Does home-based exercise improve body mass index in patients with type 2 diabetes? Results of a feasibility trial

AIMS

This feasibility trial evaluated the use, safety, and short-term benefits of a home-based exercise intervention designed to increase physical activity among adults with diabetes.

METHODS

Participants with type 2 diabetes in a group practice were recruited and randomly assigned to the home-based exercise intervention or usual care. Participants were given diabetes self-management education, instructed to exercise 30 min 5 days/week, and were followed for 3 months. The intervention contained three exercise routines (aerobic and resistance exercises). Outcomes included changes from baseline at 3 months between groups in body mass index (BMI), quality of life, A1C, and blood pressure.

RESULTS

Seventy-six sedentary adults completed the study: 49% intervention group, 68% women, 47% black, mean age 56.6+/-9.6 years. Using intention to treat analysis, a trend towards improvement between groups for BMI (mean change -0.4 versus 0.1, respectively; P=0.06) was identified. Thirty-eight percent of the intervention group adhered to 80% of the exercise recommendation and significantly improved BMI (-1.07; P<0.05). No other differences were detected between groups.

CONCLUSIONS

Home-based exercise interventions have potential to reduce BMI in patients with diabetes. The results provide variance estimates necessary to power a larger study of longer duration.

Partial breast irradiation (PBI) concurrent with adjuvant dose-dense doxorubicin and dyclophosphamide (ddAC) chemotherapy in early-stage breast cancer: Preliminary safety results from a feasibility trial

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Background: Adjuvant anthracycline-based chemotherapy regimens and radiation therapy as part of breast conservation therapy (BCT) are given sequentially to avoid excessive skin toxicity. PBI employs a shorter course of radiation therapy to a smaller breast field and is the subject of randomized efficacy trials. Concurrent administration of PBI and adjuvant chemotherapy would decrease duration of therapy, allow more women to pursue BCT, improve compliance, and potentially enhance local control. Methods: To examine the feasibility, safety, and short-term risk of recurrence of concurrent PBI with adjuvant ddAC, we are conducting a prospective one-stage, single-arm trial of PBI during the first 2 of 4 cycles of ddAC (60 and 600 mg/m2, respectively) delivered q14d with growth factor support. Patients (pts) with T1–2 N0–1 breast cancer and lumpectomy margins ≥ 3mm are eligible. PBI starts within 3 days of first chemo dose and treats the lumpectomy bed plus margin with 270 cGy fractions × 15 (4050 cGy total). Primary endpoints (skin/soft tissue toxicity and cosmetic outcome) are graded by a panel of physicians using commonly accepted scales. Digital images at baseline, during, and q 3–6 months after PBI are obtained for comparison. Additional chemo and endocrine Rx post ddAC given at the physician’s discretion. We report preliminary safety data. Results: Between 11/04 and 9/05, 10 pts were enrolled and received study therapy (accrual goal = 42); 2 pts also received dd paclitaxel 175 mg/m2 post ddAC. All pts received planned PBI (med. f/u 6 mos, range 3–12 mos). 2 pts missed 1 and 2 cycles of ddAC because of stomatitis (Gr 3) and diverticulitis, respectively. 3 other pts had 1–2 wk chemo delay because of hand-foot syndrome, brief pulmonary syndrome, and febrile neutropenia. No pts developed radiation dermatitis > Gr 1 or radiation recall. All pts had cosmetic outcome grades of good or excellent shortly after completion of therapy. No pts with ≥ 6 mos f/u since PBI had late skin toxicity. Conclusion: Early results suggest that PBI concurrent with ddAC appears feasible and safe. Trial enrolment continues and longer f/u is required. (Funded by The Breast Cancer Research Foundation).

No significant financial relationships to disclose.

Preferences for involvement in medical decision making: Comparing British and German views

Despite beneficial outcomes of patients' involvement in medical decision processes, it has been claimed that patients are generally not interested in medical decision making (MDM). Whereas current research focuses on actual MDM, this research explored the impact of nationality and perceptual processes of MDM. Preferences for involvement in decision making were examined in a sample of 204 German and 143 British university students. Hierarchical multiple regressions were employed to explore the link between socio-demographic information, individuals' perceived relationship with their GP, Health Locus of Control - Powerful Others, perceptions regarding the frequency and sufficiency of information provision and involvement in MDM, and individuals' preferred level of involvement and information. A significant amount of the variance in individuals preferences for involvement could be explained (Adjusted R2 = .59, p < .001). Independent t-test analyses showed that British and German perceptions of care differed significantly on a variety of different measures. Separate analyses for the German and British group highlighted cross-national differences in care and preferences for involvement. The study suggests that preferences to become involved might depend more on perceptual processes than actual involvement in decision making, and that communication and national health policy could play an important role.

A systematic review of cancer waiting time audits

A summary of a systematic review of clinical audits of cancer referrals in England and Wales.

Group psychoeducation as treatment for psychological nonepileptic seizures

There is no consensus for the type(s) of treatment(s) that may be effective or ineffective for psychological nonepileptic seizures (PNES). We provided an open-ended group psychotherapy program to 10 patients with PNES, including a disorder-specific psychoeducation treatment component in the first 10 weeks. Seizure frequency and questionnaire responses were examined pre- and posttreatment in all 7 of 10 individuals who completed the majority of the psychoeducational sessions. Four individuals experienced no change in seizure frequency; in three of these this was due to a cessation of events at treatment initiation. Two individuals experienced a decline; and one, an increase, in seizure frequency. Significant decreases were reported in posttraumatic (P=0.003) and dissociative (P=0.04) symptoms and emotionally based coping mechanisms (P=0.03). There was also a trend toward improved quality of life (P=0.07). Experience/expression of anger remained stable. Psychoeducation may be an effective method of treating PNES and may improve coping strategies and reduce PNES-associated psychopathology in some patients. Additional controlled studies on larger samples are needed.

Multiphasic helical computerized tomography for the assessment of microscopic hematuria: a prospective study

PURPOSE

We evaluated multiphasic helical computed tomography for the detection and characterization of lesions responsible for hematuria not diagnosed on prior urological surveillance studies.

MATERIALS AND METHODS

A total of 393 men and 207 women with recurrent microscopic hematuria but negative urological surveillance studies were examined at 4 participating institutions by multiphasic helical computerized tomography, consisting of pre-enhancement, arterial corticomedullary, parenchymal and excretory phase sequences generating 2 to 5 mm slices through the kidney and lower pelvis.

RESULTS

The cause of microscopic hematuria was established in 256 of 600 patients with prior negative urological surveillance examinations with 0.91 sensitivity and 0.94 specificity. The diagnosis was correct in all subsequently proven cases of calculous and renal vascular disease. A total of 67 of 70 inflammatory kidney lesions, 24 of 25 renal neoplasms, 15 of 16 bladder neoplasms, 27 of 35 inflammatory bladder conditions and 21 of 23 ureteral lesions were also correctly diagnosed. The diagnosis of renal medullary and papillary necrosis, and neoplastic lesions of the kidney and bladder allowed the early institution of medical therapy or appropriate surgery.

CONCLUSIONS

Multiphasic helical computerized tomography diagnosed lesions responsible for microhematuria in 42.6% of 600 patients with negative urological surveillance examinations. This relatively low cost and low co-morbidity examination is advocated for patients with negative urological surveillance examinations or even as a first examination.

Sex differences in the experience of testing positive for genital chlamydia infection: a qualitative study with implications for public health and for a national screening programme

OBJECTIVES

To explore men's and women's accounts of chlamydia testing, with a view to understanding sex differences in attitudes and in behaviours of public health importance.

METHODS

Semistructured interviews with 24 heterosexual patients (12 men; 12 women) diagnosed with genital chlamydia infection, at a large sexual health clinic in central London were transcribed and analysed using qualitative thematic analysis.

RESULTS

Participants' expressions revealed important sex differences. Women felt anxious about their future reproductive health, feared stigmatisation, and blamed themselves for contracting chlamydia; whereas men generally reported less concern, were unwilling to disclose their condition to sexual partners, and some men projected attributions of blame onto their partners. Delays in seeking care appeared to be related to perceptions of chlamydia as a relatively minor infection, particularly in men.

CONCLUSIONS

Health promotion needs to reflect sex and age differences, emphasising the negative consequences of delayed clinic attendance and exposure to repeat infections. For health professionals to respond appropriately and effectively to increasing numbers of chlamydia infections, there is a need to understand men's avoidant attitudes and behaviours in relation to sexual and reproductive health.

Leptin, body composition, adrenal and gonadal hormones among captive male baboons

Morphometric and hormonal measures were collected from 21 captive savanna baboons (Papio cynocephalus) maintained at the Tulane National Primate Research Center in order to determine age-related patterns in leptin levels over the life course as well as their relationships to body composition and adrenal and gonadal steroids. Comparison of leptin levels between peri-pubertal, adolescent, young adult, and fully mature males show lower levels among adolescent as compared with young adult males (P = 0.05 by Kruskal-Wallis ANOVA). In addition, abdominal fat varied among age groups (P = 0.003 by Kruskal-Wallis ANOVA) with the peri-pubertal animals lower than the adolescents, young adults, and prime adults. However leptin was not related to any measure of body composition, including abdominal fat, or to adrenal hormones (dehydroepiandrosterone, dehydroepiandrosterone-sulfate, and cortisol) or gonadal hormones (testosterone and estradiol). Age-related changes in leptin appear similar to those reported for captive rhesus macaques, while the failure to find an association between leptin and abdominal fat is interestingly different. These results confirm elevated levels of leptin in captive baboons compared with their wild counterparts and suggest that they result from changes in fetal development.

Screening for diabetic retinopathy: a cause for concern in people who drive

AIMS

To report a case of a road traffic accident in a lady driving home from a diabetes clinic after pupillary dilatation. We also present the findings of a questionnaire survey of health professionals to elicit their practice in dealing with such patients.

METHODS

We present the case report of a lady having a road traffic accident on her way back from a retinal screening appointment after having had pupillary dilatation. A subsequent postal questionnaire survey was undertaken to find out current practice in screening patients who drive on the day of their retinal screening.

RESULTS

A lady was involved in a road traffic accident whilst returning home after retinal screening. Her motor insurance company refused to cover subsequent claims for damage because her pupils had been dilated. She was also prosecuted by the police for driving without valid motor insurance. We conducted a postal survey of 500 health care workers including ophthalmologists, optometrists, diabetologists and general practitioners regarding the use of dilating drops in people with diabetes who intend to drive. Analysis of 320 valid responses confirmed that there is no consistent practice with regard to either the use of dilating drops in drivers or in ensuring that arrangements are made for subsequent adequate visual inspection in those whom dilatory drops are not instilled.

CONCLUSIONS

Guidelines, for use by health care professionals and people with diabetes, are clearly required regarding the use of pupillary dilating drops in drivers.

Anterior/posterior lumbar fusion versus transforaminal lumbar interbody fusion: analysis of complications and predictive factors

No previous study has compared the complications between anterior/posterior and transforaminal interbody fusions. We performed a retrospective analysis of 164 patients to compare the complications and associated predictive factors of the two techniques of circumferential lumbar fusion. Fifty-three had same-day anterior/posterior fusion (group 1), and 111 had transforaminal interbody fusion (group 2). Mean operating time (p < 0.0001) and hospital stay (p < 0.0001) was significantly longer for group 1 patients. Average blood loss was greater for group 1 patients (p < 0.01). Higher complication rates were found in group 1 patients (p < 0.004). Wound infection occurred more frequently in patients with adjunctive treatment (p < 0.04). Hospital stay was an independent predictor of complications in both groups. In group 1, body mass index was independently associated with complications. In group 2, both hospital stay and adjunctive treatment were predictive of complications. Transforaminal lumbar interbody fusion is the preferred technique because it is associated with shorter operating time, less blood loss, shorter hospital stay, and lower incidence of complications.

The NHS--a patient's perspective

A narrative account, from a user's perspective, of NHS service and procedures. Whilst there is much to applaud in the service and communications between staff and patients, some practices do not foster patient empowerment.

Legume consumption and risk of coronary heart disease in US men and women: NHANES I Epidemiologic Follow-up Study

BACKGROUND

Soybean protein and dietary fiber supplementation reduce serum cholesterol in randomized controlled trials. Consumption of legumes, which are high in bean protein and water-soluble fiber, may be associated with a reduced risk of coronary heart disease (CHD).

METHODS

A total of 9632 men and women who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (NHEFS) and were free of cardiovascular disease (CVD) at their baseline examination were included in this prospective cohort study. Frequency of legume intake was estimated using a 3-month food frequency questionnaire, and incidence of CHD and CVD was obtained from medical records and death certificates.

RESULTS

Over an average of 19 years of follow-up, 1802 incident cases of CHD and 3680 incident cases of CVD were documented. Legume consumption was significantly and inversely associated with risk of CHD (P =.002 for trend) and CVD (P =.02 for trend) after adjustment for established CVD risk factors. Legume consumption 4 times or more per week compared with less than once a week was associated with a 22% lower risk of CHD (relative risk, 0.78; 95% confidence interval, 0.68-0.90) and an 11% lower risk of CVD (relative risk, 0.89; 95% confidence interval, 0.80-0.98).

CONCLUSIONS

Our study indicates a significant inverse relationship between legume intake and risk of CHD and suggests that increasing legume intake may be an important part of a dietary approach to the primary prevention of CHD in the general population.

Component rotation and anterior knee pain after total knee arthroplasty

All patients undergoing cruciate-retaining primary total knee arthroplasty for degenerative osteoarthritis at one center were studied prospectively. Clinical and radiographic followup was obtained at a minimum 5 years in 102 knees in 73 patients. Patients were asked specifically about the presence of the pain in the anterior aspect of the knee in the vicinity of the patella and rated the severity of the pain on a visual analog scale. Significant anterior knee pain rating at least 3 of 10 on the visual analog scale was present in 16 knees (13 patients). Eleven patients with 14 symptomatic knees agreed to undergo computed tomography scanning to accurately determine the rotation of the tibial and femoral components. The epicondylar axis and tibial tubercle were used as references using a previously validated technique. A control group of 11 asymptomatic patients (14 knees), matched for age, gender, and length of followup also underwent computed tomography scanning. All patients in both groups had normal axial alignment. There was a highly significant difference in tibial component rotation between the two groups with the patients with anterior knee pain averaging 6.2 degrees internal rotation compared with 0.4 degrees external rotation in the control group. There also was a significant difference in combined component rotation with the patients with anterior knee pain averaging 4.7 degrees internal rotation compared with 2.6 degrees external rotation in the control group. There was no significant difference in the degree of radiographic patellar tilt or patellar subluxation between the two groups. Patients with combined component internal rotation were more than five times as likely to experience anterior knee pain after total knee arthroplasty compared with those with combined component external rotation. Component malrotation is a significant factor in the development of anterior knee pain after total knee arthroplasty.

Reproductive maturation in a sample of captive male baboons

Though baboons have been considered an appropriate non-human primate model for studying human reproductive and endocrine development. the overall similarity of reproductive maturation between the two species is unclear. This paper examines the role of testicular and adrenal hormones for pubertal changes in a cross-sectional sample of 21 captive male savanna baboons. Morphometric and hormonal indices demonstrate changes in size and gonadal function, but not adrenal function, during pubertal maturation among baboons. Results also indicate that gonadal, but not adrenal, androgens are related to morphometric variables. We conclude that savanna baboons do not make an appropriate evolutionary model of human pubertal maturation.