Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Effects of medical graphic narratives (patient comic) on Patient Reported Outcome Measures (PROMs) in patients undergoing coronary angiography and PCI

Background/Introduction

Increasing evidence suggests that patients scheduled for invasive cardiac procedures such as coronary angiography / PCI feel insufficiently informed about the planned procedure.

Purpose

To improve the Patient Informed Consent (IC) before coronary angiography by using “medical graphic narratives” (patient comic) that illustrate central IC-related aspects in a simple and understandable manner.

Methods

A patient comic illustrating central steps of the procedure, risks, treatment alternatives and behavioural measures was created in collaboration with professional scientific visual communicators. In a randomised, controlled, prospective trial, we included 121 patients undergoing coronary angiography/PCI. Patients were randomised to a group that was informed about the procedure using the usual Patient IC approach (official consent form and conversation with physician; Control group) or a group that additionally obtained a patient comic for reading (graphic illustrations of central IC aspects based on the official consent form; Comic group). Patient Reported Outcome Measures (PROMs), i.e. satisfaction with and perceived quality of the patient IC, were tested in both groups comparing single items of the Client Satisfaction Questionnaire-8 (CSQ-8) and self-designed single items in both IC groups. Differences were compared using the Fisher's exact test. A p-value &lt;0.05 was considered statistically significant.

Results

PROMs showed significant benefits in favour of the Comic group: Quality of the patient IC was perceived to be “very good” in 45.0% of the Comic group compared to 24.9% of patients in the Control group (p=0.023). Only 23.0% of the patients in the Control group, compared to 40.0% in the Comic group, stated that the IC procedure completely met their expectations (p=0.012). 57.4% in the Control group and 76.7% in the Comic group stated that all of their questions were satisfactorily adressed before the procedure (p=0.015). 43.3% in the Comic group, in contrast to 18.0% in the Control group, declared to feel “very satisfied” with the obtained IC procedure (p=0.002). The acceptance of the patient comic was very high: no patient (0%) expressed feelings of not being taken seriously by reading the patient comic.

Conclusions

Our data confirm pronounced limitations of the usual Patient IC practice before coronary angiography. The use of a patient comic that narratively illustrates central steps of the procedure positively impacts on patient-centered endpoints and significantly improves the patient IC procedure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Friede Springer Herz Stiftung

Quantum-accessible reinforcement learning beyond strictly epochal environments

In recent years, quantum-enhanced machine learning has emerged as a particularly fruitful application of quantum algorithms, covering aspects of supervised, unsupervised and reinforcement learning. Reinforcement learning offers numerous options of how quantum theory can be applied, and is arguably the least explored, from a quantum perspective. Here, an agent explores an environment and tries to find a behavior optimizing some figure of merit. Some of the first approaches investigated settings where this exploration can be sped-up, by considering quantum analogs of classical environments, which can then be queried in superposition. If the environments have a strict periodic structure in time (i.e. are strictly episodic), such environments can be effectively converted to conventional oracles encountered in quantum information. However, in general environments, we obtain scenarios that generalize standard oracle tasks. In this work, we consider one such generalization, where the environment is not strictly episodic, which is mapped to an oracle identification setting with a changing oracle. We analyze this case and show that standard amplitude-amplification techniques can, with minor modifications, still be applied to achieve quadratic speed-ups. In addition, we prove that an algorithm based on Grover iterations is optimal for oracle identification even if the oracle changes over time in a way that the "rewarded space" is monotonically increasing. This result constitutes one of the first generalizations of quantum-accessible reinforcement learning.

Klinisches Verhalten oxyphiler Karzinome der Schilddrüse

Aus einem Kollektiv von 1665 Patienten mit malignen Tumoren der Schilddrüse konnten von 90 (5,4%) oxyphilen Karzinomen der Schilddrüse 55 Fälle erneut histologisch untersucht und klassifiziert werden. Risikofaktoren für das Auftreten von Metastasen und Lokalrezidiven wurden retrospektiv bestimmt. Bei 92% der Patienten wurde nach der Thyreoidektomie die Ablation mit 131J durchgeführt und der Krankheitsverlauf über durchschnittlich 6,5 a verfolgt. 12 Patienten bekamen Metastasen oder Lokalrezidive, in 9 Fällen als erneutes (spätes) Tumorwachstum mit einer mittleren Manifestationszeit von 4,7 a. Späte lokale Lymphknotenmetastasen und Lokalrezidive traten im Mittel 5,4 a, späte Fernmetastasen 2,7 a postoperativ auf. Thyreoglobulin erwies sich als zuverlässiger Tumormarker in der Nachsorge mit einer Sensitivität unter Suppression von 88% und unter endogener TSH-Stimulation von 75% (Spezifität: 98%). Für den klinischen Verlauf bedeutsame Faktoren sind lokale Tumorausbreitung (pT4 vs. pT1-3), makropathologische Wachstumsform des Tumors sowie das Patientenalter zum Zeitpunkt der Operation und nicht der absolute Tumordurchmesser und das Geschlecht. Die 5- und 10-Jahres-Überlebenswahrscheinlichkeiten betragen 95 bzw. 75%. Da bei durchschnittlich 6,5 a Nachsorge 18% des Kollektivs 4,7 a postoperativ auffällig wurden, sollten alle Patienten weit über das 5. Jahr postoperativ hinaus mindestens einmal jährlich mit Tg und Halssonographie untersucht werden.

Szintigraphische Überprüfung der Funktion intraperitoneal liegender Katheter zur regionalen intraabdominellen Chemotherapie

Ziel: Vorgestellt wird im Rahmen eines radikalen Konzeptes zur chirurgischen, hyperthermen und chemotherapeutischen Behandlung von Patienten mit Peritonealkarzinose die szintigraphische Überprüfung der Funktion intraperitoneal liegender Katheter zur regionalen intraperitonealen Chemotherapie. Methoden: Zur Verwendung vorgeschlagen wird die Applikation von Tc-99m-DTPA, durchmischt in 500 ml 0,9%iger NaCI-Lösung. Applikationsprobleme, die intraperitoneale Verteilung und der zeitliche Verlauf der Resorption des Tracers werden anhand von 26 Applikationen an 20 Patienten dargestellt. Ergebnisse: Eine Leckage und drei Partialverschlüsse, die sich umgehend revidieren ließen, traten auf. Es zeigte sich, daß über den Peritoneal-Dialyse-Katheter das obere und auch das rechte Abdomen sowie die zentrale Region weniger gut erreicht werden. Im Einzelfall können erhebliche Fehlverteilungen vorliegen: Bis zu 40% des Abdomens bleiben tracerfrei. Schlußfolgerungen: Bei groben Fehlverteilungen ist die Indikation zur erneuten regionalen Chemotherapie sehr zurückhaltend zu sehen. Allerdings lassen sich aufgrund der derzeitigen Datenlage konzeptionelle Rückschlüsse oder Änderungen des individuellen Therapiekonzepts nicht begründen. Denkbar ist, daß bei Patienten mit einer groben Fehlverteilung, insbesondere mit Aussparung der Regionen und konsekutiv gehäuftem Auftreten von Rezidiven, auf die geschlossene Chemotherapie verzichtet werden kann und dann bei Notwendigkeit eine erneute offene Chemotherapie indiziert ist. Das hier vorgestellte Verfahren ist auf einfache, nicht belastende Weise in der Lage, diese Patientengruppe zu erkennen. Im bisherigen Kollektiv waren etwa 20% (4/19 Patienten) betroffen.

Szintigraphie mit 131J bei oxyphilen Karzinomen der Schilddrüse

Zur Feststellung des Speicherverhaltens von Metastasen (M) und Lokalrezidiven oxyphiler Karzinome der Schilddrüse (OTC) mit 131| wurde retrospektiv ein Kollektiv von 91 Patienten ausgewertet. Es zeigte sich, daß bei 10 von 20 Patienten mit M resp. Rezidiven (R) eine Speicherung von 131| nachweisbar war, bei 8 von 10 Patienten auch therapeutisch verwendbar. In 3 Fällen konnte Tumorfreiheit erzielt werden, wobei es sich ausschließlich um zervikale M mit früher Manifestation bis 3 Monate postoperativ und jüngere Patienten überwiegend in niedrigeren Stadien nach UICC handelte. Bei 3 Patienten wurde die M erstmalig durch die Radiojodszintigraphie (RJS) beschrieben. Patienten mit speichernden Fern-M, die durchwegs spät auftraten, hatten einen ungünstigen klinischen Verlauf trotz Therapie mit131|. Die signifikant jüngeren Patienten (55a) mit speicherndem R/M waren häufiger den Tumorstadien I und II nach UICC zuzuordnen als Patienten mit fehlendem Uptake (67a) entsprechend 7/10 resp. 2/10. Auf die RJS darf daher nicht verzichtet werden. Sie ist insbesondere in der frühen postoperativen Phase und in der Nachsorge zur Lokalisation und zur Stellung der Indikation zur Differentialtherapie anzuwenden.

Expression of the sodium iodide symporter in differentiated thyroid cancer

Aim: Molecular analysis of the expression of the sodium iodide symporter (NIS) in 32 patients with differentiated thyroid cancer (DTC) and correlation with scintigraphic findings (131I,123I) in 19 (59.4%) of them. Patients, methods: NIS expression of 27 primary tumours, 13 lymphnodes and 18 distant metastases was determined by immunostaining using a murine monoclonal anti-NIS-antibody. NIS expression and radionuclide uptake of metastases were analysed by a semiquantitative visual score. Patients were divided into two subgroups: Group 1 (n = 8 patients): indirect correlation of radioiodine uptake (RIU) of subsequent metastases with NIS expression of 7 primary tumours and 3 metastases; Group 2 (n=11 patients): direct correlation of radionuclide uptake with NIS expression of 19 metastases which were excised after imaging. Results: 49 of 58 specimens (84.5%) were NIS-positive. A preserved NIS-expression was found in 12 primary tumours and 8 of 10 (80%) synchrone and 6 of 7 (85.7%) metachrone metastases. Group 1 revealed a 100% positive predictive value (PPV) of a preserved NIS expression in the primary tumour regarding radioiodine uptake in metastases while a lack of NIS expression in the primary tumor did not reliable predict a loss of the metastases’ ability to concentrate radioiodine. In group 2, only 11 of 19 (57.9%) specimens showed a concordant NIS expression and RIU whereas in the remaining 8 cases without visible RIU NIS expression was still present. Conclusions: NIS expression of the primary tumour and metastases in DTC is usually well preserved. We found a positive correlation between NIS expression of the primary and metastatic tissue but could not identify such well correspondence between NIS expression and the RIU of subsequent metastases.

Projecting boreal bird responses to climate change: the signal exceeds the noise

For climate change projections to be useful, the magnitude of change must be understood relative to the magnitude of uncertainty in model predictions. We quantified the signal-to-noise ratio in projected distributional responses of boreal birds to climate change, and compared sources of uncertainty. Boosted regression tree models of abundance were generated for 80 boreal-breeding bird species using a comprehensive data set of standardized avian point counts (349,629 surveys at 122,202 unique locations) and 4-km climate, land use, and topographic data. For projected changes in abundance, we calculated signal-to-noise ratios and examined variance components related to choice of global climate model (GCM) and two sources of species distribution model (SDM) uncertainty: sampling error and variable selection. We also evaluated spatial, temporal, and interspecific variation in these sources of uncertainty. The mean signal-to-noise ratio across species increased over time to 2.87 by the end of the 21st century, with the signal greater than the noise for 88% of species. Across species, climate change represented the largest component (0.44) of variance in projected abundance change. Among sources of uncertainty evaluated, choice of GCM (mean variance component = 0.17) was most important for 66% of species, sampling error (mean= 0.12) for 29% of species, and variable selection (mean =0.05) for 5% of species. Increasing the number of GCMs from four to 19 had minor effects on these results. The range of projected changes and uncertainty characteristics across species differed markedly, reinforcing the individuality of species' responses to climate change and the challenges of one-size-fits-all approaches to climate change adaptation. We discuss the usefulness of different conservation approaches depending on the strength of the climate change signal relative to the noise, as well as the dominant source of prediction uncertainty.

C332C genotype of glyoxalase 1 and its association with late diabetic complications

AIMS/INTRODUCTION

Glyoxalase 1 catalyses the detoxification of methylglyoxal, a major precursor of advanced glycation end products associated with aging, neurodegenerative diseases, and microvascular complications of diabetes. Here, we examine a possible association of a single nucleotide polymorphism of glyoxalase 1 gene (Glo1 A332C, rs4746 or rs2736654) with the prevalence of microvascular diabetic complications in patients with type 1 and type 2 diabetes.

MATERIALS AND METHODS

Genotyping was performed in 209 patients with type 1 and 524 patients with type 2 diabetes using polymerase chain reaction and subsequent cleavage by restriction endonuclease Bsa I.

RESULTS

Frequencies of the glyoxalase 1 genotypes were different with respect to diabetes type with a significantly higher prevalence of A332A-genotype in type 1 diabetes (35.9% vs. 27.3%; p=0.03). In type 1 diabetes, there was no correlation of any genotype with diabetic retinopathy, nephropathy or neuropathy. In contrast, type 2 diabetic patients homozygous for the C332C allele showed a significantly increased prevalence of diabetic neuropathy (p=0.03; OR=1.49 [95%-CI: 1.04; 2.11]), while no association with diabetic nephropathy or retinopathy was found. However, the significance of this association was lost after correction for multiple testing.

CONCLUSIONS

Our data suggest a possible association of C332C-genotype of the glyoxalase 1 gene with diabetic neuropathy in type 2 diabetes, supporting the hypothesis that methylglyoxal might be an important mediator of diabetic neuropathy in type 2 diabetes.

Evolution of the magnetic structure in CeCu(5.5)Au(0.5) under pressure towards quantum criticality

In the prototypical heavy-fermion system CeCu(6-x)Au(x), a magnetic quantum critical point can be tuned by Au concentration x, hydrostatic pressure p, or magnetic field B. A striking equivalence of the tuning behavior with x or p had been found with respect to thermodynamic and transport properties. By means of elastic neutron scattering on single crystalline CeCu(5.5)Au(0.5), we demonstrate this x-p equivalence on a microscopic level by showing that the magnetic ordering wave vector q(m) can be tuned accordingly. At ambient pressure,CeCu(5.5)Au(0.5) orders at q(m)≈(0.59 0 0). Upon applying p=4.1 kbar, q(m)≈(0.61 0 0.21) is found corresponding to CeCu(5.6)Au(0.4) at ambient pressure. The transition seems to occur in a first-order fashion and to be governed by slight changes in the nesting properties of the Fermi surface.

Microsatellite fingerprinting in the genus Phaseolus

The genetic variability of the genus Phaseolus was investigated by nonradioactive DNA fingerprinting. The simple repetitive sequences (GATA)4, (GACA)4, (CAC)5, and (CA)8 were used as probes to differentiate 18 species comprised of 90 genotypes. (GATA)4, (CAC)5, and (CA)8 could be detected in the genome of nearly all species, while the (GACA)4 motif occurred only in 13 species. Almost all fragments that hybridized with (GACA)4 also hybridized with (GATA)4. All but two cultivars of Phaseolus vulgaris, P. lunatus, P. acutifolius, and P. polyanthus showed specific banding patterns with (GATA)4. The other repetitive motifs revealed only limited or no intraspecific variation. In P. vulgaris, two group-specific patterns were found with (GATA)4, giving further evidence for a Middle American and an Andean origin of the P. vulgaris genotypes. The high intraspecific pattern variation that was revealed with (GATA)4 in the predominantly self-pollinating species P. vulgaris and P. lunatus can probably be explained by there being at least two primary centres of domestication and, hence, genetic diversification. In cross-pollinating species (e.g., P. coccineus), the observed intraspecific variation was, surprisingly, rather low. The present study shows that DNA fingerprinting with microsatellites successfully distinguishes among gene pools, cultivars, and, in some cases, among individuals.

[Interhospital transport of intensive care patients in Lower Saxony : statewide need-based and effective management]

BACKGROUND

Since 2007 interhospital transport of intensive care patients in Lower Saxony appertains to the performance requirements of emergency medical services. Against this background the Working Group for Evaluation of Intensive Care Transport (Arbeitsgemeinschaft Evaluation Intensivverlegung) was established. This group formulated standardized definitions for the requirements of intensive care transport vehicles and a federal statewide monitoring of intensive care transport was implemented to analyze if simultaneously on-call intensive care transport systems (intensive care helicopter and ground based mobile intensive care units) can be deployed need-based and efficiently.

METHODS

A prospective follow-up study and evaluation of intensive care transport in Lower Saxony between April 1(st) 2008 and July 31(st) 2010 was carried out.

RESULTS

A total of 6,779 data records were evaluated in this study of which 4,941 (72.9%) missions were located in Lower Saxony, 2,928 (43.2%) missions were carried out by helicopters and 3,851 (56.8%) by ground based mobile intensive care units. The mean duration of a mission was 3 h 59min±2 h 25 min, 4 h 39 min±2 h 23 min by ground based mobile intensive care units and 2 h 21 in±30 min by helicopter units. All systems proved to be feasible for intensive care transport. The degree of urgency was estimated correctly in 94.8% of the evaluated missions and 58.0% of the transfers could not be deployed. In 76.8% patients were transferred to hospitals with a higher level of medical care, 51.7% of patients were transferred for intensive care therapy and 40.4% for an operation/intervention. Of the patients 38.2% required mechanical ventilation and in 48.3% invasive monitoring was carried out.

CONCLUSION

Interhospital transfer of intensive care patients can be carried out need-based with a limited number of intensive care transport vehicles if the missions are deployed effectively by standardized disposition in accordance with performance requirements.

Moderate weight reduction in an outpatient obesity intervention program significantly reduces insulin resistance and risk factors for cardiovascular disease in severely obese adolescents

Background. Metabolic risk factors like insulin resistance and dyslipidemia are frequently observed in severly obese children. We investigated the hypothesis that moderate weight reduction by a low-threshold intervention is already able to reduce insulin resistance and cardiovascular risk factors in severely obese children. Methods. A group of 58 severely obese children and adolescents between 8 and 17 years participating in a six-month-long outpatient program was studied before and after treatment. The program included behavioral treatment, dietary education and specific physical training. Metabolic parameters were measured in the fasting state, insulin resistance was evaluated in an oral glucose tolerance test. Results. Mean standard deviation score of the body mass index (SDS-BMI) in the study group dropped significantly from +2.5 ± 0.5 to 2.3 ± 0.6 (P < 0.0001) after participation in the program. A significant decrease was observed in HOMA (6.3 ± 4.2 versus 4.9 ± 2.4, P < 0.03, and in peak insulin levels (232.7 ± 132.4 versus 179.2 ± 73.3 μU/mL, P < 0.006). Significant reductions were also observed in mean levels of hemoglobin A(1c), total cholesterol and LDL cholesterol. Conclusions. These data demonstrate that already moderate weight reduction is able to decrease insulin resistance and dyslipidemia in severely obese children and adolescents.

Magnetic blue phase in the chiral itinerant magnet MnSi

Chiral nematic liquid crystals sometimes form blue phases characterized by spirals twisting in different directions. By combining model calculations with neutron-scattering experiments, we show that the magnetic analogue of blue phases does form in the chiral itinerant magnet MnSi in a large part of the phase diagram. The properties of this blue phase explain a number of previously reported puzzling features of MnSi such as partial magnetic order and a two-component specific-heat and thermal-expansion anomaly at the magnetic transition.

Regulation of energy balance by leptin

The high prevalence of obesity and its well documented association with the cardiovascular risk factors diabetes mellitus, dyslipidemia and hypertension represents a major problem for the general health status of industrialized societies. Although numerous studies have shown that genetic factors have a major influence on the regulation of energy homeostasis and the susceptibility to obesity, the genes and predisposing mutations involved are insufficiently understood. Among several known rodent models of obesity due to single gene mutations, mice homozygous for the obese (ob) gene exhibit massive early-onset obesity, hyperphagia, non-insulin-dependent diabetes mellitus, defective thermoregulation and infertility. Recently the ob gene was identified by positional cloning and shown to be mutated in ob/ob mice. Leptin, the product of the ob gene, is a 167-amino acid secreted protein that is synthesized exclusively in adipose tissue. With the exception of ob/ob mice, circulating plasma leptin is elevated in obesity. Administration of recombinant leptin to ob/ob mice reduces fat mass, food intake, hyperglycemia and hyperinsulinemia. The various effects of the hormone are mediated by leptin receptors expressed at high levels in the hypothalamus, but also in several other non-neuronal tissues. A mutation in the leptin receptor gene is responsible for the obese phenotype of db/db mice. Plasma leptin in humans is positively correlated with body fat mass, suggesting that leptin resistance rather than leptin deficiency is a common feature of human obesity. This review briefly summarizes the current status of the rapidly growing evidence that leptin plays an important role in the regulation of body weight and fat deposition.

[Tissue retention of T cells as a therapeutic target in rheumatoid arthritis]

Autoreactive T cells are instrumental for the induction and chronification of autoimmune diseases. While immigration of T cells into inflamed tissue is strongly enhanced during acute inflammatory phases, retention of antigen specific T cells rather than subsequent recruitment of recirculating effector cells appears to contribute to the inflammatory infiltrate seen during chronic inflammation. Patients suffering from rheumatoid arthritis also show accumulation of oligoclonal T cells within the inflamed synovia, where environmental signals seem to promote the prolonged survival of these chronically activated T cells. The survival signals and mechanisms controlling retention of T cells within the inflamed synovia are poorly characterized. However, the specific interference with these mechanisms could be a therapeutic approach in chronic inflammatory diseases like rheumatoid arthritis that are accompanied by a strong local accumulation of immune cells.

The -174G>C IL-6 gene promoter polymorphism and diabetic microvascular complications

This study examined a possible association of the G>C polymorphism at nucleotide -174 in the promoter region of the interleukin-6 (IL-6) gene (rs1800795) with the prevalence of diabetic complications in 235 patients with type 1 and 498 patients with type 2 diabetes. Genotyping was performed using polymerase chain reaction (PCR) and subsequent cleavage by Nla III restriction endonuclease. Analyzing all diabetic patients together demonstrated that 301 patients (41.1%) carried the GG genotype, 114 (15.6%) the CC genotype, and 318 (43.3%) were heterozygous for the GC genotype. However, there was no correlation of any of the genotypes with the prevalence of diabetic nephropathy or diabetic neuropathy, but subjects with the CC genotype had a significantly higher prevalence of diabetic retinopathy compared to patients with the GC and GG genotype (p=0.016). This association was mainly lost when a logistic regression model was adjusted for diabetes duration (p=0.07). Consistently, a weak but not significant association of the polymorphism with diabetic retinopathy was observed when type 1 and type 2 diabetic patients were analyzed separately (patients with type 1 diabetes: p=0.12; patients with type 2 diabetes: p=0.09). Analogically, no association of the polymorphism was found for diabetic nephropathy or diabetic neuropathy in these groups. In conclusion these data suggest no major influence of the -174G>C variant in the promoter region of the IL-6 gene on the development of microvascular complications in patients with diabetes.

[Necrotizing fasciitis caused by group G streptococci]

Necrotizing fasciitis is a soft tissue infection which is highly lethal. Its lethality can only be reduced by early diagnosis and radical débridement. A delayed diagnosis will result in streptococcal toxic shock syndrome. Any surgery neglecting radical débridement up to amputation is inadequate and cannot reduce lethality. This paper reports on two cases of necrotizing fasciitis of the leg caused by group G streptococci.

Rosiglitazone reduces angiotensin II and advanced glycation end product-dependent sustained nuclear factor-kappaB activation in cultured human proximal tubular epithelial cells

Tubular damage is a major feature in the development of diabetic nephropathy. This study investigates the effects of the thiazolidindione rosiglitazone on angiotensin II and advanced glycation end product-induced tubular activation in human proximal tubular epithelial cells IN VITRO. Angiotensin II and advanced glycation end products, both induced a dose-dependent sustained activation of the redox-sensitive transcription factor, Nuclear Factor KAPPA B (NF-kappaB). Nuclear translocation of NF-kappaB was evident already after one hour and persistent for more than four days. Co-incubation of proximal tubular epithelial cells with rosiglitazone significantly reduced angiotensin II and advanced glycation end product-mediated generation of reactive oxygen species, angiotensin II-dependent advanced glycation end product formation, NF-kappaB activation, and NF-kappaB-dependent pro inflammatory gene expression. Most importantly, rosiglitazone effects on NFkappaB activation were maximal at later time points, indicating that rosiglitazone treatment confers long lasting renoprotective effects.

Potential benefits of early addition of rosiglitazone in combination with glimepiride in the treatment of type 2 diabetes

AIM

To assess the efficacy and tolerability of early combination therapy with rosiglitazone (RSG) and glimepiride (GLIM) vs. GLIM monotherapy in patients with type 2 diabetes mellitus (T2DM).

METHODS

Strategies for the addition of RSG in combination with GLIM were evaluated with data from two randomized, double-blind, placebo (PBO)-controlled studies. Study A - addition of RSG (4 or 8 mg) or PBO to continued GLIM 3 mg once daily; study B - addition of low-dose RSG (4 mg) prior to uptitration of GLIM (from 2 to 4 mg) vs. continued uptitration of GLIM (from 2 to 8 mg).

RESULTS

Study A reported significant reductions in fasting plasma glucose (FPG) from baseline to week 26 with the addition of both 4 and 8 mg RSG to GLIM 3 mg [-21 mg/dl (-1.2 mmol/l), p = 0.0019 and -43 mg/dl (-2.4 mmol/l), p < 0.0001, respectively] and in haemoglobin A(1c) (HbA(1c)) (-0.63%, p = 0.00015 and -1.17%, p < 0.0001, respectively) from a baseline of 8.2 and 8.1%, respectively. At the end of the study, target HbA(1c) <7.0% was achieved in 43 and 68% of patients in the RSG 4 mg + GLIM and RSG 8 mg + GLIM groups, respectively, compared with 32% in the PBO + GLIM (GLIM alone) group. In study B, addition of RSG to GLIM reduced mean FPG and HbA(1c) levels at week 24 from baseline [-28 mg/dl (-1.5 mmol/l), p < 0.0001, and -0.68%, p < 0.0001, respectively]. There were no significant changes with GLIM monotherapy in either study. Favourable effects of RSG + GLIM on insulin sensitivity, beta-cell function and cardiovascular disease biomarkers were also observed. All treatments were similarly well tolerated.

CONCLUSIONS

Early addition of RSG to GLIM is an effective and well-tolerated treatment option to improve glycaemic control in sulphonylurea-treated patients with T2DM.