Impact of pharmacist-involved collaborative care on the clinical, humanistic and cost outcomes of high-risk patients with type 2 diabetes (IMPACT): a randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: With the increasing prevalence of diabetes, the physician-centred model is challenged to deliver holistic care in Asia. Diabetes may be managed effectively within a multidisciplinary collaborative care model; however, evidence on its effectiveness in Asian patients is lacking. Therefore, the primary objective was to evaluate the clinical outcomes of multidisciplinary collaborative care vs physician-centred care in diabetes. The secondary objectives were to evaluate humanistic and economic outcomes among the two types of care. METHODS: This 6-month prospective, open-label, parallel-arm, randomized, controlled study was conducted at four outpatient healthcare institutions. High-risk patients aged ≥21 years with uncontrolled type 2 diabetes, polypharmacy and comorbidities were included. Patients with type 1 diabetes or those who were unable to communicate independently were excluded. The control arm received usual care with referrals to nurses and dietitians as needed. The intervention arm (multidisciplinary collaborative care) was followed up with pharmacists regularly, in addition to receiving the usual care. The primary outcomes included HbA1c, systolic blood pressure, low-density lipoprotein and triglycerides. The secondary outcomes included scores from the Problem Areas in Diabetes (PAID) and the Diabetes Treatment Satisfaction Questionnaires (DTSQ), and diabetes-related health service utilization rates and costs. RESULTS AND DISCUSSION: Of 411 eligible patients, 214 and 197 patients were randomized into the intervention and control arms, respectively. At 6 months, 141 patients in the intervention arm (65.9%) and 189 patients in the control arm (95.9%) completed the study. Mean HbA1c reduced from 8.6%±1.5% at baseline to 8.1%±1.3% at 6 months in the intervention arm (P=.04), with up to mean HbA1c improvement of 0.8% in patients with greater levels of uncontrolled glycemia. Whereas the mean HbA1c in the control arm remained unchanged (8.5%±1.4%) throughout the 6-month period. Improvements in PAID and DTSQ scores, reduction in physician workload and an average cost savings of US$91.01 per patient were observed in the intervention arm over 6 months. WHAT IS NEW AND CONCLUSIONS: The positive clinical, humanistic and economic outcomes highlighted the value of multidisciplinary collaborative care for Asian diabetic patients, thereby supporting the effectiveness of this approach in managing chronic diseases.

Use of complementary medicine amongst asthmatic patients in primary care.

Complementary Medicine (CM) usage amongst asthmatic patients was studied. Eighty-eight patients, selected by systematic random sampling in two public polyclinics in April/May 2004, were interviewed. They completed a structured pre-tested questionnaire. Forty-one percent were using CM, majority (64%) together with conventional therapy. Eighty-one percent did not inform their physicians of their CM usage. More Malays were using CM which included nutritional supplements, herbs, yoga, homoeopathy, reflexology and massage.

Use of complementary medicine amongst hypertensive patients in a public primary care clinic in Ipoh.

The use and reasons for use of Complementary Medicine (CM) amongst hypertensive patients attending the Hypertension/ Diabetes/ Asthma Clinic in Greentown Health Clinic, Ipoh was assessed. One hundred and twenty patients were selected by systematic random sampling (1:5) over a 2-week period commencing 26/04/04. Data was obtained from interviews, questionnaires and medical records. Twenty seven percent were on CM. Most commonly used CM was herbal medicine. Majority of those using CM for BP control were Malays. The Chinese and Indians were using CM mainly for other health problems. Ninety six percent were using both CM and conventional therapy concurrently. Therefore doctors should enquire about CM usage during patient assessment to prevent possible drug interactions.

Knowledge and practice of complementary medicine amongst public primary care clinic doctors in Kinta district, Perak.

The knowledge and practice of doctors (n=40) towards complementary medicine (CM) in 16 health clinics in the Kinta District were assessed by questionnaire. Thirty-four (85%) responded. More than half felt that acupuncture (73.50), homeopathy (59%) and herbal medicine (59%) were occasionally harmful. Forty-four percent felt manipulative therapy was frequently harmful. Relaxation technique (79%) and nutritional therapy (44%) were considered most frequently useful. 59% used some form of CM. There were no significant differences found in usage rates by gender, age group and exposure to CM during undergraduate training. Sixty-seven percent had encouraged patients to seek CM. Seventy-three percent perceived an increasing demand for CM. Eighty-eight percent were in favour of a hospital based CM referral center. Only 6% were trained in CM.

Rare pulmonary complications after transarterial chemoembolisation for hepatocellular carcinoma: two case reports.

We report two rare cases of acute pulmonary complication after transarterial chemoembolisation for inoperable hepatocellular carcinoma. Both cases involved a large tumour and hepatic vein invasion. The first patient, a 27-year-old man, died of pulmonary tumour embolism 4 days after transarterial chemoembolisation. Acute dyspnoea developed in the second patient, a 63-year-old man, following the procedure due to pulmonary oil embolisation and chemical pneumonitis. The chest condition of this patient improved, but he subsequently died of liver failure 3 weeks later. Our cases illustrate the point that if locoregional treatment is offered as a palliative treatment, patients with hepatic vein invasion should be warned of the possible complications of massive tumour embolism, pulmonary oil embolisation, and subsequent death.

Use of complementary medicine amongst diabetic patients in a public primary care clinic in Ipoh.

The use of Complementary Medicine (CM) amongst diabetic patients attending the Diabetes/Hypertension, Clinic. Out Patient Department, Ipoh Hospital was studied: Forty-three patients were selected by systematic random sampling (1:5) over a one-week period starting 5/12/01. Data were collected by patient interview, from medical records and through a questionnaire. 56% were using CM together with conventional therapy. Most commonly used were herbal therapy, homeopathy and reflexology. The majority took CM daily with a mean duration of 7 years. Over half had subjective relief of pain with increased energy. Patients on CM or conventional therapy both showed poorly controlled FBS levels. There is a need to assess the effect of these therapies on diabetic outcome.

Three new flavonoids and antiallergic, anti-inflammatory constituents from the heartwood of Dalbergia odorifera.

Three new flavonoids, (3R)-4'-methoxy-2',3,7-trihydroxyisoflavanone (11), 7-methoxy-3,3',4',6-tetrahydroxyflavone (18), and 2',7-dihydroxy-4',5'-dimethoxyisoflavone (22), were isolated from the heartwood of Dalbergia odorifera T. Chen. (Leguminosae), together with twenty-two known compounds, (S)-4-methoxydalbergione (1), cearoin (2), medicarpin (3), formononetin (4), sativanone (5), 3-hydroxy-9-methoxy-coumestan (6), meliotocarpan A (7), isoliquiritigenin (8), stevein (9), liquiritigenin (10), 3',4',7-trihydroxyflavanone (12), butein (13), 3'-hydroxymelanettin (14), koparin (15), bowdichione (16), fisetin (17), melanettin (19), sulfuretin (20), 3'-hydroxydaidzein (21), 3'-O-methylviolanone (23), xenognosin B (24), and dalbergin (25). These flavonoids were evaluated in antiallergic and anti-inflammatory tests. The results showed that (S)-4-methoxydalbergione (1) and cearoin (2) exhibited antiallergic activity while (S)-4-methoxydalbergione (1), cearoin (2), butein (13), koparin (15), bowdichione (16), 3'-O-methylviolanone (23), and xenognosin B (24) showed significant anti-inflammatory activity.

Comparison of barley and sorghum grain processed at different densities for lactating dairy cows.

To vary ruminally degradable starch, sorghum grain was dry-rolled or steam-flaked to different densities and compared with dry-rolled barley in total mixed diets fed to 40 lactating cows (111 d of lactation) assigned to five dietary treatments. Diets contained (percentage of dry matter) 35% alfalfa hay, 4.1% cottonseed hulls, 10% whole cottonseed, 2% fish meal, 4% soybean meal, and 4.9% of a molasses, mineral, and vitamin supplement. Treatments were 40% sorghum grain either dry-rolled or steam-processed at flake densities of 437, 360, and 283 g/L. A fifth diet containing 42% dry-rolled barley was fed. Cows were blocked according to pretreatment (14 d) milk yield and received experimental diets for 56 d. Increasing ruminal starch degradability by including steam-flaked sorghum grain or barley in the diet did not increase milk yield or milk protein percentage and yield, as was shown in eight previous studies. Steam-flaked sorghum or dry-rolled barley in the diet decreased dry matter intake, resulting in a 10 to 19% higher efficiency of conversion of feed dry matter to milk than that for dry-rolled sorghum. Milk urea N was decreased, and milk casein yield tended to be increased, by steam-flaking sorghum at the moderate density compared with dry-rolling or fine flaking. Dietary protein was more efficiently converted to milk protein and casein from flaked sorghum and dry-rolled barley than from dry-rolled sorghum. In this study, increasing ruminal starch degradability resulted in higher feed efficiency and lower feed intakes, bu optimal flake densities for steam-processed sorghum gain to maximize milk and milk protein yield were not clarified.

A blinded clinical trial comparing conventional cleansing enema, Pico-salax and Golytely for barium enema bowel preparation.

UNLABELLED: An evaluator-blinded randomized clinical trial was undertaken to assess the effectiveness and patient acceptance of three bowel cleansing regimens: conventional cleansing enema, Pico-salax and Golytely. PATIENTS AND METHODS: One hundred and fifty patients, referred for barium enema examination, were allocated to one of the three regimens. Both the radiographers and the radiologists did not know the method of preparation. Radiographers were requested to enter the patients' data, the number of bowel openings, the patients' comments of the preparation and side effects. Films were reviewed independently by two experienced radiologists for the degree of bowel cleanliness and quality of barium coating. RESULTS: The mean (standard deviation) of bowel opening frequency for the cleansing enema, Pico-Salax and Golytely were 3.6(4.4), 8.3(4.8) and 7.1(4.2), respectively, with less bowel opening in the cleansing enema. There was less nausea associated with the cleansing enema (P = 0.006), more vomiting with Golytely (P = 0.008), less abdominal fullness with Pico-salax (P = 0.0006), less anorectal irritation with Golytely (P = 0.025), and no difference in the abdominal pain amongst three groups. There was no statistically significant difference in the number of bowel openings between the groups. Patients found that Pico-salax tasted better than Golytely (P = 0.0094) and Golytely was less accepted in the amount of fluid intake (P = 0.0018 and P < 0.0002 comparing Golytely with the cleansing enema and Pico-salax). Chi-squared testing showed no statistically significant difference in bowel cleanliness and quality of barium coating among the three preparations. CONCLUSIONS: There was no difference in the effectiveness of the three regimens. Pico-salax seems the most acceptable because it has the fewest side effects.

Use of tilmicosin for treatment of pasteurellosis in rabbits.

OBJECTIVES: To determine tilmicosin concentrations in serum and tissues of rabbits given a single dose of 25 mg of tilmicosin/kg of body weight. To examine the effects of tilmicosin treatment (25 mg/kg, s.c.) in rabbits with pasteurellosis. PROCEDURE: After receipt of tilmicosin, healthy New Zealand White female rabbits (n = 3 at each time) were euthanatized at 2, 4, 8, 24, 48, and 72 hours for collection of blood samples and tissue specimens; 4 rabbits served as untreated controls. Rabbits (male and female) with pasteurellosis (n = 42) also were treated. Tilmicosin concentration was determined in serum, lung, and uterine tissues. Rabbits with pasteurellosis were treated with tilmicosin. Response was monitored, using bacteriologic culturing and antibiotic resistance and susceptibility testing, and by scoring clinical signs of disease. RESULTS: Serum tilmicosin concentration reached 1.91 +/- 0.18 micrograms/ml after 2 hours, decreased to 0.77 +/- 0.07 microgram/ml by 8 hours, and was below minimum inhibitory concentrations for Pasteurella multocida at 24 hours. Terminal half-life in serum was 5.97 hours. Lung and uterus concentrations were 14.43 +/- 1.34 and 11.57 +/- 0.09 ppm at 2 hours, and were 5.10 +/- 1.05 and 8.87 +/- 1.66 ppm at 24 hours, respectively. 69% (29/42) of rabbits with pasteurellosis responded favorably in 3 days. Second treatment was required in 31% (13/42), and 5 of these rabbits had clinical signs on day 6; 2 of these 5 had improved. Treatment success rate was 93% (39/42). Of the rabbits that were culture positive on day 0, 35% (6/ 17) remained positive on day 3. 1 of 6 rabbits was culture positive on day 6. CONCLUSION: Tilmicosin (25 mg/kg, s.c.) was an effective treatment for pasteurellosis in New Zealand White rabbits. CLINICAL RELEVANCE: Tilmicosin treatment of pasteurellosis in rabbits is useful in research rabbits and in those destined for meat production. A single dose of antibiotic minimizes stress-associated handling.

Isolation of anti-leukemia compounds from Citrus reticulata.

In vitro effects of medicinal plant extracts from the pericarpium of Citrus reticulata (cv Jiao Gan) (PCRJ) on the growth and differentiation of a recently characterized murine myeloid leukemic cell clone WEHI 3B (JCS) were investigated. Extracts of PCRJ not only inhibited the proliferation of JCS cells in a dose dependent manner, but also induced differentiation of JCS cells into macrophages and granulocytes. Morphological differentiation of PCRJ treated JCS cells was associated with an increase in phagocytic activity of the cells. Furthermore, both in vitro clonogenicity and in vivo growth of PCRJ treated JCS leukemic cells in syngeneic BALB/c mice were significantly reduced. The survival rate of mice receiving PCRJ treated JCS tumour cells was also increased. Using 1H-NMR, 13C-NMR, and GC/MS, two active components isolated from PCRJ were identified as nobiletin and tangeretin.

Influence of steam-flaked sorghum grain and supplemental fat on performance of dairy cows in early lactation.

Effects of sorghum grain processing and fat supplementation on milk yield and composition and nutrient digestibilities were studied. Thirty-six Holstein cows were assigned at 5 d of lactation for 91 d to treatment: 1) dry-rolled sorghum, no added fat; 2) dry-rolled sorghum plus Ca salts of long-chain fatty acids; 3) steam-flaked sorghum, no added fat; and 4) steam-flaked sorghum plus Ca salts of long-chain fatty acids. Fat increased ether extract in diets from 5.7 to 7.5% of DM. Milk yield was 4.0 kg/d (12%) higher for cows fed steam-flaked than dry-rolled sorghum. Fat tended to decrease milk yield because of lower DMI, and feed efficiencies increased 15%. Milk protein decreased .14% on dry-rolled sorghum with added fat, but only .01% on the steam-flaked diet. Milk protein yield was higher for cows fed flaked than rolled sorghum. Flaking decreased milk fat percentage, but not yield. Added fat decreased shorter chain fatty acids in milk (C4 to C14), but oleic acid increased. Flaking increased C10, C12, and C14, but decreased oleic acid. Digestibilities for DM, CP, starch, and ether extract were higher for flaked and fat-supplemented diets. Flanking of sorghum prevented the milk protein decrease reported for early lactation cows fed added fat.

Effect of source and amount of supplemental fat on lactation and digestion in cows.

Thirty Holstein cows averaging 50 DIM were assigned to five dietary treatments for 75 d to determine the effects of source and amount of supplemental fat on milk yield, milk composition, and nutrient digestibilities. Diets were 1) control, 2) diet 1 plus 12% whole cotton-seed, 3) diet 2 plus 2.2% safflower oil, 4) diet 2 plus 2.2% prilled tallow fatty acids, and 5) diet 2 plus 4.4% prilled tallow fatty acids. Milk yield was increased an average of 2.1 kg/d by addition of 2.2% prilled tallow fatty acids or safflower oil to the diet (7% fatty acids) containing 12% whole cottonseed. However, when fatty acids were increased to 9.1% with additional prilled tallow fatty acids, milk yield, DMI, and fatty acid digestibility decreased. Whole cottonseed alone and in combination with all fat additions decreased milk protein concentrations. Safflower oil increased C18:0, C18:1, and C18:2 fatty acids in milk. Digestibilities of OM, NDF, and ADF were not affected by diet. Supplementation of a saturated or unsaturated fat source to increase fatty acid content to 7.0% of dietary DM increased milk yield, but a further increase in fat to 9.1% with the saturated source appeared excessive for cows yielding 30 to 35 kg/d of milk.

Effect of three supplemental fat sources on lactation and digestion in dairy cows.

Tallow, Ca salts of palm fatty acids, or prilled fatty acids were added at 2.5% to a control diet (3.7% fatty acids) containing 7.2% ammoniated whole cottonseed. Diets were fed to midlactation cows (6 cows per treatment) for 72 d to determine effects of fat supplementation and fat source on lactation performance and nutrient digestibilities. Dry matter intake did not differ among treatments. Milk yield was 31.6 kg/d for the control and increased an average of 2.1 kg/d with fat supplementation. Source of supplemental fat did not significantly affect lactation performance. Added fat decreased milk protein content but did not affect protein yield. Milk fat, lactose, and SNF contents did not differ among treatments. Overall fat supplementation did not affect digestibilities of DM, ADF, or NDF but decreased digestibility of fatty acids. Contribution of de novo fatty acids to milk fat was decreased with fat supplementation. Addition of 2.5% fat to a diet containing a medium amount of fat from whole cottonseed increased milk yield. Tallow, Ca salt of palm fatty acids, and prilled fatty acids did not differ in milk yield response.

Determination of calcium, copper, magnesium, and zinc content of identical areas in human cerebral hemispheres of normals.

The distribution of calcium, copper, magnesium and zinc in five anatomical regions of both hemispheres of the human brain were investigated. No asymmetry was observed with the exception of the distribution of copper in the white matter. The concentrations of these elements in the substantia nigra from both sides of the midbrain were also measured.