Interventions in primary care to improve cardiovascular risk factors and glycated haemoglobin (HbA1c) levels in patients with diabetes: a systematic review.

Most patients with diabetes are treated in primary care (PC). We performed a systematic review to assess the effect of single and combined interventions on cardiovascular risk factors (CVRFs) and glycated haemoglobin (HbA1c) levels in patients with diabetes in PC settings. We searched the MEDLINE database from January 1990 to October 2008. According to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria, (cluster-)randomized control studies and controlled before-and-after studies were selected and reviewed. Identified interventions were classified according to a modified EPOC intervention taxonomy. We included 68 studies. Forty-five studies evaluated the effect of any intervention on HbA1c. Seventeen studies presented a significant improvement in HbA1c. Nine out of 27 studies evaluating CVRFs [cholesterol, blood pressure (BP)] and HbA1c showed a significant improvement in at least two of these factors. Audit and feedback on performance, clinical decision support systems, multi-professional teams and patient education seemed to be successful strategies. The increasing evidence regarding the treatment of persons with chronic illnesses, summarized in the Chronic Care Model (CCM), is not reflected in most recent studies about diabetes treatment in PC. Most interventions still seem only partly adapted to the CCM. The methodological quality of many studies is still poor and often the pivotal outcomes, CVRFs and HbA1c, are not appropriately addressed. As a consequence, the potential of PC in the care of patients with diabetes may still be underestimated.

Nanowire array composites.

Long, nanometer-size metallic wires can be synthesized by injection of the conducting melt into nanochannel insulating plates. Large-area arrays of parallel wires 200 nanometers in diameter and 50 micrometers long with a packing density of 5 x 10(8) per square centimeter have been fabricated in this way. When charged, the ends of the wires generate strong, short-range electric fields. The nanowire electric fields have been imaged at high spatial resolution with a scanning force microscope.

Suicide assisted by two Swiss right-to-die organisations.

BACKGROUND: In Switzerland, non-medical right-to-die organisations such as Exit Deutsche Schweiz and Dignitas offer suicide assistance to members suffering from incurable diseases. OBJECTIVES: First, to determine whether differences exist between the members who received assistance in suicide from Exit Deutsche Schweiz and Dignitas. Second, to investigate whether the practices of Exit Deutsche Schweiz have changed since the 1990s. METHODS: This study analysed all cases of assisted suicide facilitated by Exit Deutsche Schweiz (E) and Dignitas (D) between 2001 and 2004 and investigated by the University of Zurich's Institute of Legal Medicine (E: n = 147; D: n = 274, total: 421). Furthermore, data from the Exit Deutsche Schweiz study which investigated all cases of assisted suicide during the period 1990-2000 (n = 149) were compared with the data of the present study. RESULTS: More women than men were assisted in both organisations (D: 64%; E: 65%). Dignitas provided more assistance to non-residents (D: 91%; E: 3%; p = 0.000), younger persons (mean age in years (SD): D: 64.5 (14.1); E: 76.6 (13.3); p = 0.001), and people suffering from fatal diseases such as multiple sclerosis and amyotrophic lateral sclerosis (D: 79%; E: 67%; p = 0.013). Lethal medications were more often taken orally in cases assisted by Dignitas (D: 91%; E: 76%; p = 0.000). The number of women and the proportion of older people suffering from non-fatal diseases among suicides assisted by Exit Deutsche Schweiz has increased since the 1990s (women: 52% to 65%, p = 0.031; mean age in years (SD): 69.3 (17.0) to 76.9 (13.3), p = 0.000), non-fatal diseases: 22% to 34%, p = 0.026). CONCLUSIONS: Weariness of life rather than a fatal or hopeless medical condition may be a more common reason for older members of Exit Deutsche Schweiz to commit suicide. The strong over-representation of women in both Exit Deutsche Schweiz and Dignitas suicides is an important phenomenon so far largely overlooked and in need of further study.

Asymptomatic Clostridium difficile colonization in two Australian tertiary hospitals, 2012-2014: prospective, repeated cross-sectional study.

OBJECTIVES: To investigate the prevalence and risk factors for asymptomatic toxigenic (TCD) and nontoxigenic Clostridium difficile (NTCD) colonization in a broad cross section of the general hospital population over a 3-year period. METHODS: Patients without diarrhoea admitted to two Australian tertiary hospitals were randomly selected through six repeated cross-sectional surveys conducted between 2012 and 2014. Stool specimens were cultured under anaerobic conditions, and C. difficile isolates were tested for the presence of toxin genes and ribotyped. Patients were then grouped into noncolonized, TCD colonized or NTCD colonized for identifying risk factors using multinomial logistic regression models. RESULTS: A total of 1380 asymptomatic patients were enrolled; 76 patients (5.5%) were TCD colonized and 28 (2.0%) were NTCD colonized. There was a decreasing annual trend in TCD colonization, and asymptomatic colonization was more prevalent during the summer than winter months. TCD colonization was associated with gastro-oesophageal reflux disease (relative risk ratio (RRR) = 2.20; 95% confidence interval (CI) 1.17-4.14), higher number of admissions in the previous year (RRR = 1.24; 95% CI 1.10-1.39) and antimicrobial exposure during the current admission (RRR = 2.78; 95% CI 1.23-6.28). NTCD colonization was associated with chronic obstructive pulmonary disease (RRR = 3.88; 95% CI 1.66-9.07) and chronic kidney failure (RRR = 5.78; 95% CI 2.29-14.59). Forty-eight different ribotypes were identified, with 014/020 (n = 23), 018 (n = 10) and 056 (n = 6) being the most commonly isolated. CONCLUSIONS: Risk factors differ between patients with asymptomatic colonization by toxigenic and nontoxigenic strains. Given that morbidity is largely driven by toxigenic strains, this novel finding has important implications for disease control and prevention.

[25-year old patient with angina pectoris during religious fasting]. / 25-jähriger Patient mit pektanginösen Beschwerden während des muslimischen Fastenmonats.

UNLABELLED: HISTORY AND PRESENTATION AT ADMISSION: A 25-year-old male patient presented with acute left sided chest pain. The patient reported no physical exercise but daytime fasting (with neither food nor liquid intake) which he had started several days before. INVESTIGATIONS: ECG, echocardiography and chest X-ray were normal, but blood examination revealed elevated levels for creatine kinase (CK) and lactate dehydrogenase (LDH). Ischemic lactate ammonia test revealed no increase of lactate during exercise. Muscle biopsy confirmed suspected diagnosis of glycogen storage disease type V (McArdle's disease). TREATMENT AND COURSE: As causal treatments are unavailable for McArdle's disease, careful counselling regarding adequate exercise and regular, carbohydrate rich nutrition are mandatory to ameliorate symptoms. CONCLUSION: McArdle's disease represents a rare differential diagnosis of cardiac chest pain and somatoform myalgic complaints. When taking the patient's history, questions regarding the "Second wind"-phenomenon are helpful for initiating the adequate investigations early on.

Effect of in vivo administration of recombinant acidic fibroblast growth factor on thyroid function in the rat: induction of colloid goiter.

We have recently demonstrated that the iv administration of 0.6-60 micrograms/kg.day of acidic fibroblast growth factor (acidic FGF) increases thyroid weight in male and female rats. Interestingly, measurement of serum TSH and thyroid hormones in rats treated with 6 micrograms/kg.day acidic FGF for 30 days revealed only a slight increase in serum T4 and reverse T3 concentrations. Since thyroid function was only examined 24 h after the 30th daily treatment, we performed a series of experiments to evaluate the effects of acidic FGF on thyroid function following single and 6 multiple injections of acidic FGF. There was a small increase in the serum TSH concentrations at 2, 4, 8, and 24 h after a single high dose iv injection of acidic FGF (60 micrograms/kg). In contrast, serum T3 concentrations were slightly decreased at 2, 4, and 8 h after acidic FGF administration. There was no effect of a single injection of acidic FGF on serum T4, reverse T3, or thyroglobulin concentrations. After 6 days of treatment, there was a 34% increase in the thyroid weights of rats treated with acidic FGF. Analysis of serum hormones revealed a slight increase in serum TSH, T3, and T4 concentrations in acidic FGF-treated rats, but no change in serum reverse T3 or thyroglobulin concentrations. There was no effect of acidic FGF administration on thyroid radioiodine uptake, the intrathyroidal metabolism of radioiodine, or the relative amounts of thyroidal thyroglobulin or peroxidase messenger RNAs, or on liver 5'-deiodinase activity. In hypophysectomized rats, with no detectable levels of serum TSH, acidic FGF failed to increase thyroid weight. These data suggest that FGFs may participate with TSH in the regulation of thyroid weight and colloid accumulation, and that autocrine or paracrine growth factors may be involved in the pathogenesis of colloid goiter.

[Osteoarthritis - which approach is evidence based?]. / Degenerative Gelenkerkrankungen - welche Therapie ist evidenzbasiert?

Paracetamol is the first choice mediation for osteoarthritis. The analgetic potential of NSAIDs is slightly higher and they also have some antiphlogistic effect, but their use has to be strictly limited to a short period of time. They should mainly be used in the therapy of the acute and painful phase of osteoarthritis. Among the NSAIDs, Diclofenac is the medication of first choice. In patients with an increased risk of gastrointestinal complications, a protonpumpinhibitor should be added. Patients with cardiovascular risk factors should receive NSAIDs only in case of no appropriate alternative treatments. Opioids have their place in osteoarthritis treatment and should be part of an individualized pain regime, which should also contain a pain diary and proactive monitoring. It is important to emphasize the positive effects of physical activity on the function of the joints as well as the negative effect of overweight and immobility.

[Medical check-ups on the <>. Benefit for population at risk or self-selection of healthy and health-conscious patients?]. / Medizinische Check-ups auf dem Gesundheitsschiff. Nutzen für Risikogruppen oder Selbstelektion gesunder und gesundheitsbewusster Patienten?

The aim of the present study was to assess health related characteristics and reasons for participation on the <>, second, to compare these variables with a representative Swiss Health Survey (SHS). Characteristics of the participants were collected cross-sectionally and afterwards compared with results of the SHS. Response rate was 74.6% (n = 206). Compared to the SHS population smoking rate and alcohol consumption were significantly lower and a doctor's visit within the last 12 months more frequent. Considerable differences in health related characteristics exist between our study and the SHS suggesting a self-selection of healthy people. Thus a potential health gain by this kind of medical prevention program is at least questionable.

[Income reduction due to sickness benefits--when does sickness make you poor?]. / Einkommensverluste durch den Empfang von Krankengeld -- Wann macht Krankheit arm?

PURPOSE: When absent from work due to sickness, most employees in Germany receive continued pay from their employer for six weeks. After this period, sick employees receive sickness benefits from their Statutory Sickness Fund. These sickness benefits are calculated in a rather complicated way as a percentage of gross and net salary. The paper focuses on two questions that have rarely been studied: which income groups show a particularly large difference between net salary and net sickness benefits? Which income groups move below the poverty line after receiving sickness benefits? METHODS: We calculated how much sickness benefit is actually paid to the insured, for different income and tax groups. The definition for the poverty line is outlined as well. Due to methodological difficulties, the comparison between sickness benefits and poverty must be confined to single-person households. RESULTS: In the income groups chosen here (gross salary up to 4000 Euro per month), net sickness benefits amount to about 77 % of net salary, for all insured. Financial problems can mainly be expected for the lower and the upper income groups. Expressed in absolute terms, the upper income groups experience a large reduction in net income. The lower income groups come close to the poverty line or fall below it. CONCLUSIONS: Sickness benefits provide income in case of sickness; this is an important achievement of social policy. However, we should study the financial burden which sickness benefits could have for the insured. More in-depth analyses would require data that are not yet available (e. g. on the number of insured per income group and the income of other household members). The analyses presented here already show that sickness benefits could lead to severe financial problems for at least some insured. They point to the need for more studies in this neglected field.

Acidic fibroblast growth factor modulates gene expression in the rat thyroid in vivo.

We have recently demonstrated that the iv administration of acidic fibroblast growth factor (a-FGF) to rats for 6 days results in a marked increase in thyroid weight with colloid accumulation and flat, quiescent follicular cells. Whereas a-FGF administration consistently increases thyroid weight, there are only minor alterations in serum TSH and thyroid hormones, and no change in intrathyroidal metabolism of 125I metabolism. In the present work, we studied the effects of 1 or 6 daily injections of a-FGF (60 micrograms/kg BW) or vehicle on the mRNA levels for histone, c-fos, actin, type I 5' deiodinase (5'D-I), thyroid peroxidase, and thyroglobulin and cathepsin D in the thyroid, liver and bone. Rats were sacrificed 0.5, 2, 4, 8 and 24 h after the 1st or the 6th a-FGF injection and thyroid, liver, and calvarium were removed. The relative amounts of mRNAs were determined by slot blot analysis. There was a 43% increase in thyroid weight in rats treated with a-FGF for 6 days compared to vehicle-treated rats. We observed an increase in c-fos mRNA content in the thyroid gland 0.5 to 4 h after 1 or 6 injections of a-FGF. In contrast, treatment with a-FGF for 1 or 6 days did not affect histone mRNA content, a marker of proliferative activity or actin mRNA levels. Treatment with a-FGF caused a marked decrease in thyroid 5' D-I mRNA content in the thyroid. The decrease was present 2 h after the first injection and reached a nadir 8 h later.(ABSTRACT TRUNCATED AT 250 WORDS)