Developmental vulnerability--don't investigate without a model in mind

Children who are developmentally vulnerable are at risk of a difficult start to school, and ongoing educational challenges which may adversely impact on long term health outcomes. Clinicians, researchers and service providers need a thorough understanding of both risk and protective factors and their complex interplay to understand their impact on early childhood development, in order to plan effective and comprehensive prevention and interventions strategies. In this opinion piece we recommend that investigation of developmental vulnerability should only proceed if underpinned by both a theoretical model through which the interaction between risk and protective factors may be investigated, and analytical models that are appropriate to assess these impacts.

Recall of physical activity advice was associated with higher levels of physical activity in colorectal cancer patients

OBJECTIVES

The present study tested the hypothesis that recall of receiving physical activity (PA) advice would be associated with higher levels of PA in patients with a diagnosis of colorectal cancer (CRC).

SETTING

Colorectal cancer patients who were diagnosed in 2010 or 2011, and had been treated in the English National Health Service (NHS).

PARTICIPANTS

17,753 respondents completed at least one section of the survey relevant to the current study and after exclusion of 171 with dementia (since results relied on recall), 15,254 had complete data for the current study. 60% were male, 67% were >65 years and 96% were from a white ethnic group.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients completed the 'Living with and Beyond Colorectal Cancer' Patient-Reported Outcome Measures (PROMS) survey in 2013. The survey included questions on receiving exercise advice/information ('PA advice'), and the frequency of currently doing at least 30 min of brisk PA per day ('PA level': 0, 1-4 or 5-7 days, within the past week; with the top category meeting UK guidelines).

RESULTS

A third of respondents (31%) recalled receiving PA advice. Independent of demographics and treatment, patients who recalled having PA advice were more likely to be currently doing some brisk PA (51% in the advice group vs 42% in the no advice group; OR 1.74, 95% CI 1.60 to 1.90; p<0.001), and more likely to be meeting PA guidelines (25% vs 20%; OR 1.70, CI 1.54 to 1.88; p<0.001).

CONCLUSIONS

Recalling being given PA advice after a diagnosis of CRC was associated with higher levels of PA. However, less than a third of patients recalled receiving advice. Future research should examine the context in which advice is given and randomised trials are required. However, encouraging clinicians working with patients with CRC to give brief PA advice is warranted and may help improve outcomes for CRC survivors.

Health professionals' provision of lifestyle advice in the oncology context in the United Kingdom

A healthy lifestyle following a cancer diagnosis is linked with better long-term outcomes. Health professionals can play an important role in promoting healthy lifestyles after cancer, but little is known about the factors that influence whether or not they give lifestyle advice. We conducted an online survey to examine levels of, and predictors of, health professionals' provision of lifestyle advice to cancer patients in the United Kingdom. The survey included questions on awareness of lifestyle guidelines for cancer survivors, current practices with regard to giving advice on smoking, diet, exercise, weight and alcohol, and perceived barriers to giving advice. Nurses, surgeons and physicians (N=460) responded to the survey. Many (36%) were not aware of any lifestyle guidelines for cancer survivors, but 87% reported giving some lifestyle advice; although this was lower for individual behaviours and often to <50% of patients. Respondents who were aware of lifestyle guidelines were more likely to give lifestyle advice on all behaviours (all OR's>1.76, all P's<0.05). Not believing lifestyle would affect outcomes was associated with lower odds of giving lifestyle advice (all OR's<0.48, all P's<0.05). Improved survivorship education for health professionals may increase the number of patients receiving lifestyle advice, and improve their long-term outcomes.

Improved upper limits on the stochastic gravitational-wave background from 2009-2010 LIGO and Virgo data

Gravitational waves from a variety of sources are predicted to superpose to create a stochastic background. This background is expected to contain unique information from throughout the history of the Universe that is unavailable through standard electromagnetic observations, making its study of fundamental importance to understanding the evolution of the Universe. We carry out a search for the stochastic background with the latest data from the LIGO and Virgo detectors. Consistent with predictions from most stochastic gravitational-wave background models, the data display no evidence of a stochastic gravitational-wave signal. Assuming a gravitational-wave spectrum of Ω_{GW}(f)=Ω_{α}(f/f_{ref})^{α}, we place 95% confidence level upper limits on the energy density of the background in each of four frequency bands spanning 41.5-1726 Hz. In the frequency band of 41.5-169.25 Hz for a spectral index of α=0, we constrain the energy density of the stochastic background to be Ω_{GW}(f)<5.6×10^{-6}. For the 600-1000 Hz band, Ω_{GW}(f)<0.14(f/900  Hz)^{3}, a factor of 2.5 lower than the best previously reported upper limits. We find Ω_{GW}(f)<1.8×10^{-4} using a spectral index of zero for 170-600 Hz and Ω_{GW}(f)<1.0(f/1300  Hz)^{3} for 1000-1726 Hz, bands in which no previous direct limits have been placed. The limits in these four bands are the lowest direct measurements to date on the stochastic background. We discuss the implications of these results in light of the recent claim by the BICEP2 experiment of the possible evidence for inflationary gravitational waves.

Influence of skin colour on diagnostic accuracy of the jaundice meter JM 103 in newborns

AIM

To assess the diagnostic accuracy of the JM 103 as a screening tool for neonatal jaundice and explore differential effects based on skin colour.

METHODS

We prospectively compared the transcutaneous bilirubin (TcB) and serum bilirubin (TSB) measurements of newborns over a 3 month-period. Skin colour was assigned via reference colour swatches. Diagnostic measures of the TcB/TSB comparison were made and clinically relevant TcB cut-off values were determined for each skin colour group.

RESULTS

451 infants (51 light, 326 medium and 74 dark skin colour) were recruited. The association between TcB and TSB was high for all skin colours (rs>0.9). The Bland-Altman analysis showed an absolute mean difference between the two measures of 13.3±26.4 µmol/L with broad limits of agreement (-39.4-66.0 µmol/L), with TcB underestimating TSB in light and medium skin colours and overestimating in dark skin colour. Diagnostic measures were also consistently high across skin colours, with no clinically significant differences observed.

CONCLUSIONS

The JM 103 is a useful screening tool to identify infants in need of serum bilirubin, regardless of skin colour. The effect of skin colour on the accuracy of this device at high levels of serum bilirubin could not be assessed fully due to small numbers in the light and dark groups.

Psychiatry resident outpatient clinic supervision: how training directors are balancing patient care, education, and reimbursement

OBJECTIVE

Recent literature on psychiatry resident outpatient clinic supervision is sparse. In designing outpatient supervision, training directors must balance optimization of patient care, education, and reimbursement. The authors sought to describe current practices for supervision within psychiatry resident outpatient clinics.

METHODS

Directors of US psychiatric residency training programs were surveyed to examine methods used for supervision and billing in psychiatry resident outpatient clinics.

RESULTS

Seventy of 183 (38%) training directors responded. Most programs utilize live supervision for medication management visits, but psychotherapy supervision is more varied. Billing practices are variable among programs.

CONCLUSIONS

This report is intended to help training directors consider options for optimizing patient care and resident education in their outpatient clinics, while maintaining financial solvency. Ultimately, programs should have a way of ensuring all patient cases have some form of ongoing supervision, with possible modification based on training level, resident ability, patient acuity, and appointment type.

Survey of neonatal unit outbreaks in North London: identifying causes and risk factors

BACKGROUND

This survey was undertaken after a number of neonatal unit (NNU) outbreaks were reported to the North London health protection teams (HPTs).

AIM

To determine the diversity of the outbreaks, ascertain potential sources and contributing factors, and identify the investigative procedures followed and control measures implemented.

METHODS

Using a structured questionnaire, information from the HPT database was collected for all NNU outbreaks reported between January 2010 and February 2011.

FINDINGS

Ten outbreaks were identified from seven hospitals in 14 months. There was one para-influenza outbreak, seven Staphylococcus aureus [including six meticillin-resistant S. aureus (MRSA)] outbreaks, and two Gram-negative outbreaks. Potential sources of transmission identified for the MRSA outbreaks were healthcare worker (HCW)-assisted transmission (N = 2) and mother-to-baby transmission with onward HCW-assisted transmission (N = 3). An environmental source with onward HCW-assisted transmission was documented for one of the Gram-negative outbreaks. Interventions included patient screening and enhanced cleaning (N = 10), isolating/cohorting affected neonates (N = 9), barrier nursing (N = 6), staff movement restrictions (N = 5), hand hygiene audits (N = 4), staff screening (N = 4), household contact screening (N = 3) and environmental sampling (N = 3). Potential contributing factors included inadequate staffing levels, cluttered unit, inadequate sterilization of communal milk-expressing equipment and inappropriate follow-up of MRSA results.

CONCLUSION

This survey determined the diversity of NNU outbreaks in North London, and highlighted the importance of a multi-faceted approach to outbreak control. These data will assist in the development of clinical standards for the prevention, control and reporting of NNU outbreaks, and guidance for best practice in NNUs.

Effects of daily kangaroo care on cardiorespiratory parameters in preterm infants

BACKGROUND/AIMS

Kangaroo care (KC) has possible benefits for promoting physiological stability and positive developmental outcomes in preterm infants. The purpose of this study was to compare bradycardia and oxygen desaturation events in preterm infants in standard incubator care versus KC.

METHODS

Thirty-eight infants 27 to 30 weeks gestational age were randomly assigned to 2 hours of KC daily between days of life 5 to 10 or to standard incubator care. Infants were monitored for bradycardia (heart rate <80) or oxygen desaturation (<80%). Analysis of hourly events was based on three sets of data: standard care group 24 hours daily, KC group during incubator time 22 hours daily, and KC group during holding time 2 hours daily.

RESULTS

The KC group had fewer bradycardia events per hour while being held compared to time spent in an incubator (p = 0.048). The KC group also had significantly fewer oxygen desaturation events while being held than while in the incubator (p = 0.017) and significantly fewer desaturation events than infants in standard care (p = 0.02).

CONCLUSION

KC reduces bradycardia and oxygen desaturation events in preterm infants, providing physiological stability and possible benefits for neurodevelopmental outcomes.

Search for gravitational waves associated with γ-ray bursts detected by the interplanetary network

We present the results of a search for gravitational waves associated with 223 γ-ray bursts (GRBs) detected by the InterPlanetary Network (IPN) in 2005-2010 during LIGO's fifth and sixth science runs and Virgo's first, second, and third science runs. The IPN satellites provide accurate times of the bursts and sky localizations that vary significantly from degree scale to hundreds of square degrees. We search for both a well-modeled binary coalescence signal, the favored progenitor model for short GRBs, and for generic, unmodeled gravitational wave bursts. Both searches use the event time and sky localization to improve the gravitational wave search sensitivity as compared to corresponding all-time, all-sky searches. We find no evidence of a gravitational wave signal associated with any of the IPN GRBs in the sample, nor do we find evidence for a population of weak gravitational wave signals associated with the GRBs. For all IPN-detected GRBs, for which a sufficient duration of quality gravitational wave data are available, we place lower bounds on the distance to the source in accordance with an optimistic assumption of gravitational wave emission energy of 10(-2)M⊙c(2) at 150 Hz, and find a median of 13 Mpc. For the 27 short-hard GRBs we place 90% confidence exclusion distances to two source models: a binary neutron star coalescence, with a median distance of 12 Mpc, or the coalescence of a neutron star and black hole, with a median distance of 22 Mpc. Finally, we combine this search with previously published results to provide a population statement for GRB searches in first-generation LIGO and Virgo gravitational wave detectors and a resulting examination of prospects for the advanced gravitational wave detectors.

Search for gravitational waves associated with γ-ray bursts detected by the interplanetary network

We present the results of a search for gravitational waves associated with 223 γ-ray bursts (GRBs) detected by the InterPlanetary Network (IPN) in 2005-2010 during LIGO's fifth and sixth science runs and Virgo's first, second, and third science runs. The IPN satellites provide accurate times of the bursts and sky localizations that vary significantly from degree scale to hundreds of square degrees. We search for both a well-modeled binary coalescence signal, the favored progenitor model for short GRBs, and for generic, unmodeled gravitational wave bursts. Both searches use the event time and sky localization to improve the gravitational wave search sensitivity as compared to corresponding all-time, all-sky searches. We find no evidence of a gravitational wave signal associated with any of the IPN GRBs in the sample, nor do we find evidence for a population of weak gravitational wave signals associated with the GRBs. For all IPN-detected GRBs, for which a sufficient duration of quality gravitational wave data are available, we place lower bounds on the distance to the source in accordance with an optimistic assumption of gravitational wave emission energy of 10(-2)M⊙c(2) at 150 Hz, and find a median of 13 Mpc. For the 27 short-hard GRBs we place 90% confidence exclusion distances to two source models: a binary neutron star coalescence, with a median distance of 12 Mpc, or the coalescence of a neutron star and black hole, with a median distance of 22 Mpc. Finally, we combine this search with previously published results to provide a population statement for GRB searches in first-generation LIGO and Virgo gravitational wave detectors and a resulting examination of prospects for the advanced gravitational wave detectors.

Vergleichende Analyse der nach den Extraktionsmethoden von Kirby und Georgiev aus Mäuseleber extrahierten RNS-Fraktionen / Analysis of the RNA Fractions of Mouse Liver: Comparison of the Extraction Methods of Kirby and Georgiev

Ribonucleic acids labeled with 14C- or 3H-orotic acids, respectively were extracted from aliquots of mouse liver homogenates according to the cold-phenol-method of Kirby or the method of Georgiev employing different temperature steps.

This comparative analysis showed that only ca. 50% of the total labeled RNA was extracted by the Kirby method. Especially the high molecular D-RNA and R-RNA were not sufficiently extracted, as was demonstrated by hydroxyapatite- and methylalbumin-Kieselgur column chromatography.

Reextraction of the tissue at 65 °C first extracted by the Kirby method resulted in a recovery of most of the missing nucleic acid species.

Therefore, results obtained by the Kirby and Georgiev methods will be different in regard to the nucleic acid composition. These findings could explain contradictary results about this problem in literature.

Changes in physical activity during a weight loss intervention and follow-up: a randomized controlled trial

Physical activity is an important component in weight loss treatment and weight maintenance. We evaluated the physical activity component of two weight loss programmes, either standard care (SC) as defined by national guidelines, or a commercial programme (CP; Weight Watchers) over the period of weight loss and follow-up. 772 adults (mean body mass index: 31.4 ± 2.6 kg m(-2)) were recruited by primary care practices in Australia, the United Kingdom, and Germany, and randomly assigned to 12 months SC, or the CP. They were then followed up at 24 months. Change in physical activity levels were assessed by the International Physical Activity Questionnaire (IPAQ)-short form, and pedometer recordings. Both groups reported increases in physical activity using the IPAQ from baseline to 12 months and 24 months (within groups P < 0.0001) and in pedometer steps from baseline to 12 months only (within groups P < 0.0001). Differences between groups with both methods of assessment were not significant. There was a significant difference in weight loss between the groups at 12 months favouring the CP group; however, this statistical difference was not maintained at 24 months. In conclusion, despite similar increases in reported activity, there were significant differences in weight loss and regain between groups. Therefore, greater weight loss seen with the CP is unlikely to be due to increases in physical activity. Trends in pedometer steps mirrored changes in weight over time more closely than the IPAQ; however, both assessment tools have limitations. Better activity assessment measures are needed to more accurately gauge changes in physical activity during weight loss interventions.

Impact of the London 2012 Olympic and Paralympic Games on demand for microbiology gastrointestinal diagnostic services at the Public Health Laboratory London

Planning for the London 2012 Olympic and Paralympic Games at the Public Health Laboratory London was based on the requirement to meet potential increased demand with scalable capacity. The aim of this study was to determine the impact on demand for microbiology gastrointestinal diagnostic services during the Games period. Retrospective cross-sectional time-series data analysis was used to assess the number of gastrointestinal specimens received in the laboratory and the number of positive results. There was no increase in the number of gastrointestinal specimens received during the Games period, thus the Games had no impact on demand for microbiology gastrointestinal diagnostic services at the laboratory. There was a decrease in the number of public health specimens received for culture [incidence rate ratio = 0.34, 95% confidence interval (CI) = 0.13-0.86, P = 0.02] and a decrease in the number of culture positive community specimens (odds ratio = 0.59, 95 % CI = 0.40-0.85, P = 0.005), suggesting a decrease in gastrointestinal illness during the Games period. As previous planning assumptions were not based on actual specimen activity, the results of this study may modify the extent of additional planning for microbiological services required for mass gatherings.

Race, gender, and chains of disadvantage: childhood adversity, social relationships, and health

We use a life course approach to guide an investigation of relationships and health at the nexus of race and gender. We consider childhood as a sensitive period in the life course, during which significant adversity may launch chains of disadvantage in relationships throughout the life course that then have cumulative effects on health over time. Data from a nationally representative panel study (Americans' Changing Lives, N = 3,477) reveal substantial disparities between black and white adults, especially pronounced among men, in the quality of close relationships and in the consequences of these relationships for health. Greater childhood adversity helps to explain why black men have worse health than white men, and some of this effect appears to operate through childhood adversity's enduring influence on relationship strain in adulthood. Stress that occurs in adulthood plays a greater role than childhood adversity in explaining racial disparities in health among women.

Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome

Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point.

INTRODUCTION

Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome.

METHODS

VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry.

RESULTS

Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3-17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2-15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), -0.5 ± 1.1; p = 0.001) and at 3 months (-0.6 ± 1.1; p < 0.001), but not at 6 months (-0.3 ± 1.3; p = 0.066) or 12 months (-0.3 ± 1.2; p = 0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p = 0.003). A subgroup (N = 16; 25 %) had LS BMD Z-scores that were ≤-1.0 at 12 months. In these children, each additional 1,000 mg/m(2) of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, -0.71 to -0.07; p = 0.017).

CONCLUSIONS

The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤-1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.

Reconstructing fungal natural product biosynthetic pathways

Molecular biology plays a vital role in contemporary natural product research. Responding to developments in whole genome sequencing, heterologous expression systems are being refined to accommodate whole fungal biosynthetic pathways.

Mothers' union histories and the mental and physical health of adolescents born to unmarried mothers

As nonmarital childbearing becomes a dominant pathway to family formation, understanding its long-term consequences for children's well-being is increasingly important. Analysis of linked mother-child data from the 1979 National Longitudinal Survey of Youth indicates a negative association of having been born to a never-married mother with adolescent self-assessed health but not with depressive symptoms. We also consider the role of mothers' subsequent union histories in shaping the adolescent health outcomes of youth born to unmarried mothers. With two exceptions, unmarried mothers' subsequent unions appear to have little consequence for the health of their offspring during adolescence. Adolescents whose mothers subsequently married and remained with their biological fathers reported better health, yet adolescents whose mothers continuously cohabited with their biological fathers without subsequent marriage reported worse adolescent mental health compared with adolescents whose mothers remained continually unpartnered.

Cardiac magnetic resonance, transthoracic and transoesophageal echocardiography: a comparison of in vivo assessment of ventricular function in rats

In vivo assessment of ventricular function in rodents has largely been restricted to transthoracic echocardiography (TTE). However 1.5 T cardiac magnetic resonance (CMR) and transoesophageal echocardiography (TOE) have emerged as possible alternatives. Yet, to date, no study has systematically assessed these three imaging modalities in determining ejection fraction (EF) in rats. Twenty rats underwent imaging four weeks after surgically-induced myocardial infarction. CMR was performed on a 1.5 T scanner, TTE was conducted using a 9.2 MHz transducer and TOE was performed with a 10 MHz intracardiac echo catheter. Correlation between the three techniques for EF determination and analysis reproducibility was assessed. Moderate-strong correlation was observed between the three modalities; the greatest between CMR and TOE (intraclass correlation coefficient (ICC) = 0.89), followed by TOE and TTE (ICC = 0.70) and CMR and TTE (ICC = 0.63). Intra- and inter-observer variations were excellent with CMR (ICC = 0.99 and 0.98 respectively), very good with TTE (0.90 and 0.89) and TOE (0.87 and 0.84). Each modality is a viable option for evaluating ventricular function in rats, however the high image quality and excellent reproducibility of CMR offers distinct advantages even at 1.5 T with conventional coils and software.

Anticipating early fatality: friends', schoolmates' and individual perceptions of fatality on adolescent risk behaviors

Past research indicates that anticipating adverse outcomes, such as early death (fatalism), is associated positively with adolescents' likelihood of engaging in risky behaviors. Health researchers and criminologists have argued that fatalism influences present risk taking in part by informing individuals' motivation for delaying gratification for the promise of future benefits. While past findings highlight the association between the anticipation of early death and a number of developmental outcomes, no known research has assessed the impact of location in a context characterized by high perceptions of fatality. Using data from Add Health and a sample of 9,584 adolescents (51% female and 71% white) nested in 113 schools, our study builds upon prior research by examining the association between friends', school mates', and individual perceptions of early fatality and adolescent risk behaviors. We test whether friends' anticipation of being killed prior to age 21 or location in a school where a high proportion of the student body subscribes to attitudes of high fatality, is associated with risky behaviors. Results indicate that friends' fatalism is positively associated with engaging in violent delinquency, non-violent delinquency, and drug use after controlling for individual covariates and prior individual risk-taking. Although friends' delinquency accounts for much of the effect of friends' fatalism on violence, none of the potential intervening variables fully explain the effect of friends' fatalism on youth involvement in non-violent delinquency and drug use. Our results underscore the importance of friendship contextual effects in shaping adolescent risk-taking behavior and the very serious consequences perceptions of fatality have for adolescents' involvement in delinquency and drug use.

Is a cancer diagnosis a trigger for health behaviour change? Findings from a prospective, population-based study

Background:

A healthy lifestyle following a cancer diagnosis may improve long-term outcomes. No studies have examined health behaviour change among UK cancer survivors, or tracked behaviours over time in survivors and controls. We assessed smoking, alcohol and physical activity at three times (0–2 years before a cancer diagnosis, 0–2 years post-diagnosis and 2–4 years post-diagnosis) and at matched times in a comparison group.

Methods:

Data were from waves 1–5 of the English Longitudinal Study of Ageing; a cohort of older adults in England. Behavioural measures were taken at each wave. Generalised estimating equations were used to examine differences by group and time, and group-by-time interactions.

Results:

Of the 5146 adults included in the analyses, 433 (8.4%) were diagnosed with cancer. Those with a cancer diagnosis were less likely to be physically active (P<0.01) and more likely to be sedentary (P<0.001). There were no group differences in alcohol or smoking. Smoking, alcohol and activity reduced over time in the whole group. Group-by-time interactions were not significant for smoking (P=0.17), alcohol (P=0.20), activity (P=0.17) or sedentary behaviour (P=0.86), although there were trends towards a transient improvement from pre-diagnosis to immediately post-diagnosis.

Conclusion:

We found little evidence that a cancer diagnosis motivates health-protective changes. Given the importance of healthy lifestyles, strategies for effective support for behaviour change in cancer survivors need to be identified.

Insulin vs GLP-1 analogues in poorly controlled Type 2 diabetic subjects on oral therapy: a meta-analysis

AIM

To compare insulin and GLP-1 analogues therapy on glycemic control in poorly controlled Type 2 diabetes (T2DM) subjects failing on oral therapy.

METHODS

The electronic database PubMed was systematically searched for randomized controlled trial (RCT) with duration >16 weeks comparing the addition of insulin therapy vs glucagon-like peptide (GLP-1) analogues in poorly controlled T2DM subjects on oral therapy.

RESULTS

We identified 7 RCT with 2199 patients of whom 1119 were assigned to insulin therapy and 1080 received a GLP-1 analogue. Both insulin and GLP-1 analogues were effective in lowering glycated hemoglobin (HbA(1c)) with no statistically significant difference between the mean decreases in HbA(1c). However, insulin was more effective than GLP-1 analogues in lowering the fasting plasma glucose concentration, while GLP-1 agonists were more effective in lowering the postprandial glucose concentration. Insulin therapy was associated with weight gain while GLP-1 analogues consistently caused weight loss and the difference between the mean change in body weight between the two therapies was highly statistically significant. Despite a similar decrease in HbA(1c), the risk of hypoglycemia was 35% lower (p=0.001) with GLP-1 therapy compared to insulin. Compared to insulin, GLP-1 analogues caused a significant decrease in systolic blood pressure and were associated with greater rate of gastrointestinal adverse events.

CONCLUSION/INTERPRETATION

In poorly controlled T2DM subjects on oral therapy, GLP-1 analogues and insulin are equally effective in lowering the HbA(1c). However, GLP-1 analogues have additional non-glycemic benefits and lower risk of hypoglycemia. Thus, GLP-1 analogues should be considered as a treatment option in this group of diabetic individuals.