Which oral antidiabetic drug to combine with metformin to minimize the risk of hypoglycemia when initiating basal insulin?: A randomized controlled trial of a DPP4 inhibitor versus insulin secretagogues.

We conducted a pilot study to evaluate two therapeutic strategies at the time of insulin initiation in type 2 diabetic patients insufficiently controlled with metformin+insulin-secretagogues (IS, sulfonylureas or glinides). Patients were randomized to remain under the same dual therapy or to receive metformin+DPP4 inhibitors while starting insulin. Similar glycemic control was achieved in both groups. However less hypoglycemia was observed with DPP4 inhibitors despite higher doses of insulin.

Attitudes to and application of the concept of overall cardiovascular risk: comparison of male and female primary care providers.

The aim of this observational study was to assess whether there were differences in perception of overall cardiovascular risk (OCVR) in hypertensive patients depending on the gender of the primary care provider (PCP). We performed this study in 2003: 2979 male PCPs (MPCPs) and 562 female PCPs (FPCPs) participated throughout France. The patients included were hypertensive either treated or untreated, uncontrolled (blood pressure (BP) >or=140/90 mm Hg) with at least one other cardiovascular risk factor (CVRF) associated. OCVR of patients was both calculated according to French Agence Nationale d'Accréditation et d'Evaluation en Santé guidelines for uncontrolled hypertensive patients and subjectively estimated by the PCP as 'low', 'moderate', 'high' or 'very high'. About 11 770 patients were included, mean age was 63.7+/-11.2 years and 54.1% were men. Mean BP was 157+/-13/90+/-9 mm Hg. According to French guidelines, the calculated OCVR was 'moderate' in 23.7% of patients, 'high' in 47.5% and 'very high' in 28.8%. The PCP perceived OCVR was that 9.1% of patients were considered to be at 'low risk', 40.7% at 'moderate risk', 38.1% at 'high risk', and only 11.2% at 'very high risk' (OCVR was not estimated for 0.9% of patients). The overall agreement rate between the PCPs' estimation of OCVR and its calculation was 43.5%. Thus, in spite of extensive diffusion of ANAES guidelines, we found that PCPs in France generally underestimated OCVR though there were no significant differences between male and female physicians (45% for FPCPs and 43.2% for MPCPs).

Comparison of the effects of heat and moisture exchangers and heated humidifiers on ventilation and gas exchange during weaning trials from mechanical ventilation.

Heat and moisture exchangers (HME) are increasingly used to warm and humidify inspired gases in intubated ventilated patients. But these devices add dead space that may alter the alveolar ventilation. This could impair the efficiency of spontaneous ventilation (SV) during weaning trials from mechanical ventilation. Fifteen patients were tested with an HME (Hygrobac-DAR) and a heated humidifier (HH) (Fischer-Paykel MR 450) in a random order during weaning trials in SV with inspiratory pressure support. Minute ventilation VE, tidal volume), and respiratory rate were recorded and arterial blood was sampled for blood gas analysis with each device. The HME gave a significantly greater VE than the HH (9.3 +/- 0.8 L/min vs 8.1 +/- 0.8 L/min; p < 0.005), because of increased respiratory rate (21 +/- 2/min vs 19 +/- 2/min; p < 0.05). Tidal volume was unchanged for HME and HH (470 +/- 32 mL vs 458 +/- 39 mL). The higher PaCO2 with HME than with HH (44 +/- 2 mm Hg vs 42 +/- 2 mm Hg; p < 0.005) revealed an insufficient alveolar ventilation response to the increase in dead space. Arterial Po2 rose with the HME, but not significantly above the HH values (103 +/- 6 mm Hg vs 97 +/- 6 mm Hg; p = 0.055), possibly because of a positive end-expiratory pressure effect of the HME. The need to increase VE in SV when an HME is used should be taken into account during difficult weaning from mechanical ventilation.