Effects of 12-week treatment with dapagliflozin and gliclazide on faecal microbiome: Results of a double-blind randomized trial in patients with type 2 diabetes.

AIMS/HYPOTHESIS: Patients with type 2 diabetes (T2D) are usually treated with (combinations of) glucose-lowering medication. The effects of these drugs can be influenced by intestinal microbiota and vice versa, as these drugs can also influence microbiome composition. However, as there is currently little clinical insight into this bug-drug interaction, our study aimed to evaluate the effects of 12-week treatment with the SGLT2 inhibitor dapagliflozin and sulphonylurea gliclazide on gut microbiome composition in T2D patients treated with metformin. METHODS: A total of 44 patients were randomized to either dapagliflozin or gliclazide treatment for 12 weeks. At baseline and after 12 weeks, faecal samples and 24-h urine were collected. During study visits, anthropometric data were measured and blood samples drawn after an overnight fast. Microbiome composition was determined by 16S rRNA gene sequencing. Plasma glucose, insulin, HbA1c and urinary glucose excretion were measured using conventional methods. RESULTS: While dapagliflozin and gliclazide similarly improved glycaemic control, dapagliflozin reduced and gliclazide increased fasting insulin. Dapagliflozin also greatly increased urinary glucose excretion whereas gliclazide did not, while body mass index, fat mass percentage and waist circumference were reduced by dapagliflozin, but increased by gliclazide. However, neither treatment significantly affected either gut microbiome alpha diversity or composition and, after treatment, no associations were found between microbiome composition and other clinical parameters. CONCLUSION: Even though gliclazide and dapagliflozin have different metabolic actions in patients with T2D, neither treatment altered the faecal microbiome, thereby suggesting that the observed metabolic changes are not mediated by their effects on the microbiota.

Telehealth requires expansion of physicians' communication competencies training.

We are in the midst of transformation of health systems where remote consulting (via video, telephone, email, and mobile messaging) is soon to become the dominant mode of consultation. Most of the literature on telehealth omits mentioning the need for telehealth communication competencies. Yet evidence base has been growing about how critical this training is - whether from clinical communication research or litigation claims analysis. In this article, we are calling for an urgent expansion of communication skills curricula to encompass these new telehealth domains from medical schools, specialty trainings to CMEs.

The impact of laboratory closing times on delay of adequate therapy in blood stream infections.

BACKGROUND: Patients with bloodstream infections need early adequate antimicrobial treatment to reduce mortality. This raises the question of timing and logistics. How important is the time of day when a culture is flagged positive to the processing of blood cultures and optimisation of antimicrobial therapy? METHODS: We performed a retrospective study assessing the time delay of a positive blood culture result during and after office hours and its impact on adequate antimicrobial therapy. Process duration from the moment of culture positivity to Gram stain completion was compared at different timepoints during the day in a medium-sized hospital with an offsite microbiological laboratory. RESULTS: Ninety-four patients with positive, noncontaminated blood cultures were included. Sixty-six patients (70%) received adequate empirical therapy; this increased to 76 cases (82%) and to 88 cases (95%) after analysis of Gram stain results and complete determination, respectively (p < 0.05 for all comparisons). Median duration from culture positivity to Gram stain completion (including offsite culture transport) increased from a median of four to 12 hours if time of cultures turned positive after office hours (p < 0.05), irrespective of the adequacy of empirical coverage. This also resulted in a median 12-hour delay for the complete process from time of culture positivity to administration of the antimicrobial drug (p < 0.05). CONCLUSION: Processing blood cultures after office hours is often deferred, which can lead to a delay in adequate antimicrobial therapy for patients with bloodstream infections.

Hospital standardised mortality ratio: A reliable indicator of quality of care?

BACKGROUND: This study investigates (1) whether the hospital standardised mortality ratio (HSMR) model underestimates or overestimates disease severity and (2) the completeness of the data collected by administrators to calculate HSMR in a cohort of deceased patients with the diagnosis of pneumonia. METHODS: In this retrospective cohort study Pneumonia Severity Index (PSI) and Abbreviated Mortality in Emergency Department Sepsis (abbMEDS) scores and associated mortality probabilities were obtained from 32 deceased pneumonia patients over the year 2014 in the VU University Medical Centre. These were compared with mortality probabilities of the Central Bureau for Statistics (CBS) calculated for every patient using the HSMR model. Clinical charts were examined to extract relevant comorbidities to determine the reliability of data sent to the national registration of hospital care. RESULTS: Risk categories determined by using the PSI and the abbMEDS were significantly higher compared with the risk categories according to HSMR (p = 0.001, respectively p = 0.000). The mean difference between the number of comorbidities in our registration and the coders' registration was 1.97 (p = 0.00). The mean difference was 0.97 (p = 0.000) for the number of comorbidities of influence on the Charlson Comorbidity Index (CCI) and 1.25 (p = 0.001) for the calculated CCI. CONCLUSION: The results of this study suggest that the mortality probabilities as calculated by the CBS are an underestimation of the risk of dying for each patient. Our study also showed that the registration of data sent to the CBS underestimated the actual comorbidities of the patient, and could possibly influence the HSMR.

Nudging to improve hand hygiene.

BACKGROUND: Hand hygiene is paramount to prevent healthcare-associated infections, but improving compliance is challenging. When healthcare workers seldom encounter healthcare-associated infections, they will consider the odds of causing infections through poor hand hygiene negligible. Cognitive biases such as these may induce non-compliance. Nudging, 'a friendly push to encourage desired behaviour', could provide an easily implemented, inexpensive measure to address cognitive biases and thus support hand hygiene interventions. AIM: To investigate whether behavioural nudges, displayed as posters, can increase the use of alcohol-based hand rub. METHODS: We developed nudges based on a systematic review of previously described cognitive biases, and tested these through a cross-sectional survey among the target audience. We then conducted a controlled before-after trial on two hospital wards, to assess the effect of these nudges on the use of alcohol-based hand rub, measured with electronic dispensers. FINDINGS: Poisson regression analyses adjusted for workload showed that nudges displayed next to dispensers increased their overall use on one ward [poster 1: relative risk: 1.6 (95% confidence interval: 1.2-2.2); poster 2: 1.7 (1.2-2.5)] and during doctor's rounds on both wards [poster 1: ward A: 1.7 (1.1-2.6); ward B: 2.2 (1.3-3.8)]. Use of dispensers without adjacent nudges did not increase. CONCLUSION: Nudges based on cognitive biases that play a role in hand hygiene, and displayed as posters, could provide an easy, inexpensive measure to increase use of alcohol-based hand rub. When applying nudges to change behaviour, it is important to identify the right nudge for the right audience.

Keeping safe. Continuous glucose monitoring (CGM) in persons with Type 1 diabetes and impaired awareness of hypoglycaemia: a qualitative study.

AIM: To further our understanding of individual use and experience of continuous glucose monitoring (CGM) in adults with Type 1 diabetes and impaired awareness of hypoglycaemia, we conducted a qualitative study supplementary to a randomized controlled trial, using semi-structured interviews. METHODS: Twenty-three participants of the IN CONTROL trial were interviewed within 4 weeks after the last study visit. The interview centred around experiences of CGM, taking into account the person's expectations prior to the trial. The interview was semi-structured, using open-ended questions and, if needed, prompts were offered to elicit further responses. Using thematic analysis, the interview transcripts were coded independently by three members of the research team. The consolidated criteria for reporting qualitative research (COREQ) were followed. RESULTS: Overall, CGM was experienced as helpful in gaining more insight into glucose variability, and temporarily improved sense of control, reduced distress and made participants less dependent on others. However, some participants experienced confrontation with CGM output as intrusive, while some reported frustration due to failing technique and difficulty trusting the device. Participants reported active and passive self-management behaviours mirroring individual differences in attitudes and coping styles. CONCLUSIONS: In adults with Type 1 diabetes at risk of recurrent hypoglycaemia due to impaired awareness of hypoglycaemia, CGM use enhances a sense of control and safety for most, but not all. Future studies should further explore differential use of CGM in this population in the context of active and passive self-management styles.

Acute medical units: The way to go? A literature review.

BACKGROUND: Acute healthcare chains in the Netherlands are increasingly under pressure because of rising emergency department (ED) admissions, relative bed shortages and government policy changes. In order to improve acute patient flow and quality of care through hospitals, an acute medical unit (AMU) might be a solution, as demonstrated in the UK. However, limited information is available concerning AMUs in the Netherlands. Therefore, the aims of this study were to METHODS: A systematic literature search was performed searching 3 electronic databases: PubMed, Cochrane and EMBASE. All 106 hospitals in the Netherlands were contacted, inquiring about the status of an ED, the AMU or future plans to start one. RESULTS: The literature search resulted in 31 studies that met inclusion criteria. In general, these studies reported significant benefits on number of admissions, hospital length of stay (LOS), mortality, other wards and readmissions. Among the Dutch hospitals with an ED, 33 out of 93 implemented an AMU or similar ward, these are however organized heterogeneously. Following current trends, more AMUs are expected to be realized in the future. CONCLUSION: In order to improve the current strain on the Dutch acute healthcare system, an AMU could potentially provide benefits. However, uniform guideline is warranted to optimize and compare quality of care throughout the Netherlands.

Long-term health related quality of life in patients with sepsis after intensive care stay: A systematic review.

Sepsis is a major health care issue and sepsis survivors are often confronted with long-term complications after admission to the intensive care unit (ICU) which may negatively influence their health related quality of life (HRQOL). This study aimed to systematically evaluate the outcome in terms of HRQOL in patients with sepsis after ICU discharge. A literature search was conducted in the bibliographic databases PubMed, EMBASE, and CINAHL, including reference lists of published guidelines, reviews and associated articles. Sixteen studies were included, thirteen (81.3%) reported that sepsis survivors suffer from impaired HRQOL in physical and mental domains which persist from months to years after a sepsis episode. More focus on improving long-term outcomes for patients surviving sepsis and the ICU is needed.

Physician consensus on preventability and predictability of readmissions based on standard case scenarios.

BACKGROUND: Policy makers struggle with unplanned readmissions as a quality indicator since integrating preventability in such indicators is difficult. Most studies on the preventability of readmissions questioned physicians whether they consider a given readmission to be preventable, from which conclusions on factors predicting preventable readmissions were derived. There is no literature on the interobserver agreement of physician judgement. AIM: To assess the degree of agreement among physicians regarding predictability and preventability of medical readmissions. DESIGN: An online survey based on eight real-life case scenarios was distributed to European physicians. METHODS: Physicians were requested to rate from the first four (index admission) scenarios whether they expected these patients to be readmitted within 30 days (the predictability). The remaining four cases, describing a readmission, were used to assess the preventability. The main outcome was the degree of agreement among physicians determined using the intra class correlation coefficient (ICC). RESULTS: 526 European medical physicians completed the survey. Most physicians had internal medicine as primary specialism. The median years of clinical experience was 11. ICC for predictability of readmission was 0.67 (moderate to good) and ICC for preventability of readmission was 0.13 (poor). CONCLUSION: There was moderate to good agreement among physicians on the predictability of readmissions while agreement on preventability was poor. This study indicates that assessing preventability of readmissions based solely on the judgement of physicians is far from perfect. Current literature on the preventability of readmissions and conclusions derived on the basis of physician opinion should be interpreted with caution.

Ganciclovir-induced ataxia and encephalopathy.

BACKGROUND: Ganciclovir can be used to treat a primary cytomegalovirus (CMV) infection, however it can cause side effects. CASE DESCRIPTION: We describe a 60-year-old immunocompromised woman with a primary CMV infection who was treated with ganciclovir. She developed an encephalopathy which resolved after discontinuation of ganciclovir. CONCLUSION: A reversible encephalopathy as a side effect of ganciclovir.

Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link.

IMPORTANCE: Unplanned readmissions within 30days are a common phenomenon in everyday practice and lead to increasing costs. Although many studies aiming to analyze the probable causes leading to unplanned readmissions have been performed, an in depth-study analyzing the human (healthcare worker)-, organizational-, technical-, disease- and patient-related causes leading to readmission is still missing. OBJECTIVE: The primary objective of this study was to identify human-, organizational-, technical-, disease- and patient-related causes which contribute to acute readmission within 30days after discharge using a Root-Cause Analysis Tool called PRISMA-medical. The secondary objective was to evaluate how many of these readmissions were deemed potentially preventable, and to assess which factors contributed to these preventable readmissions in comparison to non-preventable readmissions. DESIGN: Cross-sectional retrospective record study. SETTING: An academic medical center in Amsterdam, The Netherlands. PARTICIPANTS: Fifty patients aged 18years and older discharged from an internal medicine department and acutely readmitted within 30days after discharge. MAIN OUTCOME MEASURES: Root causes of preventable and unpreventable readmissions. RESULTS: Most root causes for readmission were disease-related (46%), followed by human (healthcare worker)- (33%) and patient- (15%) related root causes. Half of the readmissions studied were considered to be potentially preventable. Preventable readmissions predominantly had human-related (coordination) failures. CONCLUSION AND RELEVANCE: Our study suggests that improving human-related (coordinating) factors contributing to a readmission can potentially decrease the number of preventable readmissions.

Acute renal haemodynamic effects of glucagon-like peptide-1 receptor agonist exenatide in healthy overweight men.

AIMS: To determine the acute effect of glucagon-like peptide-1 (GLP-1) receptor agonist exenatide and the involvement of nitric oxide (NO) on renal haemodynamics and tubular function, in healthy overweight men. METHODS: Renal haemodynamics and tubular electrolyte handling were measured in 10 healthy overweight men (aged 20-27 years; BMI 26-31 kg/m(2)) during intravenous administration of placebo (saline 0.9%), exenatide, and exenatide combined with the NO-synthase inhibitor L-N(G)-monomethyl arginine (L-NMMA). Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were determined by inulin and para-aminohippurate clearance techniques, respectively, based on timed urine sampling. Glomerular hydrostatic pressure and vascular resistance of afferent and efferent renal arterioles were calculated using the Gomez formulae. Urinary electrolytes, osmolality and pH were also measured. RESULTS: GFR increased by a mean of 18 ± 20 (+20%; p = 0.021) and ERPF increased by a median (interquartile range) of 68 (26; 197) ml/min/1.73 m(2) (+14%; p = 0.015) during exenatide infusion versus placebo. During L-NMMA infusion, exenatide increased GFR by mean 8 ± 12 ml/min/1.73 m(2) (+9%; p = 0.049). Exenatide increased estimated glomerular pressure by +6% (p = 0.015) and reduced afferent renal vascular resistance by -33% (p = 0.038), whereas these effects were blunted during L-NMMA infusion. Exenatide increased absolute and fractional sodium excretion, urinary osmolality and urinary pH. The tubular effects of exenatide were not altered by concomitant L-NMMA infusion. CONCLUSIONS: Exenatide infusion in healthy overweight men acutely increases GFR, ERPF and glomerular pressure, probably by reducing afferent renal vascular resistance, and at least partially in an NO-dependent manner. As baseline renal haemodynamics in patients with type 2 diabetes differ from those in healthy individuals, clinical studies on the renal effects of GLP-1 receptor agonists are warranted.

Shift in responsibilities in diabetes care: the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT).

AIMS: To investigate the feasibility, safety and efficacy of the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT), which consists of nurse-driven correctional therapy, in addition to physician-guided basal therapy, and is carried out by trained ward nurses. METHODS: Data on 210 patients with diabetes consecutively admitted in the 5-month period after the introduction of N-DIABIT (intervention group) were compared with the retrospectively collected data on 200 consecutive patients with diabetes admitted in the 5-month period before N-DIABIT was introduced (control group). Additional per-protocol analyses were performed in patients in whom mean patient-based protocol adherence was ≥ 70% (intervention subgroup, n = 173 vs. control subgroup, n = 196). RESULTS: There was no difference between the intervention and the control group in mean blood glucose levels (8.9 ± 0.1 and 9.1 ± 0.2 mmol/l, respectively; P = 0.38), consecutive hyperglycaemic (blood glucose ≥ 10.0 mmol/l) episodes; P = 0.15), admission duration (P = 0.79), mean number of blood glucose measurements (P = 0.21) and incidence of severe hypoglycaemia (P = 0.29). Per-protocol analyses showed significant reductions in mean blood glucose levels and consecutive hypoglycaemia and hyperglycaemia in the intervention compared with the control group. CONCLUSIONS: Implementation of N-DIABIT by trained ward nurses in non-intensive care unit diabetes care is feasible, safe and non-inferior to physician-driven care alone. High protocol adherence was associated with improved glycaemic control.

Gastrointestinal actions of glucagon-like peptide-1-based therapies: glycaemic control beyond the pancreas.

The gastrointestinal hormone glucagon-like peptide-1 (GLP-1) lowers postprandial glucose concentrations by regulating pancreatic islet-cell function, with stimulation of glucose-dependent insulin and suppression of glucagon secretion. In addition to endocrine pancreatic effects, mounting evidence suggests that several gastrointestinal actions of GLP-1 are at least as important for glucose-lowering. GLP-1 reduces gastric emptying rate and small bowel motility, thereby delaying glucose absorption and decreasing postprandial glucose excursions. Furthermore, it has been suggested that GLP-1 directly stimulates hepatic glucose uptake, and suppresses hepatic glucose production, thereby adding to reduction of fasting and postprandial glucose levels. GLP-1 receptor agonists, which mimic the effects of GLP-1, have been developed for the treatment of type 2 diabetes. Based on their pharmacokinetic profile, GLP-1 receptor agonists can be broadly categorized as short- or long-acting, with each having unique islet-cell and gastrointestinal effects that lower glucose levels. Short-acting agonists predominantly lower postprandial glucose excursions, by inhibiting gastric emptying and intestinal glucose uptake, with little effect on insulin secretion. By contrast, long-acting agonists mainly reduce fasting glucose levels, predominantly by increased insulin and reduced glucagon secretion, with potential additional direct inhibitory effects on hepatic glucose production. Understanding these pharmacokinetic and pharmacodynamic differences may allow personalized antihyperglycaemic therapy in type 2 diabetes. In addition, it may provide the rationale to explore treatment in patients with no or little residual ß-cell function.

Glucagon-like peptide-1 receptor agonist exenatide has no acute effect on MRI-measured exocrine pancreatic function in patients with type 2 diabetes: a randomized trial.

AIMS: To investigate the effect of infusion of the glucagon-like peptide-1 (GLP-1) receptor agonist exenatide on exocrine pancreatic function. METHODS: This was a randomized, placebo-controlled, double-blind, crossover study in 12 male patients with type 2 diabetes, treated with oral glucose-lowering agents. On two separate occasions, exenatide or placebo (saline 0.9%) were administered intravenously, in randomized order. Exocrine pancreatic function was measured using secretin-enhanced magnetic resonance cholangiopancreatography. The primary outcome measure was defined as secretin-stimulated pancreatic excretion volume. Secondary outcome measures were maximum secretion speed and the time to reach this maximum. In addition, changes in pancreatic duct (PD) diameter were measured. RESULTS: Exenatide did not change secretin-stimulated pancreatic excretion volume, as compared with placebo (mean ± standard error of the mean 142.2 ± 15.6 ml vs 142.6 ± 8.5 ml, respectively; p = 0.590). Also, exenatide did not change the maximum secretion speed (33.1 ± 1.4 vs 36.9 ± 2.2; p = 0.221), nor the time to reach this maximum (both 4 min 30 s). No differences in PD diameter were observed between the two groups. CONCLUSIONS: Infusion of exenatide did not directly influence MRI-measured exocrine pancreatic excretion in patients with type 2 diabetes. Although long-term studies are warranted, these findings suggest that potential adverse pancreatic effects of GLP-1 receptor agonists are not mediated by changes in exocrine pancreatic secretion.

What are we waiting for? Factors influencing completion times in an academic and peripheral emergency department.

BACKGROUND: A long completion time in the Emergency Department (ED) is associated with higher morbidity and in-hospital mortality. A completion time of more than four hours is a frequently used cut-off point. Mostly, older and sicker patients exceed a completion time of four hours on the ED. The primary aim was to examine which factors currently contribute to overcrowding and a time to completion of more than four hours on the EDs of two different hospitals, namely: the VU Medical Center (VUmc), an academic level 1 trauma centre and the St. Antonius Hospital, a large community hospital in Nieuwegein. In addition, we compared the differences between these hospitals. METHODS: In this observational study, the time steps in the process of diagnosing and treatment of all patients visiting the EDs of the two hospitals were measured for four weeks. Patients triaged as Emergency Severity Index (ESI) category 2/3 or Manchester Triage System (MTS) orange/yellow were followed more closely and prospectively by researchers for detailed information in the same period from 12.00-23.00 hrs. RESULTS: In the VUmc, 89% of the patients had a completion time of less than four hours. The average completion time (n = 2262) was 2:10 hours, (median 1:51 hours, range: 0:05-12:08). In the St. Antonius Hospital, 77% of patients had a completion time shorter than four hours (n = 1656). The average completion time in hours was 2:49 (n = 1655, median 2:34, range: 0:08-11:04). In the VUmc, a larger percentage of ESI 1, 2 and 3 patients did not achieve the 4-hour target (14%, 20% and 19%) compared with ESI 4 and 5 patients (2.7% and 0%), p < 0.001. At the St. Antonius Hospital, a greater percentage of orange and yellow categorised patients exceeded four hours on the ED (32% and 28%) compared with red (8%) and green/blue (13%), p < 0.001. For both hospitals there was a significant dependency between exceeding four hours on the ED and the following: whether a consultation was performed (p < 0.001), the number of radiology tests performed (p < 0.001), and an age above 65 years. CONCLUSION: Factors leading to ED stagnation were similar in both hospitals, namely old age, treatment by more than one speciality and undergoing radiological tests. Uniform remedial measures should be taken on a nationwide level to deal with these factors to reduce stagnation in the EDs.

Exploring the performance of the National Early Warning Score (NEWS) in a European emergency department.

BACKGROUND: Several triage systems have been developed for use in the emergency department (ED), however they are not designed to detect deterioration in patients. Deteriorating patients may be at risk of going undetected during their ED stay and are therefore vulnerable to develop serious adverse events (SAEs). The national early warning score (NEWS) has a good ability to discriminate ward patients at risk of SAEs. The utility of NEWS had not yet been studied in an ED. OBJECTIVE: To explore the performance of the NEWS in an ED with regard to predicting adverse outcomes. DESIGN: A prospective observational study. Patients Eligible patients were those presenting to the ED during the 6 week study period with an Emergency Severity Index (ESI) of 2 and 3 not triaged to the resuscitation room. INTERVENTION: NEWS was documented at three time points: on arrival (T0), hour after arrival (T1) and at transfer to the general ward/ICU (T2). The outcomes of interest were: hospital admission, ICU admission, length of stay and 30 day mortality. RESULTS: A total of 300 patients were assessed for eligibility. Complete data was able to be collected for 274 patients on arrival at the ED. NEWS was significantly correlated with patient outcomes, including 30 day mortality, hospital admission, and length of stay at all-time points. CONCLUSION: The NEWS measured at different time points was a good predictor of patient outcomes and can be of additional value in the ED to longitudinally monitor patients throughout their stay in the ED and in the hospital.

Sex-specific effects of naturally occurring variants in the dopamine receptor D2 locus on insulin secretion and type 2 diabetes susceptibility.

AIMS: Modulation of dopamine receptor D2 (DRD2) activity affects insulin secretion in both rodents and isolated pancreatic ß-cells. We hypothesized that single nucleotide polymorphisms in the DRD2/ANKK1 locus may affect susceptibility to type 2 diabetes in humans. METHODS: Four potentially functional variants in the coding region of the DRD2/ANKK1 locus (rs1079597, rs6275, rs6277, rs1800497) were genotyped and analysed for type 2 diabetes susceptibility in up to 25 000 people (8148 with type 2 diabetes and 17687 control subjects) from two large independent Dutch cohorts and one Danish cohort. In addition, 340 Dutch subjects underwent a 2-h hyperglycaemic clamp to investigate insulin secretion. Since sexual dimorphic associations related to DRD2 polymorphisms have been previously reported, we also performed a gender-stratified analysis. RESULTS: rs1800497 at the DRD2/ANKK1 locus was associated with a significantly increased risk for type 2 diabetes in women (odds ratio 1.14 (1.06-1.23); P = 4.1*104) but not in men (odds ratio 1.00 (95% CI 0.93-1.07); P = 0.92) or the combined group. Although rs1800497 was not associated with insulin secretion, we did find another single nucleotide polymorphism in this locus, rs6275, to be associated with increased first-phase glucose-stimulated insulin secretion in women (P = 5.5*104) but again not in men (P = 0.34). CONCLUSION: The present data identify DRD2/ANKK1 as a potential sex-specific type 2 diabetes susceptibility gene.

The changing face of internal medicine: patient centred care.

Patient centred care is now considered the gold standard and there should be 'no decision about me, without me'. Internists who treat patients with complex multi-morbidities should consider patients' preferred outcomes, following a 'goal-oriented' principle. Perhaps the most important barrier to goal-oriented care is that medicine is deeply rooted in a disease-outcome-based paradigm. Rather than asking what patients want, the culture of modern medicine has prioritised optimal disease management according to guidelines and population goals. Doing what is right for the patient should be based on trust. Patients and internists must therefore meet as equals: 'I' and 'you' should be replaced by 'we'.