The impact of obstructive sleep apnea treatment on microvascular complications in patients with type 2 diabetes: a feasibility randomized controlled trial.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is associated with an increased risk of diabetes-related complications. Hence, it is plausible that Continuous Positive Airway Pressure (CPAP) could have a favorable impact on these complications. To assess the feasibility of conducting a randomized control trial (RCT) in patients with type 2 diabetes (T2D) and OSA over 2 years. METHODS: An open-label multicenter feasibility RCT of CPAP vs no CPAP in patients with T2D and OSA. Patients with resting oxygen saturation <90%, central apnea index >15/hour or Epworth Sleepiness Scale (ESS) ≥11 were excluded. OSA was diagnosed using a multichannel portable device (ApneaLink Air, ResMed). The primary outcome measures were related to feasibility, and the secondary outcomes were changes in various clinical and biochemical parameters related to diabetes outcomes. RESULTS: Eighty-three (40 CPAP vs 43 no CPAP) patients were randomized, with a median (IQR) follow-up of 645 [545, 861] days. CPAP compliance was inadequate, with a median usage of approximately 3.5 hours/night. Early CPAP use predicted longer-term compliance. The adjusted analysis showed a possible favorable association between being randomized to CPAP and several diabetes-related endpoints (chronic kidney disease (CKD), neuropathy, and quality of life (QoL)). CONCLUSIONS: It was feasible to recruit, randomize, and achieve a high follow-up rate over 2 years in patients with OSA and T2D. CPAP compliance might improve by a run-in period before randomization. A full RCT is necessary to assess the observed favorable association between CPAP and CKD, neuropathy, and QoL in patients with T2D. CLINICAL TRIAL REGISTRATION: Registry: ISRCTN; URL: https://www.isrctn.com/ISRCTN12361838; Title: The impact of sleep disorders in patients with type 2 diabetes; Identifier: ISRCTN12361838.

Reboot coaching programme: a mixed-methods evaluation assessing resilience, confidence, burnout and depression in medical students.

BACKGROUND: Poor mental health in medical students is a global concern. Effective interventions are required, which are tailored towards the training-related stressors medical students experience. The Reboot coaching programme is an online, tailored intervention based on cognitive-behavioural principles. AIMS: To evaluate whether the Reboot coaching programme tailored for medical students was feasible and associated with improvements in mental health outcome indicators. METHODS: Medical students participated in two group online workshops and a one-to-one coaching call with a Reboot-trained licensed psychological therapist. Participants provided data at: baseline (T1), post-workshops (T2), post-coaching call (T3) and 4-month follow-up (T4). Outcome measures included resilience, confidence, burnout and depression. Feedback was provided regarding the workshops at T2. RESULTS: 115 participants (93/80.9% women; mage = 23.9; SD = 2.8) were recruited, 83 (72.2%) completed all intervention elements and 82 (71.3%) provided T4 data, surpassing recruitment and retention targets. There were significant improvements following baseline in resilience (ps < .001), confidence (ps < .001), burnout (ps < .001) and depression (ps ≤ .001). Most participants agreed the workshops imparted useful skills (n = 92; 99%) and would recommend Reboot to others (n = 89; 95.6%). CONCLUSIONS: Existing interventions have produced mixed results regarding their effectiveness in improving medical students' mental health. Reboot is a feasible intervention in this group which is associated with improvements in resilience, confidence, burnout and depression. Further controlled studies of Reboot are now needed.

Glycaemic control in critical care: Can flash glucose monitoring help?

Good glycaemic control confers an outcome benefit in both diabetic and non-diabetic critically unwell patients. Critically unwell patients receiving intravenous insulin in the intensive care unit (ICU) require hourly glucose monitoring. This brief communication highlights the impact of the introduction of the FreeStyle Libre glucose monitor, a form of continuous glucose monitoring, on the frequency of glucose recordings in patients receiving intravenous insulin in the ICU at York Teaching Hospital NHS Foundation Trust.

Clinical accuracy of infrared temperature measurement devices: a comparison against non-invasive core-body temperature.

During the coronavirus 2019 (COVID-19) pandemic, the implementation of non-contact infrared thermometry (NCIT) became an increasingly popular method of screening body temperature. However, data on the accuracy of these devices and the standardisation of their use are limited. In the current study, the body temperature of non-febrile volunteers was measured using infrared (IR) thermography, IR tympanic thermometry and IR gun thermometry at different facial feature locations and distances and compared with SpotOn core-body temperature. Poor agreement was found between all IR devices and SpotOn measurements (intra-class correlation coefficient <0.8). Bland-Alman analysis showed the narrowest limits of agreement with the IR gun at 3 cm from the forehead (bias = 0.19°C, limits of agreement (LOA): -0.58°C to 0.97°C) and widest with the IR gun at the nose (bias = 1.40°C, LOA: -1.15°C to 3.94°C). Thus, our findings challenge the established use of IR thermometry devices within hospital settings without adequate standard operating procedures to reduce operator error.

Roux-en-Y gastric bypass could slow progression of retinopathy in type 2 diabetes: a pilot study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a well-recognised complication of obesity. One of the microvascular complications of T2DM is diabetic retinopathy (DR). Bariatric surgery has been shown to effectively treat obesity and can induce remission of T2DM. It is not known what effect this improvement may have on pre-existing DR. We aimed to investigate this. METHOD: A dual-centre, observer-blinded, case-control study investigated the progression of DR in patients who received Roux-en-Y gastric bypass (treatment group (TG)), compared with controls who received medical therapy (control group (CG)) for their T2DM. Retinal images were taken pre-operatively and approximately 2 years post-operatively for the TG and over a 2-year interval for the CG. Data were collected for confounding variables, including glycaemic control (HbA(1c)) and BMI. RESULTS: Forty-five patients were recruited (TG = 21, CG = 24). Groups were significantly heterogeneous. DR showed significant progression for those in the CG (p = 0.03) but not in TG (p = 0.135), no significant difference was found when adjusting for confounding variables (p = 0.480). There was a significant trend in favour of surgery in improvement of glycaemic control (p = 0.017). CONCLUSION: The trends within these pilot data may represent a real difference in the progression of DR in patients who have received surgery, compared with medical treatment alone. Due to heterogeneity of group characteristics, further work needs to be done to validate these results. Should there be a true difference, there will be potential cost savings for the National Health Service (NHS) along with a reduced burden of disease for patients.

Reversibility of fibrotic appearance of lungs with thyroxine replacement therapy in patients with severe hypothyroidism.

OBJECTIVE: To present 2 cases of hypothyroidism with hypoxia associated with computed tomographic (CT) features suggestive of pulmonary fibrosis that resolved with correction of the hypothyroidism. METHODS: Clinical case histories are described, comparative radiologic pulmonary images before and after treatment are provided, and the pertinent literature regarding possible pathologic mechanisms is reviewed. RESULTS: Our first patient, a 68-year-old woman, presented with symptomatic severe hypothyroidism associated with respiratory failure. A CT scan of her lungs showed appearances suggestive of pulmonary fibrosis. Replacement therapy with levothyroxine led to correction of hypoxia and radiologic abnormalities. Our second patient, a 26-year-old man, presented with symptoms suggestive of obstructive sleep apnea that persisted despite use of positive pressure ventilation. Biochemical evaluation revealed severe hypothyroidism, and a CT scan disclosed pulmonary appearances consistent with fibrosis. His symptoms and radiologic abnormalities also improved after correction of hypothyroidism with levothyroxine therapy. CONCLUSION: Radiologic pulmonary abnormalities suggestive of fibrotic disease are associated with severe hypothyroidism. Invasive investigations such as lung biopsy should be deferred until the clinical and radiologic responses to thyroxine replacement therapy have been assessed.

Myopathy following postoperative ablative radioiodine for follicular carcinoma of the thyroid.

We highlight a case of disabling myopathy following radioablative iodine treatment for follicular carcinoma of the thyroid. A 34-year-old man presented with a tender neck swelling, ultrasound and biopsy were suggestive of thyroid malignancy. Thyroidectomy was undertaken and histology confirmed follicular carcinoma of the thyroid. Treatment with ablative radioiodine followed and within days the patient developed disabling myopathy. Investigations to date do not reveal any other cause for the myopathy and there is no evidence to suggest that this is a paraneoplastic phenomenon. We believe this is the first reported case of ablative radioiodine-induced mypoathy.

Atrial fibrillation associated with a thyroid stimulating hormone-secreting adenoma of the pituitary gland leading to a presentation of acute cardiac decompensation: a case report.

INTRODUCTION: Hyperthyroidism is a well established cause of atrial fibrillation (AF). Thyroid Stimulating Hormone-secreting pituitary tumours are rare causes of pituitary hyperthyroidism. Whilst pituitary causes of hyperthyroidism are much less common than primary thyroid pathology, establishing a clear aetiology is critical in minimising complications and providing appropriate treatment. Measuring Thyroid Stimulating Hormone (TSH) alone to screen for hyperthyroidism may be insufficient to appropriately evaluate the thyroid status in such cases. CASE PRESENTATION: A 63-year-old Caucasian man, previously fit and well, presented with a five-day history of shortness of breath associated with wheeze and dry cough. He denied symptoms of hyperthyroidism and his family, social and past history were unremarkable. Initial investigation was in keeping with a diagnosis of atrial fibrillation (AF) with fast ventricular response leading to cardiac decompensation.TSH 6.2 (Normal Range = 0.40 - 4.00 mU/L), Free T3 of 12.5 (4.00 - 6.8 pmol/L) and Free T4 51(10-30 pmol/L). Heterophilic antibodies were ruled out. Testosterone was elevated at 43.10 (Normal range: 10.00 - 31.00 nmol/L) with an elevated FSH, 18.1 (1.0-7.0 U/L) and elevated LH, 12.4 (1.0-8.0 U/L). Growth Hormone, IGF-1 and prolactin were normal. MRI showed a 2.4 cm pituitary macroadenoma. Visual field tests showed a right inferotemporal defect.While awaiting neurosurgical removal of the tumour, the patient was commenced on antithyroid medication (carbimazole) and maintained on this until successful trans-sphenoidal excision of the macroadenoma had been performed. AF persisted post-operatively, but was electrically cardioverted subsequently and he remains in sinus rhythm at twelve months follow-up off all treatment. CONCLUSION: This case reiterates the need to evaluate thyroid function in all patients presenting with atrial fibrillation. TSH-secreting pituitary adenomas must be considered when evaluating the cause of hyperthyroidism. Early diagnosis and treatment of such adenomas is critical in reducing neurological and endocrine complications.

The effect of thyroid dysfunction on N-terminal pro-B-type natriuretic peptide concentrations.

BACKGROUND: B-type natriuretic peptides and N-terminal pro-B-type natriuretic peptides (NT-proBNP) have been suggested as being useful for the diagnosis of congestive heart failure. We have shown previously that changes in thyroid function are associated with changes in concentrations of other low molecular weight molecules. Therefore, the aim of this study was to assess whether similar changes occurred with NT-proBNP concentrations following treatment of thyroid dysfunction. METHODS: Seventeen patients (12 female, 5 male, age range 24-77 years) with newly diagnosed hypothyroidism and 21 patients (16 female, 5 male, age range 21-66 years) with newly diagnosed hyperthyroidism had NT-proBNP measured at baseline and when they subsequently became euthyroid. RESULTS: NT-proBNP levels were not significantly different in the hyperthyroid group from the hypothyroid, either before (P = 0.706) or after treatment to euthyroidism (P = 0.170). The hypothyroid group showed a rise in NT-proBNP after treatment (P < 0.001). There was a marginally significant fall in the NT-proBNP levels in the hyperthyroid group (P = 0.05). However, these changes were within the expected wide range of biological variability of NT-proBNP shown in earlier studies. CONCLUSIONS: Hypothyroidism alters NT-proBNP concentrations, but the magnitude of this effect may be lost in the wide biological variability of natriuretic peptides and this statistically significant finding is not likely to be of clinical relevance.

The LH/FSH ratio has little use in diagnosing polycystic ovarian syndrome.

BACKGROUND: The luteinizing hormone/follicle stimulating hormone (LH/FSH) ratio is often requested to help diagnose polycystic ovarian syndrome (PCOS) despite a recent consensus recommending against its use. This study aimed to compare the variability of the LH/FSH ratio in PCOS with that of normal menstruating women over a full cycle in order to establish the diagnostic utility, or otherwise, of the test. METHODS: Twelve women with PCOS and 11 matched controls had blood collected at four-day intervals on 10 consecutive occasions over a complete menstrual cycle. RESULTS: The median LH/FSH ratio for individual subjects did not differ significantly between the PCOS and the non-affected group (1.6 versus 1.2, P = 0.14). Only 7.6% of samples from PCOS patients had an LH/FSH ratio above three, compared with 15.6% of samples from normal subjects. CONCLUSION: This study confirms that measurement of the LH/FSH ratio is of limited use in the diagnosis of PCOS.

Biological variation of homeostasis model assessment-derived insulin resistance in type 2 diabetes.

OBJECTIVE: Individuals with type 2 diabetes are particularly vulnerable to cardiovascular disease. Insulin resistance is a major determinant of this increased risk and is a potential therapeutic target. This study was undertaken to establish the natural biological variation of insulin resistance in individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS: The biological variation of insulin resistance was assessed by measuring insulin resistance at 4-day intervals on 10 consecutive occasions in 12 postmenopausal women with diet-controlled type 2 diabetes and in 11 weight- and age-matched postmenopausal women without type 2 diabetes. Insulin resistance was derived using the homeostasis model assessment for insulin resistance (HOMA-IR) method. RESULTS: The distribution of HOMA-IR was log Gaussian in the type 2 diabetic study group and Gaussian in the control group. The HOMA-IR in the type 2 diabetic group was significantly greater than that of the control group (mean +/- SD: 4.33 +/- 2.3 vs. 2.11 +/- 0.79 units, P = 0.001). After accounting for analytical variation, the mean intraindividual variation was also substantially greater in the type 2 diabetic group than in the control group (mean 1.05 vs. 0.15, P = 0.001). Consequently, at any level of HOMA-IR, a subsequent sample must increase by >90% or decrease by >47% to be considered significantly different from the first. CONCLUSIONS: HOMA-IR is significantly greater and more variable for individuals with type 2 diabetes. Therefore, this inherent variability needs to be accounted for in studies evaluating therapeutic reduction of HOMA-IR in this group.

Beneficial effects of soy phytoestrogen intake in postmenopausal women with type 2 diabetes.

OBJECTIVE: Phytoestrogen consumption has been shown to reduce risk factors for cardiovascular disease. Type 2 diabetes confers an adverse cardiovascular risk profile particularly in women after menopause. The aim of this study was to determine whether a dietary supplement with soy protein and isoflavones affected insulin resistance, glycemic control, and cardiovascular risk markers in postmenopausal women with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 32 postmenopausal women with diet-controlled type 2 diabetes completed a randomized, double blind, cross-over trial of dietary supplementation with phytoestrogens (soy protein 30 g/day, isoflavones 132 mg/day) versus placebo (cellulose 30 g/day) for 12 weeks, separated by a 2-week washout period. RESULTS: Compliance with the dietary supplementation was >90% for both treatment phases. When compared with the mean percentage change from baseline seen after 12 weeks of placebo, phytoestrogen supplementation demonstrated significantly lower mean values for fasting insulin (mean +/- SD 8.09 +/- 21.9%, P = 0.006), insulin resistance (6.47 +/- 27.7%, P = 0.003), HbA(1c) (0.64 +/- 3.19%, P = 0.048), total cholesterol (4.07 +/- 8.13%, P = 0.004), LDL cholesterol (7.09 +/- 12.7%, P = 0.001), cholesterol/HDL cholesterol ratio (3.89 +/- 11.7%, P = 0.015), and free thyroxine (2.50 +/- 8.47%, P = 0.004). No significant change occurred in HDL cholesterol, triglycerides, weight, blood pressure, creatinine, dehydroepiandrosterone sulfate, androstenedione, and the hypothalamic-pituitary-ovarian axis hormones. CONCLUSIONS: These results show that dietary supplementation with soy phytoestrogens favorably alters insulin resistance, glycemic control, and serum lipoproteins in postmenopausal women with type 2 diabetes, thereby improving their cardiovascular risk profile.