Physician gender is associated with the quality of type 2 diabetes care

OBJECTIVES

Patient gender influences the quality of medical care whilst the role of physician gender is not well established. To investigate the influence of physician gender on quality of care in patients with type 2 diabetes.

DESIGN AND METHODS

Cross-sectional study in 51 053 outpatients (48.6% male), treated by 3096 office-based physicians (66.3% male; 74.0% general practitioners, 21.8% internists and 4.2% diabetologists). Outcome measures included processes of care, intermediate outcomes and medical management. Quality of care measures were based on current ADA guidelines. Hierarchical regression models were used to avoid case-mix bias and to correct for physician-level clustering. Adjusted odds ratios were calculated controlling for age, gender, disease duration and presence of atherosclerotic disease.

RESULTS

The patients of female physicians were more often women, more obese, older and had more often atherosclerotic disease (34% in the total cohort). The patients of female physicians more often reached target values in glycaemic control (HbA1c < 6.5%; OR 1.14; 1.05-1.24, P = 0.002), blood lipoproteins (LDL-C < 100 mg dL(-1); OR 1.16; 1.06-1.27, P = 0.002), and blood pressure (systolic values < 130 mmHg; OR 1.11; 1.02-1.22, P = 0.018). They were more likely to receive antihypertensive drug therapy in general (OR 1.35; 1.24-1.46, P < 0.0001) and angiotensin converting enzyme (ACE) inhibitors in particular (OR 1.17; 1.09-1.25, P < 0.0001). The patients of female physicians less often performed glucose self-monitoring (OR 0.83; 0.76-0.91, P < 0.0001) and less often received oral hypoglycaemic agents (OR 0.88; 0.82-0.95, P = 0.001).

CONCLUSIONS

Physician gender influences quality of care in patients with type 2 diabetes. Female physicians provide an overall better quality of care, especially in prognostically important risk management.

The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement

Objective. Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc.

Methods. A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features.

Results. Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005).

Conclusion. In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

[Valsartan improves symptoms and quality of life in patients with chronic heart failure]

AIM

The aim of the study was to assess efficacy of outpatient treatment of chronic heart failure with the angiotensin-receptor-blocker valsartan within guideline recommendations.

METHODS

The trial was conducted in Germany as an open label, multicentre, prospective trial including 1863 consecutive patients, enrolled by 829 physicians. Inclusion criteria correspond to guideline recommended treatment of chronic heart failure with valsartan. NYHA-classification, quality of life, blood pressure reduction and adverse events were evaluated within follow-up of 12 weeks.

RESULTS

NYHA-classification, quality of life and general condition improved after treatment with valsartan for 12 weeks. Systolic and diastolic blood pressure decreased dependent on dosage used. Incidende of adverse events was 0.2%.

CONCLUSION

The results confirm prior randomized, placebo controlled trials regarding improvement of heart failure symptoms by guideline recommended treatment with the angiotensin-receptor-blocker valsartan, even in an outpatient setting.

Activities of respiratory chain complexes and pyruvate dehydrogenase in isolated muscle mitochondria in premature neonates

BACKGROUND AND AIMS

Most diseases in premature neonates are secondary to immaturity of various organ systems. Also the inadequate capacity of mitochondrial energy production may play an important role in the neonatal morbidity.

SUBJECTS AND METHODS

The activities and amount of respiratory chain (RC) complexes, pyruvate dehydrogenase (PDH) and citrate synthase (CS) were analysed in isolated muscle mitochondria obtained at autopsy in 19 premature neonates using spectrophotometric and radioenzymatic methods and blue-native electrophoresis and Western blotting. Two groups of children recommended for muscle biopsy at the age of 0.5-2 and 3-18 years served as controls.

RESULTS

In premature neonates, the activities of RC complexes III, IV, PDH and CS were markedly lower in comparison with older children. On the contrary, the activity of complex I was higher in premature neonates than in older children. The ratios between RC complexes I, II and III and CS were significantly higher in premature neonates in comparison with older children. In addition, the protein amount of RC complexes and PDH subunits were lower in premature neonates in comparison with older children.

CONCLUSION

The results of our study document the age-dependent differences in activities of PDH and respiratory chain complexes in early childhood. Lower functional capacity of mitochondrial energy-providing system in critically ill neonates may be explained by combination of various factors including the delay in maturation of PDH and respiratory chain complexes in very premature neonates and increased degradation of mitochondrial proteins in connection with sepsis, tissue hypoperfusion or hypoxemia.

The Ca2+-binding capacity of epidermal furin is disrupted by H2O2-mediated oxidation in vitiligo

The Ca(2+)-dependent precursor convertase furin is abundantly expressed in epidermal keratinocytes and melanocytes. In this context, it is noteworthy that proopiomelanocortin (POMC) cleavage is also processed by furin, leading to ACTH, beta-lipotropin, and beta-endorphin. All prohormone convertases including furin are regulated by Ca(2+). Because numerous epidermal peptides and enzymes are affected by H(2)O(2)-mediated oxidation, including the POMC-derived peptides alpha-MSH and beta-endorphin as shown in the epidermis of patients with vitiligo, we here asked the question of whether furin could also be a possible target for this oxidation mechanism by using immunofluorescence, RT-PCR, Western blotting, Ca(2+)-binding studies, and computer modeling. Our results demonstrate significantly decreased in situ immunoreactivity of furin in the epidermis of patients with progressive vitiligo (n = 10), suggesting H(2)O(2)-mediated oxidation. This was confirmed by (45)Ca(2+)-binding studies with human recombinant furin identifying the loss of one Ca(2+)-binding site from the enzyme after oxidation with H(2)O(2). Computer simulation supported alteration of one of the two Ca(2+)-binding sites on furin. Taken together, our results implicate that the Ca(2+)-dependent proteolytic activity of this convertase is targeted by H(2)O(2), which in turn could contribute to the reduced epidermal expression of the POMC-derived peptides alpha-MSH and beta-endorphin as documented earlier in patients with vitiligo.

[Preoperative risk evaluation in heart failure]

The primary target in preoperative risk evaluation is not to classify patients as operable or inoperable but rather to reduce perioperative morbidity and mortality. Indications for perioperative diagnostic and therapeutic procedures are mostly the same as for patients without subsequent non-cardiac surgery. However, the time schedule often depends on cofactors such as urgency and severity of surgical interventions. Perioperative risk management requires exceedingly good communication and collaboration between surgeons, anesthesiologists and internists and offers the chance to diagnose and treat perioperative risk factors in a justifiable time and cost context.

[Drug treatment of chronic heart failure]

Drug treatment of chronic heart failure is undergoing continuous modifications according to the data of new trials. Treatment has to be adjusted to current guidelines. The state of the art of medical treatment of chronic heart failure is addressed in this report.

The role of heart rate in the development of cardiovascular disease

Heart rate is an independent risk factor for patients with cardiovascular disease, in particular with arterial hypertension, myocardial infarction, coronary artery disease and heart failure. This relation is supported by a large number of animal studies as well as clinical trials which are summarized in this article. These studies demonstrated detrimental effects of increased heart rate on the function and structure of the cardiovascular system. Heart rate can be easily detected during physical examination of the patient and therefore allows a simple conclusion on prognosis and efficiency of therapy.

Erectile dysfunction correlates with left ventricular function and precedes cardiovascular events in cardiovascular high-risk patients

Erectile dysfunction (ED) is related to cardiovascular risk factors by an impairment of endothelial function. Therefore, symptoms of ED are probably to precede cardiovascular disease and events. Moreover, endothelial dysfunction is common in patients with decreased left ventricular ejection fraction (LVEF). Hence, left ventricular dysfunction probably results in a decreased erectile function. A total of 192 cardiovascular high-risk patients from the EROSS Programme (Evaluation of Role of Sexual Dysfunction in the Saarland Programme) were evaluated regarding onset and severity of ED using the IIEF-5 questionnaire. LVEF was measured with magnetic resonance imaging, angiographically or echocardiographically. Prevalence of ED was 80.6%. Patients with moderate or severe impairment of ejection fraction had a significant increase of ED (p = 0.001). Multivariate analysis identified LV dysfunction as an independent risk factor for ED independent of heart failure symptoms (p = 0.001). Moreover, symptoms of ED appeared 3.04 +/- 7.2 years prior to the cardiovascular event (p = 0.005). LVEF is an independent risk factor for the development or increase of ED in cardiovascular high-risk patients, probably caused by an impairment of endothelial function. Hence, ED is suggested to be an early symptom of generalised cardiovascular disease and events. Thus, cardiovascular evaluation is recommended in patients with ED providing the opportunity of optimised preventional treatment.

What are subcutaneous adipocytes really good for?

Our acute awareness of the cosmetic, psychosocial and sexual importance of subcutaneous adipose tissue contrasts dramatically with how poorly we have understood the biology of this massive, enigmatic, often ignored and much-abused skin compartment. Therefore, it is timely to recall the exciting, steadily growing, yet underappreciated body of evidence that subcutaneous adipocytes are so much more than just 'fat guys', hanging around passively to conspire, at most, against your desperate attempts to maintain ideal weight. Although the subcutis, quantitatively, tends to represent the dominant architectural component of human skin, conventional wisdom confines its biological key functions to those of energy storage, physical buffer, thermoregulation and thermoinsulation. However, already the distribution of human superficial adipose tissue, by itself, questions how justified the popular belief is that 'skin fat' (which actually may be more diverse than often assumed) serves primarily thermoinsulatory purposes. And although the metabolic complications of obesity are well appreciated, our understanding of how exactly subcutaneous adipocytes contribute to extracutaneous disease - and even influence important immune and brain functions! - is far from complete. The increasing insights recently won into subcutaneous adipose tissue as a cytokine depot that regulates innate immunity and cell growth exemplarily serve to illustrate the vast open research expanses that remain to be fully explored in the subcutis. The following public debate carries you from the evolutionary origins and the key functional purposes of adipose tissue, via adipose-derived stem cells and adipokines straight to the neuroendocrine, immunomodulatory and central nervous effects of signals that originate in the subcutis - perhaps, the most underestimated tissue of the human body. The editors are confident that, at the end, you shall agree: No basic scientist and no doctor with a serious interest in skin, and hardly anyone else in the life sciences, can afford to ignore the subcutaneous adipocyte - beyond its ample impact on beauty, benessence and body mass.

Structure of the C-terminal MA-3 domain of the tumour suppressor protein Pdcd4 and characterization of its interaction with eIF4A

Programmed cell death protein 4 (Pdcd4) is a novel tumour suppressor protein, which is involved in the control of eukaryotic transcription and translation. The regulation of translation involves specific interactions with eukaryotic initiation factor (eIF)4A and eIF4G, which are mediated via the two tandem MA-3 domains. We have determined the structure of the C-terminal MA-3 domain of Pdcd4 (Pdcd4 MA-3(C)), characterized its interaction with eIF4A and compared the features of nuclear magnetic resonance (NMR) spectra obtained from the single domain and tandem MA-3 region. Pdcd4 MA-3(C) is composed of three layers of helix-turn-helix hairpins capped by a single helix and shows close structural homology to the atypical HEAT repeats found in many eIFs. The sequence conservation and NMR data strongly suggest that the tandem MA-3 region is composed of two equivalent domains connected by a somewhat flexible linker. Pdcd4 MA-3(C) was found to interact with the N-terminal domain of eIF4A through a conserved surface region encompassing the loop connecting alpha5 and alpha6 and the turn linking alpha3 and alpha4. This site is strongly conserved in other MA-3 domains known to interact with eIF4A, including the preceding domain of Pdcd4, suggesting a common mode of binding.

[Invasive diagnosis of pulmonary hypertension and its effects on the right heart]

When pulmonary hypertension (HPT) is suspected invasive diagnosis provides final diagnosis, establishes the most important parameters for making a prognosis and identifies resulting abnormalities of the right and left ventricles. Cardiac catheterization gives data on cardiac function and thus additional information on the limits of physical capacity and prognostic assessment. Invasive diagnosis thus plays a key role, but clearly is not part of primary diagnosis, which in addition to clinical examination emphasizes Doppler echocardiography as a valid screening method. Noninvasive examinations are preferred for follow-up.

Electroosmotic flow patterning using microfluidic delay loops

A theoretical and experimental investigation of alternating electroosmotic flow patterns by means of specially designed delay loops is presented. Using elementary methods of compact network modeling and detailed FEM simulations the flow behavior and, in particular, the rearrangement of sample plugs is modeled. The proposed designs rely on flow splitting in combination with electroosmotic delay loops leading to a runtime difference or phase shift between two sub-streams. Due to this phase shift, a new fluid interface is generated at the merging point. The approach is experimentally validated by injection of a Rhodamine 6G solution into an aqueous sodium tetraborate buffer.

Perioperative immunomodulation with interleukin-2 in patients with renal cell carcinoma: results of a controlled phase II trial

We conducted a non-randomised controlled phase II trial to investigate the role of preoperative administration of interleukin-2 (IL-2) in patients with renal cell carcinoma undergoing tumour nephrectomy. A total of 120 consecutive patients were allocated alternately to the two study groups: perioperative immunomodulation with IL-2 (IL-2 group; n=60) and perioperative immunomonitoring without immunomodulation (control group; n=60). Patients from the IL-2 group received four doses of 10 × 10⁶ IU m⁻² twice daily subcutaneously a week before operation followed by a daily maintenance dose of 3 × 10⁶ IU m⁻² subcutaneously until a day before the operation. Parameters of cellular and humoral immunity (leucocytes, T-cell markers CD3, CD4, and CD8, B-cell marker CD19, monocyte marker CD14, natural killer (NK) cell markers CD16, CD56, and CD57, activation markers CD6, CD25, CD28, and CD69, progenitor cell marker CD34, as well as IL-2, IL-6, IL-10, soluble IL-2 receptor, IL-1 receptor antagonist, transforming growth factor-β1, and vascular endothelial growth factor) were measured in peripheral venous blood at various intervals. Interleukin-2-related toxicity was WHO grade 1 (24%), 2 (67%), and 3 (9%). In the postoperative period, T-cell markers, activation markers, and NK cell markers decreased, and IL-6 and IL-10 increased. However, all these alterations were significantly less accentuated in patients who had been pretreated with IL-2. Median follow-up was 40 months. Tumour-specific survival in the IL-2 group and the control group was 98 vs 81% after 1 year and 86 vs 73% after 5 years (P=0.04). A similar effect was found for progression-free survival. We conclude that IL-2 can be safely administered in the perioperative period and modulates immunological parameters. However, to validate the survival data, a larger randomised phase III trial is needed.

Die Skelettszintigraphie beim neu diagnostizierten Prostatakarzinom

BACKGROUND

The indication for a radionuclide bone scan in patients with newly diagnosed, untreated prostate cancer remains controversial.

PATIENTS AND METHODS

In this retrospective study we examined 406 patients who had received a staging bone scan irrespective of their PSA serum level and histology. We evaluated different guidelines and recommendations with respect to their usefulness. The costs were calculated according to EBM and GOA. We evaluated the classification systems of bone metastases according to Soloway, Crawford, and Rigaud.

RESULTS

The bone scan was positive in 41 (10%) of 406 patients. The EAU guidelines turned out to be useful with respect to both clinical value and cost efficiency. The Rigaud classification of bone metastases predicted outcome better than the Soloway or Crawford classification.

CONCLUSIONS

The EAU guidelines from 2005 are a useful tool to decide whether to perform a bone scan in patients with newly diagnosed, untreated prostate cancer. A bone scan should be performed if PSA levels exceed 20 ng/ml in patients with a G1/G2 histology, and in patients with G3 histology and locally advanced disease irrespective of PSA level. Bone scan metastases should be classified according to Rigaud.