Optimization of Upper Extremity Rehabilitation by Combining Telerehabilitation With an Exergame in People With Chronic Stroke: Protocol for a Mixed Methods Study

BACKGROUND

Exergames have the potential to provide an accessible, remote approach for poststroke upper extremity (UE) rehabilitation. However, the use of exergames without any follow-up by a health professional could lead to compensatory movements during the exercises, inadequate choice of difficulty level, exercises not being completed, and lack of motivation to pursue exercise programs, thereby decreasing their benefits. Combining telerehabilitation with exergames could allow continuous adjustment of the exercises and monitoring of the participant's completion and adherence. At present, there is limited evidence regarding the feasibility or efficacy of combining telerehabilitation and exergames for stroke rehabilitation.

OBJECTIVE

This study aims to (1) determine the preliminary efficacy of using telerehabilitation combined with exergames on UE motor recovery, function, quality of life, and motivation in participants with chronic stroke, compared with conventional therapy (the graded repetitive arm supplementary program; GRASP); (2) examine the feasibility of using the technology with participants diagnosed with stroke at home; and (3) identify the obstacles and facilitators for its use by participants diagnosed with stroke and stroke therapists and understand the shared decision-making process.

METHODS

A mixed methods study protocol is proposed, including a randomized, blinded feasibility trial with an embedded multiple case study. The intervention consists of the provision of a remote rehabilitation program, during which participants will use the Jintronix exergame for UE training and the Reacts Application to conduct videoconferenced sessions with the therapists (physical or occupational therapists). We plan to recruit 52 participants diagnosed with stroke, randomly assigned to a control group (n=26; 2-month on-paper home exercise program: the GRASP with no supervision) and an experimental group (n=26; 2-month home program using the technology). The primary outcome is the Fugl-Meyer UE Assessment, a performance-based measure of UE impairment. The secondary outcomes are self-reported questionnaires and include the Motor Activity Log-28 (quality and frequency of use of the UE), Stroke Impact Scale-16 (the quality of life), and Treatment Self-Regulation Questionnaire (motivation). Feasibility data include process, resources, management, and scientific outcomes. Qualitative data will be collected by interviews with both participants and therapists.

RESULTS

At present, data collection was ongoing with one participant who had completed the exergame- telerehabilitation based intervention. We expect to collect preliminary efficacy data of this technology on the functional and motor recovery of the UE, following a stroke; collect feasibility data with users at home (adherence, safety, and technical difficulties); and identify the obstacles and facilitators for the technology use and understand the shared decision-making process.

CONCLUSIONS

This paper describes the protocol underlying the study of a telerehabilitation-exergame technology to contribute to understanding its feasibility and preliminary efficacy for UE stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03759106; http://clinicaltrials.gov/show/NCT03759106.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14629.

Practical advice on monitoring of U and Pu with marine bivalve mollusks near the Fukushima Daiichi Nuclear Power Plant

Following the Fukushima Daiichi nuclear power plant accident in 2011, some marine radionuclide monitoring studies report a lack of evidence for contamination of Japanese coastal waters by U and Pu, or state that marine contamination by them was negligible. Nevertheless, Fukushima-derived U and Pu were reported as associated with Cs-rich microparticles (CsMPs) found in local soil, vegetation, and river/lake sediments. Over time, CsMPs can be transported to the sea via riverine runoff where actinides, as expected, will leach. We recommend establishing a long-term monitoring of U and Pu in the nearshore area of the Fukushima Prefecture using marine bivalve mollusks; shells, byssal threads and soft tissues should all be analyzed. Here, based on results from Th biosorption experiments, we propose that U and Pu could be present at concentrations several times higher in shells with a completely destroyed external shell layer (periostracum) than in shells with intact periostracum.

Oceans and human health—navigating changes on Canada’s coasts

Ocean conditions can affect human health in a variety of ways that are often overlooked and unappreciated. Oceans adjacent to Canada are affected by many anthropogenic stressors, with implications for human health and well-being. Climate change further escalates these pressures and can expose coastal populations to unique health hazards and distressing conditions. However, current research efforts, education or training curriculums, and policies in Canada critically lack explicit consideration of these ocean–public health linkages. The objective of this paper is to present multiple disciplinary perspectives from academics and health practitioners to inform the development of future directions for research, capacity development, and policy and practice at the interface of oceans and human health in Canada. We synthesize major ocean and human health linkages in Canada, and identify climate-sensitive drivers of change, drawing attention to unique considerations in Canada. To support effective, sustained, and equitable collaborations at the nexus of oceans and human health, we recommend the need for progress in three critical areas: ( i) holistic worldviews and perspectives, ( ii) capacity development, and ( iii) structural supports. Canada can play a key role in supporting the global community in addressing the health challenges of climate and ocean changes.

Shell deformity as a marker for retrospective detection of a pathogenic unicellular alga, Coccomyxa sp., in mytilid mussels: A first case study and research agenda

An L-shaped shell deformity (LSSD) on the posterior shell edge is known exclusively in wild mytilid mussels infected with photosynthetic Coccomyxa-like algae. LSSD forms due to the appearance of extra shell material; it only occurs if the mussel is heavily infected with the alga. Traditionally, observation of high amount of the green spots (algal colonies) on a large area of host soft tissues (most of the mantle and in adductor muscle) has been used to indicate a high infection rate. We examined 300 Mytilus spp. (100 small, 20-30 mm; 200 large, 40-60 mm) with a high degree of LSSD (parameter "d" > 5 mm) from the Lower St. Lawrence Estuary (Québec, Canada). Green spots were absent in two large mussels, and were only present along the mantle posterior edge in 14 large mussels; other individuals had high infection levels. Our observations suggest that some individuals could be in a state of remission, or, even more optimistically - mussels may be able to resist the pathogen. LSSD is the stable through-time marker for detection of mytilid mussels that are or were infected with Coccomyxa algae, and, thus, may provide information for the study of mussel immunity and control of alga distribution/migration in coastal waters worldwide.

Changes in infaunal assemblage structure influence nutrient fluxes in sediment enriched by mussel biodeposition

Although many studies have described the influence of bivalve aquaculture on the benthic environment, effects on benthic functional diversity are poorly known, as are links with ecosystem processes. We investigated the response of a benthic ecosystem in terms of taxonomic and functional diversity (infauna >500 μm), biogeochemical indicators (organic matter content, redox potential, sulfides level, bacteria) and metabolism (nutrient fluxes), subjected to various levels of mussel biodeposition as a general model of organic enrichment. Results show that local benthic conditions may recover fairly quickly depending on environmental conditions whereas modifications of the benthic community structure persist over a longer time scale with an impact on benthic ecosystem functioning. Fauna-mediated oxidation of the sediment likely increased nitrogen recycling through nitrification whereas binding and release of phosphorus to the water column seems to be driven by more complex processes. Results highlight the importance of species identity (ecological traits) on biogeochemical cycling and solute exchange across the sediment-water interface, with implications for the ecological functioning of exploited areas.

Ecological risk assessment of predicted marine invasions in the Canadian Arctic

Climate change is impacting environmental conditions, especially with respect to temperature and ice cover in high latitude regions. Predictive models and risk assessment are key tools for understanding potential changes associated with such impacts on coastal regions. In this study relative ecological risk assessment was done for future potential introductions of three species in the Canadian Arctic: periwinkle Littorina littorea, soft shell clam Mya arenaria and red king crab Paralithodes camtschaticus. These species occur in locations connected to Canadian Arctic ports through shipping and have the potential to be introduced via ballast water discharge. The methodology proposed in this study is unique in the sense that it considers not only ballast water origin, but also the distribution of the species being assessed and the sensitivity of the receiving habitat. It combines detailed information (ballast water source of each tank, transit time, time of the year when the water is released, environmental suitability of receiving habitat, impact, and habitat sensitivity) in order to assess ecological risk. Through the use of this approach it is highlighted that domestic discharge events pose a higher relative overall risk on a vessel-specific and cumulative annual bases than international discharges. The main ports of Deception Bay and Churchill were classified as being at moderate to high relative risk for L. littorea and M. arenaria, especially from domestic vessels, while relative overall risk for P. camtschaticus was low for international vessels and null for domestic vessels due to few ships transiting from its range of distribution to Canadian Arctic ports. This work can serve as an approach to help build a list of potential high risk species–a “grey” watch list–for the Canadian Arctic, and provides useful information for consideration in future decision making actions such as the identification of high risk pathways, species and ports.

Electromyogram-Related Neuromuscular Electrical Stimulation for Restoring Wrist and Hand Movement in Poststroke Hemiplegia: A Systematic Review and Meta-Analysis

Background. Clinical trials have demonstrated some benefits of electromyogram-triggered/controlled neuromuscular electrical stimulation (EMG-NMES) on motor recovery of upper limb (UL) function in patients with stroke. However, EMG-NMES use in clinical practice is limited due to a lack of evidence supporting its effectiveness. Objective. To perform a systematic review and meta-analysis to determine the effects of EMG-NMES on stroke UL recovery based on each of the International Classification of Functioning, Disability, and Health (ICF) domains. Methods. Database searches identified clinical trials comparing the effect of EMG-NMES versus no treatment or another treatment on stroke upper extremity motor recovery. A meta-analysis was done for outcomes at each ICF domain (Body Structure and Function, Activity and Participation) at posttest (short-term) and follow-up periods. Subgroup analyses were conducted based on stroke chronicity (acute/subacute, chronic phases). Sensitivity analysis was done by removing studies rated as poor or fair quality (PEDro score <6). Results. Twenty-six studies (782 patients) met the inclusion criteria. Fifty percent of them were considered to be of high quality. The meta-analysis showed that EMG-NMES has a robust short-term effect on improving UL motor impairment in the Body Structure and Function domain. No evidence was found in favor of EMG-NMES for the Activity and Participation domain. EMG-NMES had a stronger effect for each ICF domain in chronic (≥3 months) compared to acute/subacute phases. Conclusion. EMG-NMES is effective in the short term in improving UL impairment in individuals with chronic stroke.

Biogeography and adaptations of torquaratorid acorn worms (Hemichordata: Enteropneusta) including two new species from the Canadian Arctic

The enteropneust family Torquaratoridae, discovered in 2005, has the fewest species of the four living families. It is composed of seven species that live on the cold, deep-sea floor. Torquarator bullocki Holland, Clague, Gordon, Gebruk, Pawson and Vecchione, 2005 was the first species described and collected from the Northeastern Pacific. Two new species of Torquaratoridae were collected from the Eastern Pacific and described as Tergivelum baldwinae Holland, Jones, Ellena, Ruhl and Smith, 2009 and Allapasus aurantiacus Holland, Kuhnz and Osborn, 2012. A further three species have been collected from the North Atlantic: Yoda purpurata Priede, Osborn, Gebruk, Jones, Shale, Rogacheva and Holland, 2012, Allapasus isidis Priede, Osborn, Gebruk, Jones, Shale, Rogacheva and Holland, 2012, and Tergivelum cinnabarinum Priede, Osborn, Gebruk, Jones, Shale, Rogacheva and Holland, 2012. The latest Torquaratoridae species was collected from the Russian Arctic in 2013. We add two new species to the Torquaratoridae from Baffin Bay and Viscount Melville Sound, in the eastern Arctic of Canada. Terminstomo arcticus gen. nov. and sp. nov. was collected at a depth of 505 m and is characterized by lacking a heart and a stomochord that extends from the posterior end of the proboscis through the entire length of the collar. Allapasus fuscus sp. nov. was collected from a depth of 444 m and is characterized by a typhlosole process along the dorsal midline of the collar buccal cavity.

eDNA metabarcoding as a new surveillance approach for coastal Arctic biodiversity

Because significant global changes are currently underway in the Arctic, creating a large-scale standardized database for Arctic marine biodiversity is particularly pressing. This study evaluates the potential of aquatic environmental DNA (eDNA) metabarcoding to detect Arctic coastal biodiversity changes and characterizes the local spatio-temporal distribution of eDNA in two locations. We extracted and amplified eDNA using two COI primer pairs from ~80 water samples that were collected across two Canadian Arctic ports, Churchill and Iqaluit, based on optimized sampling and preservation methods for remote regions surveys. Results demonstrate that aquatic eDNA surveys have the potential to document large-scale Arctic biodiversity change by providing a rapid overview of coastal metazoan biodiversity, detecting nonindigenous species, and allowing sampling in both open water and under the ice cover by local northern-based communities. We show that DNA sequences of ~50% of known Canadian Arctic species and potential invaders are currently present in public databases. A similar proportion of operational taxonomic units was identified at the species level with eDNA metabarcoding, for a total of 181 species identified at both sites. Despite the cold and well-mixed coastal environment, species composition was vertically heterogeneous, in part due to river inflow in the estuarine ecosystem, and differed between the water column and tide pools. Thus, COI-based eDNA metabarcoding may quickly improve large-scale Arctic biomonitoring using eDNA, but we caution that aquatic eDNA sampling needs to be standardized over space and time to accurately evaluate community structure changes.

What's in a tide pool? Just as much food web network complexity as in large open ecosystems

Understanding the fundamental laws that govern complex food web networks over large ecosystems presents high costs and oftentimes unsurmountable logistical challenges. This way, it is crucial to find smaller systems that can be used as proxy food webs. Intertidal rock pool environments harbour particularly high biodiversity over small areas. This study aimed to analyse their food web networks to investigate their potential as proxies of larger ecosystems for food web networks research. Highly resolved food webs were compiled for 116 intertidal rock pools from cold, temperate, subtropical and tropical regions, to ensure a wide representation of environmental variability. The network properties of these food webs were compared to that of estuaries, lakes and rivers, as well as marine and terrestrial ecosystems (46 previously published complex food webs). The intertidal rock pool food webs analysed presented properties that were in the same range as the previously published food webs. The niche model predictive success was remarkably high (73–88%) and similar to that previously found for much larger marine and terrestrial food webs. By using a large-scale sampling effort covering 116 intertidal rock pools in several biogeographic regions, this study showed, for the first time, that intertidal rock pools encompass food webs that share fundamental organizational characteristics with food webs from markedly different, larger, open and abiotically stable ecosystems. As small, self-contained habitats, intertidal rock pools are particularly tractable systems and therefore a large number of food webs can be examined with relatively low sampling effort. This study shows, for the first time that they can be useful models for the understanding of universal processes that regulate the complex network organization of food webs, which are harder or impossible to investigate in larger, open ecosystems, due to high costs and logistical difficulties.

Bioturbation activity of three macrofaunal species and the presence of meiofauna affect the abundance and composition of benthic bacterial communities

Given concerns of increasing rates of species extinctions, the relationship between biodiversity and ecosystem functioning has become a major research focus over the past two decades. Many studies have shown that biodiversity per se (e.g. species richness) or species-specific traits may be good predictors of changes in ecosystem function. Although numerous studies on this subject have focused on terrestrial systems, few have evaluated benthic marine systems. We used the Limecola balthica community as a model to test whether the number or identity of three well-studied macrofaunal species influence the sediment bacterial compartment, which drives important biogeochemical processes and influence ecosystem functioning. We also investigated the poorly known role of meiofauna in the interactions between macrofauna and bacteria. Eight combinations of 0-3 species were maintained in microcosms for 34 days in the presence or absence of meiofauna. The abundance and composition of the bacterial community, defined by the relative percentage of cells with a high (HNA) vs low (LNA) nucleic acid content, were measured. Species identity of macrofauna was a better indicator of changes in the microbial compartment than was species richness per se. In particular, the gallery-diffuser behaviour of the polychaete Alitta virens likely induced strong changes in sediment physical and geochemical properties with a major impact on the bacterial compartment. Moreover, the presence of meiofauna modulated the influence of macrofauna on bacterial communities. This study provides evidence that species identity provides greater explanatory power than species richness to predict changes in the bacterial compartment. We propose that multi-compartment approaches to describe interactions amongst different size classes of organisms and their ecological roles should be further developed to improve our understanding of benthic ecosystem functioning.

O4 -Alkylated-2-Deoxyuridine Repair by O6 -Alkylguanine DNA Alkyltransferase is Augmented by a C5-Fluorine Modification

Oligonucleotides containing various adducts, including ethyl, benzyl, 4-hydroxybutyl and 7-hydroxyheptyl groups, at the O⁴ atom of 5-fluoro-O⁴ -alkyl-2'-deoxyuridine were prepared by solid-phase synthesis. UV thermal denaturation studies demonstrated that these modifications destabilised the duplex by approximately 10 °C, relative to the control containing 5-fluoro-2'-deoxyuridine. Circular dichroism spectroscopy revealed that these modified duplexes all adopted a B-form DNA structure. O⁶ -Alkylguanine DNA alkyltransferase (AGT) from humans (hAGT) was most efficient at repair of the 5-fluoro-O⁴ -benzyl-2'-deoxyuridine adduct, whereas the thymidine analogue was refractory to repair. The Escherichia coli AGT variant (OGT) was also efficient at removing O⁴ -ethyl and benzyl adducts of 5-fluoro-2-deoxyuridine. Computational assessment of N1-methyl analogues of the O⁴ -alkylated nucleobases revealed that the C5-fluorine modification had an influence on reducing the electron density of the O⁴ -C_α bond, relative to thymine (C5-methyl) and uracil (C5-hydrogen). These results reveal the positive influence of the C5-fluorine atom on the repair of larger O⁴ -alkyl adducts to expand knowledge of the range of substrates able to be repaired by AGT.

Mytilus trossulus and hybrid (M. edulis-M. trossulus) - New hosts organisms for pathogenic microalgae Coccomyxa sp. from the Estuary and northwestern Gulf of St. Lawrence, Canada

During summer 2014-2017, wild mytilid mussels, highly infested with the pathogenic Coccomyxa-like microalgae, were collected along the Estuary and northwestern part of Gulf of St. Lawrence (Québec, Canada). Molecular identification showed that algae can be assigned to a single taxon, Coccomyxa sp. (KJ372210), whereas hosts are represented by Mytilus edulis, M. trossulus and hybrid between these two species. This is the first record of M. trossulus and hybrid among hosts of this pathogenic alga. Our results are indicative of a possible widespread distribution of Coccomyxa sp. in the Lower St. Lawrence Estuary and along coastal waters of Canadian Maritime provinces.

Ecological Virtual Reality Evaluation of Neglect Symptoms (EVENS): Effects of Virtual Scene Complexity in the Assessment of Poststroke Unilateral Spatial Neglect

Background. Unilateral spatial neglect (USN) is a highly prevalent and disabling poststroke impairment. USN is traditionally assessed with paper-and-pencil tests that lack ecological validity, generalization to real-life situations and are easily compensated for in chronic stages. Virtual reality (VR) can, however, counteract these limitations. Objective. We aimed to examine the feasibility of a novel assessment of USN symptoms in a functional shopping activity, the Ecological VR-based Evaluation of Neglect Symptoms (EVENS). Methods. EVENS is immersive and consists of simple and complex 3-dimensional scenes depicting grocery shopping shelves, where joystick-based object detection and navigation tasks are performed while seated. Effects of virtual scene complexity on navigational and detection abilities in patients with (USN+, n = 12) and without (USN−, n = 15) USN following a right hemisphere stroke and in age-matched healthy controls (HC, n = 9) were determined. Results. Longer detection times, larger mediolateral deviations from ideal paths and longer navigation times were found in USN+ versus USN− and HC groups, particularly in the complex scene. EVENS detected lateralized and nonlateralized USN-related deficits, performance alterations that were dependent or independent of USN severity, and performance alterations in 3 USN− subjects versus HC. Conclusion. EVENS’ environmental changing complexity, along with the functional tasks of far space detection and navigation can potentially be clinically relevant and warrant further empirical investigation. Findings are discussed in terms of attentional models, lateralized versus nonlateralized deficits in USN, and tasks-specific mechanisms.

Benthic macroinfaunal community structure, resource utilisation and trophic relationships in two Canadian Arctic Archipelago polynyas

Climate change driven alterations to patterns of Arctic marine primary production, with increasing phytoplankton- and decreasing ice algal production, have the potential to change the resource utilisation and trophic structure of the benthic communities relying on the algae for food. To predict the benthic responses to dietary changes, we studied the macroinfaunal community compositions, and used the faunal δ13C and δ15N signatures to investigate their main food sources and trophic positions in North Water (NOW) and Lancaster Sound (LS) polynyas in the Canadian Arctic Archipelago. Macroinfaunal density (10 952 ind. m-2) and biomass (3190 mg C m-2) recorded in NOW were higher than previously found in the Arctic at depths >500m, and significantly higher than in LS (8355 ind. m-2 and 2110 mg C m-2). This was attributed to higher particulate organic matter fluxes to seafloor in NOW. Polychaetes were significant taxa at both sites in terms of density and biomass, and in addition crustacean density in NOW and bivalve density in LS were high. Facultative filter and surface deposit feeders were highly prevalent at both sites, suggesting feeding plasticity is a successful strategy for accessing different food sources. The macrofaunal δ13C signatures reflected the signatures of pelagic particulate organic matter at the sites, and an isotope mixing model confirmed phytoplankton as the main food source for most taxa and feeding guilds. The food web length in LS was longer than in NOW (3.2 vs. 2.8 trophic levels). This was attributed to a larger reliance on reworked organic matter by the benthic community in LS, whereas the high export fluxes at the highly productive NOW resulted in higher rates of selective consumption of fresh algal matter. Despite studies suggesting that loss of ice algae from consumer diets in the Arctic might have a negative impact on the benthos, this study suggests that Arctic macrobenthic communities thrive using phytoplankton as their main food source and should thus be able to cope or even benefit from predicted changes to patterns of primary production.

Incorporating public priorities in the Ocean Health Index: Canada as a case study

The Ocean Health Index (OHI) is a framework to assess ocean health by considering many benefits (called 'goals') provided by the ocean provides to humans, such as food provision, tourism opportunities, and coastal protection. The OHI framework can be used to assess marine areas at global or regional scales, but how various OHI goals should be weighted to reflect priorities at those scales remains unclear. In this study, we adapted the framework in two ways for application to Canada as a case study. First, we customized the OHI goals to create a national Canadian Ocean Health Index (COHI). In particular, we altered the list of iconic species assessed, added methane clathrates and subsea permafrost as carbon storage habitats, and developed a new goal, 'Aboriginal Needs', to measure access of Aboriginal people to traditional marine hunting and fishing grounds. Second, we evaluated various goal weighting schemes based on preferences elicited from the general public in online surveys. We quantified these public preferences in three ways: using Likert scores, simple ranks from a best-worst choice experiment, and model coefficients from the analysis of elicited choice experiment. The latter provided the clearest statistical discrimination among goals, and we recommend their use because they can more accurately reflect both public opinion and the trade-offs faced by policy-makers. This initial iteration of the COHI can be used as a baseline against which future COHI scores can be compared, and could potentially be used as a management tool to prioritise actions on a national scale and predict public support for these actions given that the goal weights are based on public priorities.

Creating an inclusive mall environment with the PRECEDE-PROCEED model: a living lab case study

PURPOSE

Although public environments provide opportunities for participation and social inclusion, they are not always inclusive spaces and may not accommodate the wide diversity of people. The Rehabilitation Living Lab in the Mall is a unique, interdisciplinary, and multi-sectoral research project with an aim to transform a shopping complex in Montreal, Canada, into an inclusive environment optimizing the participation and social inclusion of all people.

METHODS

The PRECEDE-PROCEDE Model (PPM), a community-oriented and participatory planning model, was applied as a framework. The PPM is comprised of nine steps divided between planning, implementation, and evaluation.

RESULTS

The PPM is well suited as a framework for the development of an inclusive mall. Its ecological approach considers the environment, as well as the social and individual factors relating to mall users' needs and expectations. Transforming a mall to be more inclusive is a complex process involving many stakeholders. The PPM allows the synthesis of several sources of information, as well as the identification and prioritization of key issues to address. The PPM also helps to frame and drive the implementation and evaluate the components of the project.

CONCLUSION

This knowledge can help others interested in using the PPM to create similar enabling and inclusive environments world-wide. Implication for rehabilitation While public environments provide opportunities for participation and social inclusion, they are not always inclusive spaces and may not accommodate the wide diversity of people. The PRECEDE PROCEDE Model (PPM) is well suited as a framework for the development, implementation, and evaluation of an inclusive mall. Environmental barriers can negatively impact the rehabilitation process by impeding the restoration and augmentation of function. Removing barriers to social participation and independent living by improving inclusivity in the mall and other environments positively impacts the lives of people with disabilities.

Efficacy and safety of DPP-4 inhibitors in patients with type 2 diabetes: Meta-analysis of placebo-controlled randomized clinical trials

BACKGROUND

Guidelines for type 2 diabetes (T2D) recommend reducing HbA_1c through lifestyle interventions and glucose-lowering drugs (metformin, then combination with dipeptidyl peptidase-4 inhibitors [DPP-4Is] among other glucose-lowering drugs). However, no double-blind randomized clinical trial (RCT) compared with placebo has so far demonstrated that DDP-4Is reduce micro- and macrovascular complications in T2D. Moreover, the safety of DPP-4Is (with increased heart failure and acute pancreatitis) remains controversial.

METHODS

A systematic review of the literature (PubMed, Cochrane Library Central Register of Controlled Trials [CENTRAL] and https://clinicaltrials.gov), including all RCTs vs placebo published up to May 2015 and the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), published June 2015, was performed. Primary endpoints were all-cause mortality and death from cardiovascular causes; secondary endpoints were macrovascular and microvascular events. Safety endpoints were acute pancreatitis, pancreatic cancer, serious adverse events and severe hypoglycaemia.

RESULTS

A total of 36 double-blind RCTs were included, allowing analyses of 54,664 patients. There were no significant differences in all-cause mortality (RR=1.03, 95% confidence interval [CI]=0.95-1.12), cardiovascular mortality (RR=1.02, 95% CI=0.92-1.12), myocardial infarction (RR=0.98, 95% CI=0.89-1.08), strokes (RR=1.02, 95% CI=0.88-1.17), renal failure (RR=1.06, 95% CI=0.88-1.27), severe hypoglycaemia (RR=1.14, 95% CI=0.95-1.36) and pancreatic cancer (RR=0.54, 95% CI=0.28-1.04) with the use of DPP-4Is. However, DDP-4Is were associated with an increased risk of heart failure (RR=1.13, 95% CI=1.01-1.26) and of acute pancreatitis (RR=1.57, 95% CI=1.03-2.39).

CONCLUSION

There is no significant evidence of short-term efficacy of DPP-4Is on either morbidity/mortality or macro-/microvascular complications in T2D. However, there are warning signs concerning heart failure and acute pancreatitis. This suggests a great need for additional relevant studies in future.