of the limb that the brain uses for movement.

Expectation of pain replicates the effect of pain in a hand laterality recognition task: bias in information processing toward the painful side?

BACKGROUND: People in pain, or expecting pain, sometimes bias their attention towards pain-relevant cues. Perhaps they also bias their attention towards the body part in question. AIM: To determine if experimentally induced pain, and the expectation of pain, involve an information processing bias towards the hand in question. METHODS: Seventeen asymptomatic subjects performed a hand laterality recognition task during three conditions: control, during hand pain induced by intramuscular injection of hypertonic saline (pain), and during expectation of hand pain, induced by isotonic saline injection (expectation). Mean response time (RT) was determined for three 45 s epochs within each condition and RT was compared between hands, conditions and epochs using a 2 x 3 x 3 repeated measures multivariate analysis of variance. RESULTS: There was a hand x condition interaction and a hand x condition x epoch interaction (p<0.05 for both). RT to recognise the opposite hand was approximately 600 ms longer during epochs when subjects were in pain or expected pain than during control trials. During those epochs, RT to recognise the opposite hand was approximately 600 ms longer than RT to recognise the injected hand, which was consistent across conditions and across epochs. CONCLUSIONS: Both pain and the expectation of pain increased RT to recognise the opposite hand. The findings are consistent with a bias in information processing toward the painful or impending painful hand.