Comparison of basal insulin therapies with regard to the risk of acute myocardial infarction in patients with type 2 diabetes: an observational cohort study.

AIMS: To assess the risk of acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus treated with long-acting insulin analogues in comparison with other basal insulin therapy. METHODS: We used German insurance claims data from the years 2004-2009 to conduct a study in a retrospective cohort of patients with type 2 diabetes. Naïve insulin users were defined as patients who had an insulin-free history before the first prescription of long-acting analogue insulin, human NPH insulin or premixed insulin and who were pretreated with oral antidiabetic drugs. Adjusted hazard ratios (HRs) of AMI and corresponding 95% confidence intervals (CIs) were calculated using sex-stratified Cox models. Propensity-score-matched analyses were conducted as sensitivity analyses. RESULTS: We identified 21,501 new insulin users. Patients treated with premixed insulin were older than patients treated with analogue or NPH insulin (mean age 70.7 vs. 64.1 and 61.6 years, respectively) and had more comorbidities. Regarding the risk of AMI, adjusted HRs showed no statistically significant difference between NPH and analogue insulin (HR 0.94, 95% CI 0.74-1.19), but a higher risk for premixed than for analogue insulin (HR 1.27, 95% CI 1.02-1.58). Contrary to the primary analysis, the propensity-score-matched analysis did not show an increased risk for premixed insulin. CONCLUSIONS: In contrast to a former database study, no difference was observed for the risk of AMI between long-acting analogue and NPH insulin in this study. Neither long-acting analogue insulin nor premixed insulin appears to be associated with AMI in patients with type 2 diabetes.

Public engagement with information on renewable energy developments: The case of single, semi-urban wind turbines.

This paper explores perceptions of public engagement with information on renewable energy developments. It draws on a case study of proposals by a major supermarket chain to construct single wind turbines in two semi-urban locations in the UK, analysing data from interviews with key actors in the planning process and focus groups with local residents. The paper concludes that key actors often had high expectations of how local people should engage with information, and sometimes implied that members of the public who were incapable of filtering or processing information in an organised or targeted fashion had no productive role to play in the planning process. It shows how the specific nature of the proposals (single wind turbines in semi-urban locations proposed by a commercial private sector developer) shaped local residents' information needs and concerns in a way that challenged key actors' expectations of how the public should engage with information.

Insulin glulisine, insulin lispro and regular human insulin show comparable end-organ metabolic effects: an exploratory study.

AIMS: To compare the end-organ metabolic effects of insulin glulisine (glulisine), insulin lispro (lispro) and regular human insulin (RHI) in patients with type 1 diabetes mellitus. METHODS: Eighteen patients with type 1 diabetes mellitus (mean age 36.9 +/- 8.6 years, BMI 23.6 +/- 2.8 kg/m(2), haemoglobin A(1c) 7.4 +/- 0.9%) were randomized in this single-centre, double-blind, three-period cross-over, standard Latin-square, euglycaemic glucose clamp trial. Patients received sequential, primed stepwise intravenous infusions of glulisine, lispro or RHI (infusion rates were increased in a stepwise manner from an initial rate of 0.33 [180 min] to 0.66 [180 min] and 1.00 [180 min] mU/kg/min). The primary variables were the suppression of endogenous glucose production (S(EGP)) and glucose uptake (GU). RESULTS: Mean basal endogenous glucose production (EGP) was 1.88, 2.12 and 2.12 mg/kg/min for glulisine, lispro and RHI respectively. Mean (+/-s.e.) maximum absolute S(EGP) (adjusted for basal EGP) was -1.64 +/- 0.06, -1.72 +/- 0.05 and -1.56 +/- 0.05 mg/kg/min respectively. Mean (+/-s.e.) maximum absolute increase in GU (adjusted for basal GU) was 6.46 +/- 0.26, 6.23 +/- 0.24 and 6.72 +/- 0.24 mg/kg/min respectively. There were no clinically relevant differences between the three insulin treatments with respect to serum insulin, free fatty acid (FFA), glycerol or lactate levels. No serious adverse events and no episodes of severe hypoglycaemia were reported. CONCLUSIONS: This study shows that glulisine, lispro and RHI have similar effects on S(EGP), GU, FFA, glycerol and lactate levels, providing evidence for similar end-organ metabolic effects.

Critical care education: an examination of students' perspectives.

Specialist nursing education at the tertiary level is a relatively recent occurrence in Australia. With this move to higher education a variety of issues such as course duration, award level and clinical versus theoretical outcomes provided the impetus for this study. This study examined critical care nursing students' perceptions of undertaking post-graduate education within the higher education sector. Four themes arose from analysis of eight focus group interviews with a total of 42 students from 35 courses offered in eight universities across Australia. The first theme, student burden, included subthemes of financial, heavy workload and student-work conflicts. Student benefits, the second theme, encompassed financial and other benefits. The third theme, clinical experience, incorporated clinical capability, synthesizing, support required and clinical learning. The final theme of student attitude included the subthemes of individual, technology and course. Without student evaluations, curricular improvements including assessment and clinical experience will not evolve to the best of their potential.

The patients' perception of recovery after coronary angioplasty.

Coronary angioplasty and stent placement is associated with short hospital stays. Patients are expected to recover at home, alone, following limited care time with nurses. The purpose of the study was to describe participants' perceptions of recovery after angioplasty. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Data analysis revealed three major categories: awareness of the problem, coping response and appraisal of the situation. These were linked via a problem solving process. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. These categories were further defined by four phases identified as: pre-admission, admission, during the angioplasty and recovery. This paper describes the recovery phase. Awareness of the problem in the recovery phase was associated with 'relief from chest pain' for most participants. In contrast, anxiety continued and was associated with 'uncertainty over future health'. Participants described coping responses of "taking control of their life again" by undertaking both physical and psychological strategies. Finally, the situation was appraised to be either a 'good' or a 'bad' recovery. This appraisal was based on such considerations as the absence of chest pain, improvement in well-being and energy levels. The results of this study highlight patients' concerns and support the need for greater emphasis on their psychosocial needs. This care must be provided within the time constraints of short hospital stays. Nurses must also consider providing support to patients in the pre-admission and recovery phases.

Preparing for coronary angioplasty: the patients' experiences.

Coronary angioplasty and stent placement procedures now represent one of the fastest growing specialties in cardiac care; patients undergo a short stay admission with limited care time with nurses. The purpose of this study was to describe participants' experiences of preparing for angioplasty in such an environment. Eight men and three women were interviewed 1 month after discharge from hospital. Verbatim transcripts were analysed for major themes using the qualitative techniques of grounded theory. Participants described working through a problem solving process in response to the perceived health threat associated with undergoing angioplasty. In step one, the problem was identified. In step two, coping responses were taken to try and solve the problem. In step three, the results of the coping responses were appraised or evaluated. The two problems identified were ongoing chest pain and anxiety related to fear of the unknown. The coping responses initiated included acquiring knowledge of the angioplasty, confidence in the skill of the doctor, support from family and gearing up psychologically. In the final appraisal of the coping responses, the participants decided to either go ahead with, or delay the angioplasty procedure. The results of this study indicate that the preparation for angioplasty represents a period of adjustment that may be anxiety provoking. Participants' experiences provide new knowledge of the concerns and challenges faced when undergoing such an invasive procedure in a short stay environment. The results clearly highlight that psychosocial aspects of nursing care are an essential component of nursing practice for angioplasty patients.

The experience of spouses whose partners have suffered a myocardial infarction: a phenomenological study.

This phenomenological study describes the lived experience of spouses whose partners have suffered a myocardial infarction. In-depth interviews were conducted with three participants (two females and one male) about their experiences. The findings from the participants were analysed using Giorgi's method (1985). Informants' experiences were captured within five major themes: (i) crushing uncertainty, (ii) overwhelming emotional turmoil, (iii) the need for support, (iv) the lack of information heightened anxiety and (v) the acceptance of lifestyle changes. The implications from this study suggest that health care workers need to: embellish their skills in managing spouses' emotions; communicate with community health professionals regarding support systems; provide families with information concerning the emotional issues associated with MI; provide advice in terms of financial aid; and identify community support groups if these are required. The in-depth knowledge gained from the study will enable nurses to understand how family members feel when a spouse/partner has suffered an MI. It will also provide a framework with which practitioners and families can understand their reactions and assist in the overall rehabilitation of clients.

Pharmacokinetics of single and multiple infusions of 5S intravenous immunoglobulin.

A prospective, open and uncontrolled trial was performed to investigate the pharmacokinetics of a 5S intravenous immunoglobulin (IVIG) after single and multiple infusions. Twelve healthy volunteers received a 5S-IVIG enriched in antibodies against Staphylococcus aureus alpha-toxin (aSAT) either as a single infusion or as three infusions in daily intervals. The fate of the injected immunoglobulin was observed by serial measurements of the serum level of aSAT titres. The 5S-IVIG had a half-life with a median of 0.24 (distribution) and 2.0 (terminal) days, respectively. The pharmacokinetic parameters did not differ with dose groups or number of applications. The study medication was well tolerated.

Characterization of a factor from rat serum with blocking activity in the passive cutaneous anaphylactic reaction.

A blocking factor (BF) was obtained from normal and rat reaginic serum which inhibited the passive cutaneous anaphylactic (PCA) reaction of mouse and rat IgE in rat skin. Several chromatographic procedures on DEAE- and CM-cellulose at various pH values were compared in an attempt to obtain BF with high activity. BF-containing fractions after DEAE chromatography at pH 5,4 revealed two components on SDS-polyacrylamide gel: one at 50,000-60,000 and the other at 65,000-70,000 daltons. The latter component was also obtained when normal or rat reaginic serum was adsorbed on Sepharose anti rat IgG. The eluate inhibited the PCA reaction and demonstrated two bands on SDS-polyacrylamide gel, one at 150,000 (IgG) and another at 65,000-70,000 daltons. Purified IgG and rat albumin did not inhibit the PCA reaction. Antisera against BF were obtained with the component at 65,000-70,000 daltons. Anti-BF revealed a specificity for two bands in the cathodal position when assayed against normal rat serum; one of which was IgG. Anti-BF recognized one component in the DEAE fraction when analyzed against the DEAE fraction which contained blocking activity. BF is immunologically distinct from IgG. After immunoadsorption of normal or rat reaginic serum on Sepharose anti-BF columns, an eluate was obtained which showed blocking activity in the PCA reaction and two components on SDS-polyacrylamide gel, one at 150,000 and the other at 65,000-70,000 daltons. Evaluation of blocking factor by isoelectric focussing obtained after various procedures revealed an isoelectric point of 4.7. BF shows dual functions: it inhibits and at high dilutions also enhances the PCA reaction. It is suggested that this factor has a modulatory role in the allergic disease process.

[Cardiovascular risk stratification in general practice]. / Kardiovaskuläre Risikostratifizierung in der Allgemeinpraxis. Die Erfahrungen der Scoring-Woche 2002.

CONCLUSION: The ESC risk charts are helpful to identify high risk patients in general practice who are candidates for preventive treatment. The use of the ESC charts is one important step to initiate "evidence based medicine" in the daily practice of preventive cardiology.Cardiovascular diseases are the most important causes of premature disability and death in Germany. High risk patients however are frequently not recognized. A systematic risk stratification in general practice could identify high risk persons and allow a cost effective treatment approach. The goal of the CAD-scoring week was to identify high risk persons with the use of the ESC risk charts and to evaluate the treatment resulting from risk stratification. In addition the feasibility of the risk charts in daily office routine was to be evaluated. A total of 1122 of 20 000 (5.6%) contacted general physicians agreed to participate in the screening procedure. More than 27 000 patients (> 50 yrs) were evaluated using the ESC risk charts. 21.6% of women (n = 15 018) vs 22.2%* of men (n = 12 361) had markedly elevated blood pressure (> 150 mmHg), 29 vs. 24%* had a total cholesterol > 250 mg/dl (6.5 mmol/l), 25.5 vs 29.9%* smoked and 28.4 vs. 31.9%* had diabetes (*female vs male: p < 0.0003). Altogether 19.4% of women vs. 53% of men were newly identified as high risk patients (risk > 20% in 10 years). More than 40% of these high risk patients received drug treatment for prevention (ASA, lipid lowering drugs or ACE inhibitors). More than 70% of the participating physicians judged the risk charts to be helpful in patient management.

Vaccination against tick-borne encephalitis (TBE): influence of simultaneous application of TBE immunoglobulin on seroconversion and rate of adverse events.

One hundred and twenty-one of 128 enrolled healthy adult subjects were immunized against tick-borne encephalitis (TBE) either by TBE vaccine on days 0 and 28 (61 subjects) or simultaneously by TBE vaccine plus TBE immunoglobulin on day 0 plus TBE vaccine on day 28 (60 subjects). Formation of TBE antibodies were measured in ELISA on days 0, 28 and 56. On day 28 median TBE antibodies were twice as high in the vaccine group (2400) as in the vaccine plus immunoglobulin group (1200). Adverse events were more often observed after the first vaccination than after the second in both groups. In the vaccine group, adverse events after the first vaccine dose were remarkably more frequent (45% of these subjects reported 38 adverse events) than in the group who received vaccine plus immunoglobulin (25% of these subjects reported 18 adverse events). All types of adverse events (chills, flu-like symptoms, injection site pain) were reported less frequently in the vaccine plus immunoglobulin group. After the second vaccination the rate of adverse events was 7% in both groups. Seroconversion was achieved in all subjects on day 56 except one subject in the vaccine plus immunoglobulin group. Simultaneous application of TBE vaccine plus TBE immunoglobulin can be recommended for persons who need immediate protection plus active TBE vaccination.

Critical care nurses' perceptions of their educational needs.

A survey of nurses working in critical care units in 89 Queensland hospitals was conducted to investigate their perceptions of critical care nurses' educational needs. Two thirds of the 62 respondents were from rural units and one third were from metropolitan units. Most respondents, irrespective of geographic location, wanted critical care education to be located in hospitals and to be accredited as a graduate diploma course. Rural and metropolitan nurses had similar educational needs and many worked for hospitals that were not offering adequate orientation or inservice critical care education. The findings that nursing staff turnover was a problem in metropolitan units and that the rural workforce was more stable have implications for the development of educational programs.

Inhibition of histamine release from rat peritoneal mast cells by a factor from human serum--identification as transferrin.

Recently, we described the presence of a blocking factor (BF) in rat serum which inhibited the histamine release from rat mast cells in vivo and in vitro. The blocking activity was demonstrated in human serum as well. Purification of the human-BF was carried out in a similar way as previously described for the rodent molecule. Both protein fractions produced a marked suppression of histamine release from rat mast cells and human basophils in a dose-dependent fashion. Qualitative analysis of the purified preparations demonstrated a major component with a molecular weight of 70,000 daltons. In human serum the blocking factor was identified as transferrin by serological and biochemical methods. It is suggested that this molecule may play an important role in regulating histamine release during allergic and inflammatory reactions.

Purification of serum proteins with inhibitory activity on the histamine release in vitro and/or in vivo.

Recently, we described a factor in rat and human serum with inhibitory activity on the 2-hour passive cutaneous anaphylactic (PCA) reaction in rat skin. The Ca-ionophore-induced histamine release from rat peritoneal mast cells was inhibited as well. In human serum, inhibitory activity for the in vitro histamine release from rat mast cells was shown to be present within two serum fractions. One molecule was purified by 50-70% ammonium sulfate precipitation and subsequent DEAE chromatography at pH 5.4. The main component showed complete identity with transferrin. Commercially available transferrin was active in vitro as well. The dose-response plot revealed two inhibition maxima at transferrin concentrations of 0.05-5 ng/ml and at more than 1 mg/ml, respectively. Subsequently it was shown that the degree of iron saturation was critical for the decrease in histamine release. The mediator release in vivo (PCA) could not be inhibited by the iron transport protein. Inhibitory activity in vivo was however mediated by the second serum fraction, which was characterized by a molecular weight of approximately 150,000 daltons and an IEP within the alkaline range. These data suggest that exogenous factors may be potent modulators of inflammatory reactions.

Inhibition of histamine release in vitro by a blocking factor from human serum: comparison with the iron binding proteins transferrin and lactoferrin.

Recently, we described the presence of a blocking factor (BF) in rat serum, which inhibited the histamine release from rat mast cells in vivo and in vitro. The blocking activity was demonstrated in human serum as well. Qualitative analysis of the purified preparations demonstrated a major component with an apparent molecular weight of 70,000 daltons. In human serum the blocking factor was identified as transferrin (TF) by serological and biochemical methods. BF (DEAE-peak 1) and the iron binding proteins transferrin and lactoferrin (LF) are shown to inhibit the histamine release in vitro. The dose response curves reveal that inhibition by these proteins is dependent on their degree of iron saturation. Furthermore, unlike lactoferrin, the effects of transferrin and BF (DEAE-peak 1) follow the same pattern. Their mechanism of action remains to be elucidated.