Preprocedural fasting policies for patients receiving tube feeding: A national survey.

BACKGROUND: Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures. METHODS: The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated. RESULTS: The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed. CONCLUSIONS: Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

The association of intraoperative low driving pressure ventilation and nonhome discharge: a historical cohort study.

PURPOSE: To evaluate whether intraoperative ventilation using lower driving pressure decreases the risk of nonhome discharge. METHODS: We conducted a historical cohort study of patients aged ≥ 60 yr who were living at home before undergoing elective, noncardiothoracic surgery at two tertiary healthcare networks in Massachusetts between 2007 and 2018. We assessed the association of the median driving pressure during intraoperative mechanical ventilation with nonhome discharge using multivariable logistic regression analysis, adjusted for patient and procedural factors. Contingent on the primary association, we assessed effect modification by patients' baseline risk and mediation by postoperative respiratory failure. RESULTS: Of 87,407 included patients, 12,584 (14.4%) experienced nonhome discharge. In adjusted analyses, a lower driving pressure was associated with a lower risk of nonhome discharge (adjusted odds ratio [aOR], 0.88; 95% confidence interval [CI], 0.83 to 0.93, per 10 cm H2O decrease; P < 0.001). This association was magnified in patients with a high baseline risk (aOR, 0.77; 95% CI, 0.73 to 0.81, per 10 cm H2O decrease, P-for-interaction < 0.001). The findings were confirmed in 19,518 patients matched for their baseline respiratory system compliance (aOR, 0.90; 95% CI, 0.81 to 1.00; P = 0.04 for low [< 15 cm H2O] vs high [≥ 15 cm H2O] driving pressures). A lower risk of respiratory failure mediated the association of a low driving pressure with nonhome discharge (20.8%; 95% CI, 15.0 to 56.8; P < 0.001). CONCLUSIONS: Intraoperative ventilation maintaining lower driving pressure was associated with a lower risk of nonhome discharge, which can be partially explained by lowered rates of postoperative respiratory failure. Future randomized controlled trials should target driving pressure as a potential intervention to decrease nonhome discharge.

RéSUMé: OBJECTIF: Évaluer si la ventilation peropératoire utilisant une pression motrice plus faible diminue le risque de congé hors domicile. MéTHODE: Nous avons réalisé une étude de cohorte historique de patients âgés de ≥ 60 ans vivant à la maison avant de bénéficier d'une chirurgie non cardiothoracique non urgente dans deux réseaux de soins de santé tertiaires du Massachusetts entre 2007 et 2018. Nous avons évalué l'association entre la pression motrice médiane pendant la ventilation mécanique peropératoire et le congé ailleurs qu'au domicile à l'aide d'une analyse de régression logistique multivariable, ajustée pour tenir compte des facteurs liés aux patients et à l'intervention. En fonction de l'association primaire, nous avons évalué la modification de l'effet par le risque initial des patients et la médiation par l'insuffisance respiratoire postopératoire. RéSULTATS: Sur les 87 407 patients inclus, 12 584 (14,4 %) ont reçu leur congé ailleurs qu'au domicile. Dans les analyses ajustées, une pression motrice plus faible était associée à un risque réduit de congé hors domicile (rapport de cotes ajusté [RCa], 0,88; intervalle de confiance [IC] à 95 %, 0,83 à 0,93, par diminution de 10 cm H2O; P < 0,001). Cette association a été amplifiée chez les patients présentant un risque initial élevé (RCa, 0,77; IC 95 %, 0,73 à 0,81, par diminution de 10 cm H2O, P-pour-interaction < 0,001). Les résultats ont été confirmés chez 19 518 patients appariés pour la compliance initiale de leur système respiratoire (RCa, 0,90; IC 95 %, 0,81 à 1,00; P = 0,04 pour des pressions motrices faibles [< 15 cm H2O] vs élevées [≥ 15 cm H2O]). Un risque plus faible d'insuffisance respiratoire a entraîné une association entre une faible pression motrice et un congé à l'extérieur du domicile (20,8 %; IC 95 %, 15,0 à 56,8 ; P < 0,001). CONCLUSION: La ventilation peropératoire maintenant une pression motrice plus faible a été associée à un risque plus faible de congé hors domicile, ce qui peut s'expliquer en partie par des taux réduits d'insuffisance respiratoire postopératoire. Les futures études randomisées contrôlées devraient cibler la pression motrice comme intervention potentielle pour réduire les congés hors domicile.

Reintubation After Lung Cancer Resection: Development and External Validation of a Predictive Score.

BACKGROUND: Reintubation after lung cancer resection is an important quality metric because of increased disability, mortality and cost. However, no validated predictive instrument is in use to reduce reintubation after lung resection. This study aimed to create and validate the PRediction Of REintubation After Lung cancer resection (PROREAL) score. METHODS: The study analyzed lung resection cases from 2 university hospitals. The primary end point was reintubation within 7 days after surgery. Predictors were selected through backward stepwise logistic regression and bootstrap resampling. The investigators used reclassification and receiver-operating characteristic (ROC) curve analyses to assess score performance and compare it with an established score for all surgical patients (Score for Prediction of Postoperative Respiratory Complications [SPORC]). RESULTS: The study included 2672 patients who underwent resection for lung cancer (1754, development cohort; 918, validation cohort) between 2008 and 2020, of whom 71 (2.7%) were reintubated within 7 days after surgery. Identified score variables were surgical extent and approach, American Society of Anesthesiologists physical status, heart failure, renal disease, and diffusing capacity of the lung for carbon monoxide. The score achieved excellent discrimination in the development cohort (ROC AUC, 0.90; 95% CI, 0.87-0.94) and good discrimination in the validation cohort (ROC AUC, 0.74, 95% CI; 0.66-0.82), thus outperforming the SPORC in both cohorts (P < .001 and P = .018, respectively; validation cohort net reclassification improvement, 0.39; 95% CI, 0.18-0.60; P = .001). The score cutoff of ≥5 yielded a sensitivity of 88% (95% CI, 72-95) and a specificity of 81% (95% CI,79-83) in the development cohort. CONCLUSIONS: A simple score (PROREAL) specific to lung cancer predicts postoperative reintubation more accurately than the nonspecific SPORC score. Operative candidates at risk may be identified for preventive intervention or alternative oncologic therapy.

Association between intraoperative tidal volume and postoperative respiratory complications is dependent on respiratory elastance: a retrospective, multicentre cohort study.

BACKGROUND: The impact of high vs low intraoperative tidal volumes on postoperative respiratory complications remains unclear. We hypothesised that the effect of intraoperative tidal volume on postoperative respiratory complications is dependent on respiratory system elastance. METHODS: We retrospectively recorded tidal volume (Vt; ml kg-1 ideal body weight [IBW]) in patients undergoing elective, non-cardiothoracic surgery from hospital registry data. The primary outcome was respiratory failure (requiring reintubation within 7 days of surgery, desaturation after extubation, or both). The primary exposure was defined as the interaction between Vt and standardised respiratory system elastance (driving pressure divided by Vt; cm H2O/[ml kg-1]). Multivariable logistic regression models, with and without interaction terms (which categorised Vt as low [Vt ≤8 ml kg-1] or high [Vt >8 ml kg-1]), were adjusted for potential confounders. Additional analyses included path mediation analysis and fractional polynomial modelling. RESULTS: Overall, 10 821/197 474 (5.5%) patients sustained postoperative respiratory complications. Higher Vt was associated with greater risk of postoperative respiratory complications (adjusted odds ratio=1.42 per ml kg-1; 95% confidence interval [CI], 1.35-1.50]; P<0.001). This association was modified by respiratory system elastance (P<0.001); in patients with low compliance (<42.4 ml cm H2O-1), higher Vt was associated with greater risk of postoperative respiratory complications (adjusted risk difference=0.3% [95% CI, 0.0-0.5] at 41.2 ml cm H2O-1 compliance, compared with 5.8% [95% CI, 3.8-7.8] at 14 ml cm H2O-1 compliance). This association was absent when compliance exceeded 41.2 ml cm H2O-1. Adverse effects associated with high Vt were entirely mediated by driving pressures (P<0.001). CONCLUSIONS: The association of harm with higher tidal volumes during intraoperative mechanical ventilation is modified by respiratory system elastance. These data suggest that respiratory elastance should inform the design of perioperative trials testing intraoperative ventilatory strategies.

Characteristics and Outcomes of US Patients Hospitalized With COVID-19.

BACKGROUND: Understanding COVID-19 epidemiology is crucial to clinical care and to clinical trial design and interpretation. OBJECTIVE: To describe characteristics, treatment, and outcomes among patients hospitalized with COVID-19 early in the pandemic. METHODS: A retrospective cohort study of consecutive adult patients with laboratory-confirmed, symptomatic SARS-CoV-2 infection admitted to 57 US hospitals from March 1 to April 1, 2020. RESULTS: Of 1480 inpatients with COVID-19, median (IQR) age was 62.0 (49.4-72.9) years, 649 (43.9%) were female, and 822 of 1338 (61.4%) were non-White or Hispanic/Latino. Intensive care unit admission occurred in 575 patients (38.9%), mostly within 4 days of hospital presentation. Respiratory failure affected 583 patients (39.4%), including 284 (19.2%) within 24 hours of hospital presentation and 413 (27.9%) who received invasive mechanical ventilation. Median (IQR) hospital stay was 8 (5-15) days overall and 15 (9-24) days among intensive care unit patients. Hospital mortality was 17.7% (n = 262). Risk factors for hospital death identified by penalized multivariable regression included older age; male sex; comorbidity burden; symptoms-to-admission interval; hypotension; hypoxemia; and higher white blood cell count, creatinine level, respiratory rate, and heart rate. Of 1218 survivors, 221 (18.1%) required new respiratory support at discharge and 259 of 1153 (22.5%) admitted from home required new health care services. CONCLUSIONS: In a geographically diverse early-pandemic COVID-19 cohort with complete hospital folllow-up, hospital mortality was associated with older age, comorbidity burden, and male sex. Intensive care unit admissions occurred early and were associated with protracted hospital stays. Survivors often required new health care services or respiratory support at discharge.

Postintubation Decline in Oxygen Saturation Index Predicts Mortality in COVID-19: A Retrospective Pilot Study.

BACKGROUND: Acute respiratory failure from COVID-19 pneumonia is a major cause of death after SARS-CoV-2 infection. We investigated whether PaO2/FiO2, oxygenation index (OI), SpO2/FiO2, and oxygen saturation index (OSI), commonly used to assess the severity of acute respiratory distress syndrome (ARDS), can predict mortality in mechanically ventilated COVID-19 patients. METHODS: In this single-centered retrospective pilot study, we enrolled 68 critically ill mechanically ventilated adult patients with confirmed COVID-19. Physiological variables were recorded on the day of intubation (day 0) and postintubation days 3 and 7. The association between physiological parameters, PaO2/FiO2, OI, SpO2/FiO2, and OSI with mortality was assessed using multiple variable logistic regression analysis. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. RESULTS: The ARDS severity indices were not statistically different on the day of intubation, suggesting similar baseline conditions in nonsurviving and surviving patients. However, these indices were significantly worse in the nonsurviving as compared to surviving patients on postintubation days 3 and 7. On intubation day 3, PaO2/FiO2 was 101.0 (61.4) in nonsurviving patients vs. 140.2 (109.6) in surviving patients, p=0.004, and on day 7 106.3 (94.2) vs. 178.0 (69.3), p < 0.001. OI was 135.0 (129.7) in nonsurviving vs. 84.8 (86.1) in surviving patients (p=0.003) on day 3 and 150.0 (118.4) vs. 61.5 (46.7) (p < 0.001) on day 7. OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7. Similarly, SpO2/FiO2 was 130 (90) vs. 210 (90) (p=0.003) on day 3 and 130 (90) vs. 230 (50) (p < 0.001) on day 7, while OSI was 12.0 (11.7) vs. 8.0 (10.0) (p=0.006) on day 3 and 14.7 (13.2) vs. 6.5 (5.4) (p < 0.001) on day 7 in the nonsurviving and surviving patients, respectively. All measures were independently associated with hospital mortality, with significantly greater odds ratios observed on day 7. The area under the receiver operating characteristic curve (AUC) for mortality prediction was greatest on intubation day 7 (AUC = 0.775, 0.808, and 0.828 for PaO2/FiO2, OI, SpO2/FiO2, and OSI, respectively). CONCLUSIONS: Decline in oxygenation indices after intubation is predictive of mortality in COVID-19 patients. This time window is critical to the outcome of these patients and a possible target for future interventions. Future large-scale studies to confirm the prognostic value of the indices in COVID-19 patients are warranted.

Clinical Research Redirection and Optimization During a Pandemic.

The COVID-19 pandemic has seen many hurdles to crucial research processes, in particular those that depend on personnel interactions, in providing safeguards against the incipient infectious disease. At the same time, there was a rapid redirection of research, driven by popular and social media and demand for pandemic-related content, to the detriment of non-COVID-19 research and perhaps to COVID-19 research itself. This article provides historical context to research redirection and discusses approaches to optimizing research methodology in the setting of COVID-19 pandemic.

Cardiopulmonary resuscitation (CPR) during spaceflight - a guideline for CPR in microgravity from the German Society of Aerospace Medicine (DGLRM) and the European Society of Aerospace Medicine Space Medicine Group (ESAM-SMG).

BACKGROUND: With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest. METHODS: After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology. RESULTS: We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved. DISCUSSION: CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

Controversies in Perioperative Antimicrobial Prophylaxis.

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.

Variation in Frequency of Intraoperative Arterial, Central Venous and Pulmonary Artery Catheter Placement During Kidney Transplantation: An Analysis of Invasive Monitoring Trends.

The rapidly increasing number of kidney transplantations warrants assessment of anesthesia care in this patient population. We explored the frequency of arterial catheter (AC), central venous catheter (CVC) and pulmonary artery catheter (PAC) placement during kidney transplantation in the USA using data from the National Anesthesia Clinical Outcomes Registry (NACOR) and assessed the between-facility variation in the frequency of catheter placement. We defined cases of kidney transplantation using Agency for Healthcare Research and Quality Clinical Classification Software. Placement of AC, CVC and PAC was defined by respective Current Procedural Terminology codes. The frequency of vascular catheter placement across facility types was compared using Pearson χ2 test. We identified 10,580 cases of kidney transplantation performed in 100 facilities from January 1, 2010 to December 31, 2014. Placement of an AC was reported in 1700 (16.1%), CVC in 2580 (24.4%) and PAC in 50 (0.5%) of cases. The frequency of placement of specific types of catheters was statistically different across facility types (p < 0.001). Within individual facilities that reported at least 50 cases of kidney transplantation, the percentages of cases performed with AC, CVC and PAC ranged from 0% to 86%, 0% to 90% and 0% to 3%, respectively. Considerable between-facility variation in the frequency of AC, CVC and PAC placement during kidney transplantation raises concerns about the need for better practice standardization. Excess invasive monitoring may represent a safety risk as well as unnecessary additional cost. If kidney transplantation can be safely performed without an AC, CVC or PAC in most patients, facilities with above-average catheter placement rates may have an opportunity for measurable reduction in catheter-related perioperative complications. Optimizing perioperative monitoring is an important component of ensuring high functioning, high-value medical systems.

Growth of Nonoperating Room Anesthesia Care in the United States: A Contemporary Trends Analysis.

BACKGROUND: Although previous publications suggest an increasing demand and volume of nonoperating room anesthesia (NORA) cases in the United States, there is little factual information on either volume or characteristics of NORA cases at a national level. Our goal was to assess the available data using the National Anesthesia Clinical Outcomes Registry (NACOR). METHODS: We performed a retrospective analysis of NORA volume and case characteristics using NACOR data for the period 2010-2014. Operating room (OR) and NORA cases were assessed for patient, provider, procedural, and facility characteristics. NACOR may indicate general trends, since it collects data on about 25% of all anesthetics in the United States each year. We examined trends in the annual proportion of NORA cases, the annual mean age of patients, the annual proportions of American Society of Anesthesiologists physical status (ASA PS) III-V patients, and outpatient cases. Regression analyses for trends included facility type and urban/rural location as covariables. The most frequently reported procedures were identified. RESULTS: The proportion of NORA cases overall increased from 28.3% in 2010 to 35.9% in 2014 (P < .001). The mean age of NORA patients was 3.5 years higher compared with OR patients (95% CI 3.5-3.5, P < .001). The proportion of patients with ASA PS class III-V was higher in the NORA group compared with OR group, 37.6% and 33.0%, respectively (P < .001). The median (quartile 1, 3) duration of NORA cases was 40 (25, 70) minutes compared with 86 (52, 141) minutes for OR cases (P < .001). In comparison to OR cases, more NORA cases were started after normal working hours (9.9% vs 16.7%, P < .001). Colonoscopy was the most common procedure that required NORA. There was a significant upward trend in the mean age of NORA patients in the multivariable analysis-the estimated increase in mean age was 1.06 years of age per year of study period (slope 1.06; 95% confidence interval [CI] 1.05-1.07, P < .001). Multivariable analysis demonstrated that the mean age of NORA patients increased significantly faster compared with OR patients (difference in slopes 0.39; 95% CI 0.38-0.41, P < .001). The annual increase in ordinal ASA PS of NORA patients was small in magnitude, but statistically significant (odds ratio 1.03; 95% CI 1.03-1.03, P < .001). The proportion of outpatient NORA cases increased from 69.7% in 2010 to 73.3% in 2014 (P < .001). CONCLUSIONS: Our results demonstrate that NORA is a growing component of anesthesiology practice. The proportion of cases performed outside of the OR increased during the study period. In addition, we identified an upward trend in the age of patients receiving NORA care. NORA cases were different from OR cases in a number of aspects. Data collected by NACOR in the coming years will further characterize the trends identified in this study.

The Patterns of Utilization of Interscalene Nerve Blocks for Total Shoulder Arthroplasty.

The interscalene block (ISB) is a common adjunct to general anesthesia for total shoulder arthroplasty (TSA). The aim of the study was to report the current national demographics of the patients who are receiving ISB for TSAs. We performed a retrospective analysis of data from the National Anesthesia Clinical Outcomes Registry from 2010 to 2015. Of 28,810 cases, 42.1% received an ISB. Only 0.83% of cases received regional anesthesia as the primary anesthetic. From 2010 to 2014, there has been an increase in ISB utilization for this surgery (odds ratio, 1.21; 95% confidence interval, 1.19-1.23; P < .0001). Furthermore, we report a geographic distribution of block utilization in the United States. We have identified national patterns for the utilization of regional anesthesia for TSAs that may provide insight into future design of research studies.

Utilization of Femoral Nerve Blocks for Total Knee Arthroplasty.

BACKGROUND: Little information exists on national trends in the utilization of femoral nerve blocks (FNBs) in total knee arthroplasties (TKAs). We sought to describe the variations in anesthetic practice for FNB using the National Anesthesia Clinical Outcomes Registry. METHODS: We used the National Anesthesia Clinical Outcomes Registry to obtain patient, procedural, and provider information from January 2010 to June 2015. Case characteristics and clinical outcomes were compared using chi-square or t tests. We used logistic regression to identify associations between patient and case characteristics with anesthetic technique. RESULTS: Overall, 219,327 cases met the inclusion criteria, in which 72.7% and 27.3% did not or did receive a FNB, respectively. Patients less than 18 years old and those with higher American Society of Anesthesiologists physical status class (≥III) were less likely to receive a FNB. Surgeries performed after 5:00 PM also were less likely to receive the block. Cases with urban zip code had approximately 20% increased odds of receiving a FNB. General or neuraxial anesthesia types were not associated with utilization of FNB. FNB was associated with decreased percentage of extended recovery room stays and postoperative nausea and/or vomiting. CONCLUSION: There is considerable practice variation in the use of FNB for TKA, which is associated with various factors such as geographic location, time of day, and patient-specific comorbidities. Approximately one fourth of TKA cases include FNB. Overall, our study supports the clinical utility of FNB in TKA. As more data are compiled, it will be important to examine how national trends shift in the future.

Smoking cessation in adults with diabetes: a systematic review and meta-analysis of data from randomised controlled trials.

OBJECTIVES: To evaluate the effects of more intensive smoking cessation interventions compared to less intensive interventions on smoking cessation in people with type 1 or type 2 diabetes. DESIGN: A systematic review and meta-analysis of randomised trials of smoking cessation interventions was conducted. Electronic searches were carried out on the following databases: MEDLINE, EMBASE, CINAHL and PsycINFO to September 2013. Searches were supplemented by review of trial registries and references from identified trials. Citations and full-text articles were screened by two reviewers. A random-effect Mantel-Haenszel model was used to pool data. SETTING: Primary, secondary and tertiary care. PARTICIPANTS: Adults with type 1 or type 2 diabetes. INTERVENTIONS: Smoking cessation interventions or medication (more intensive interventions) compared to usual care, counselling or optional medication (less intensive interventions). OUTCOME MEASURES: Biochemically verified smoking cessation was the primary outcome. Secondary outcomes were adverse events and effects on glycaemic control. We also carried out a pooled analysis of self-reported smoking cessation outcomes. RESULTS: We screened 1783 citations and reviewed seven articles reporting eight trials in 872 participants. All trials were of 6 months duration. Three trials included pharmacotherapy for smoking cessation. The risk ratio of biochemically verified smoking cessation was 1.32 (95% CI 0.23 to 7.43) for the more intensive interventions compared to less intensive interventions with significant heterogeneity (I(2)=76%). Only one trial reported measures of glycaemic control. CONCLUSIONS: There is an absence of evidence of efficacy for more intensive smoking cessation interventions in people with diabetes. The more intensive strategies tested in trials to date include interventions used in the general population, adding in diabetes-specific education about increased risk. Future research should focus on multicomponent smoking cessation interventions carried out over a period of at least 1 year, and also assess impact on glycaemic control.

Stepwise self-titration of oral glucose-lowering medication using a mobile telephone-based telehealth platform in type 2 diabetes: a feasibility trial in primary care.

BACKGROUND: Telehealth-supported clinical interventions may improve diabetes self-management. We explored the feasibility of stepwise self-titration of oral glucose-lowering medication guided by a mobile telephone-based telehealth platform for improving glycemic control in type 2 diabetes. METHODS: We recruited 14 type 2 diabetes patients to a one-year feasibility study with 1:1 randomization. Intervention group patients followed a stepwise treatment plan for titration of oral glucose-lowering medication with self-monitoring of glycemia using real-time graphical feedback on a mobile telephone and remote nurse monitoring using a Web-based tool. We carried out an interim analysis at 6 months. RESULTS: We screened 3476 type 2 diabetes patients; 94% of the ineligible did not meet the eligibility criteria for hemoglobin A1c (HbA1c) or current treatment. Mean (standard deviation) patient age at baseline was 58 (11) years, HbA1c was 65 (12) mmol/mol (8.1% [1.1%]), body mass index was 32.9 (6.4) kg/m2, median [interquartile range (IQR)] diabetes duration was 2.6 (0.6 to 4.7) years, and 10 (71%) were men. The median (IQR) change in HbA1c from baseline to six months was -10 (-21 to 3) mmol/mol (-0.9% [-1.9% to 0%]) in the intervention group and -5 (-13 to 6) mmol/mol (-0.5% [-1.2% to 0.6%]) in the control group. Six out of seven intervention group patients and four out of seven control group patients changed their oral glucose-lowering medication (p = .24). CONCLUSIONS: Self-titration of oral glucose-lowering medication in type 2 diabetes with self-monitoring and remote monitoring of glycemia is feasible, and further studies using adapted recruitment strategies are required to evaluate whether it improves clinical outcomes.

Diagnostic accuracy of urine dipstick testing in screening for microalbuminuria in type 2 diabetes: a cohort study in primary care.

BACKGROUND: Clinical guidelines recommend annual screening for microalbuminuria in diabetes. Detection of microalbuminuria is important because it is associated with increased morbidity and mortality. Dipstick tests for microalbuminuria may be convenient, but their accuracy is uncertain. OBJECTIVE: To assess the utility of urine dipstick testing for microalbuminuria in type 2 diabetes. METHODS: In a 6-week cohort study in four general practices in Oxfordshire, UK, first-pass urine samples were obtained at two weekly intervals from patients with type 2 diabetes and tested in the practice using Micral-Test and Microalbustix urine dipsticks. Parallel samples were sent for laboratory albumin-creatinine ratio (ACR) assay. Results of single dipstick tests and sequences of dipstick and laboratory tests were compared with a clinical testing strategy based on current guidelines to assess the accuracy and estimate costs of testing. RESULTS: The prevalence of microalbuminuria was 12.5% (n = 88). Mean (standard deviation) age was 68 (10) years, 56 (57%) were men. Median (interquartile range) diabetes duration was 6.2 (2.0-10.0) years. The sensitivity and specificity, respectively, of a single Micral-Test were 91.7% and 44.0% and of a Microalbustix test 33.3% and 92.0%. Testing strategies involving dipstick and laboratory ACR measurements or dipstick tests had similar accuracy. The costs of using dipstick tests were overall lower than laboratory ACR-based testing. CONCLUSIONS: Dipstick testing in this study did not reliably identify diabetes patients with microalbuminuria. Although dipstick testing would decrease testing costs, it could either fail to diagnose most patients with microalbuminuria or increase the numbers of patients retested depending on the dipstick used.

Predictors of suboptimal glycaemic control in type 2 diabetes patients: the role of medication adherence and body mass index in the relationship between glycaemia and age.

AIMS: To analyse predictors of glycaemic control including medication adherence and body mass index (BMI) in UK general practice patients with sub-optimally controlled type 2 diabetes. METHODS: Baseline demographic, health- and treatment-related measures were evaluated as predictors of one year glycaemic control defined separately as HbA(1c)≤ 7.5% and a continuous measure of HbA(1c) concentration, using multivariate regression models. Significant predictors were adjusted for objectively assessed medication adherence and BMI. RESULTS: One-year HbA(1c) concentration was associated with baseline HbA(1c) (p<0.001), BMI (p=0.02), and inversely associated with age (p=0.007) and objectively assessed adherence. Adherent patients had one-year (adjusted) HbA(1c) concentration 0.65% (95% CI -1.04, -0.25; p=0.001) lower than nonadherent. Odds ratios (95% CI) of HbA(1c)≤ 7.5% for 10-year higher age were 1.63 (1.08, 2.45); for adherent compared to non-adherent patients 1.89 (0.84, 4.25); for patients receiving >5 compared to ≤ 5 medications 0.32 (0.13, 0.76); and for each 1% increment in baseline HbA(1c) 0.48 (0.31, 0.73). CONCLUSIONS: The lower HbA(1c) achieved from greater adherence to glucose lowering treatment is comparable to that achieved with additional medication. Relationships between older age and better glycaemic control are not explained by better adherence, but may partly relate to lower BMI.