Impaired self-awareness of cognitive deficits in Parkinson's disease relates to cingulate cortex dysfunction

BACKGROUND

Impaired self-awareness of cognitive deficits (ISAcog) has rarely been investigated in Parkinson's disease (PD). ISAcog is associated with poorer long-term outcome in other diseases. This study examines ISAcog in PD with and without mild cognitive impairment (PD-MCI), compared to healthy controls, and its clinical-behavioral and neuroimaging correlates.

METHODS

We examined 63 PD patients and 30 age- and education-matched healthy controls. Cognitive state was examined following the Movement Disorder Society Level II criteria. ISAcog was determined by subtracting z-scores (based on controls' scores) of objective tests and subjective questionnaires. Neural correlates were assessed by structural magnetic resonance imaging (MRI) and 2-[fluorine-18]fluoro-2-deoxy-d-glucose-positron emission tomography (FDG-PET) in 47 patients (43 with MRI) and 11 controls. We analyzed whole-brain glucose metabolism and cortical thickness in regions where FDG-uptake correlated with ISAcog.

RESULTS

PD-MCI patients (N = 23) showed significantly more ISAcog than controls and patients without MCI (N = 40). When all patients who underwent FDG-PET were examined, metabolism in the bilateral superior medial frontal gyrus, anterior and midcingulate cortex negatively correlated with ISAcog (FWE-corrected p < 0.001). In PD-MCI, ISAcog was related to decreased metabolism in the right superior temporal lobe and insula (N = 13; FWE-corrected p = 0.023) as well as the midcingulate cortex (FWE-corrected p = 0.002). Cortical thickness was not associated with ISAcog in these regions. No significant correlations were found between ISAcog and glucose metabolism in controls and patients without MCI.

CONCLUSIONS

Similar to Alzheimer's disease, the cingulate cortex seems to be relevant in ISAcog in PD. In PD-MCI patients, ISAcog might result from a disrupted network that regulates awareness of cognition and error processes.

Autogenous Bone Block versus Collagenated Xenogeneic Bone Block in the reconstruction of the atrophic alveolar ridge: a non-inferiority randomized clinical trial

OBJECTIVE

To compare the efficacy of equine derived collagenated bone blocks (CXBB) and autogenous bone block (ABB) for lateral alveolar ridge augmentation and two-stage implant placement.

MATERIALS AND METHODS

Sixty-four patients with tooth gaps up to 4 teeth and atrophic alveolar ridges with ≤ 4 mm were randomly assigned to lateral augmentation using CXBB or ABB. Lateral bone thickness was measured 2 mm below the alveolar crest at augmentation surgery and 30 weeks later at implant placement. Implant related outcomes, adverse events, surgery duration, pain sensation, analgesic consumption and oral health-related quality of life were also assessed. Data was analyzed using Fisher's exact, Mann-Whitney, and Wilcoxon signed-rank tests.

RESULTS

At 30 weeks, the median change in lateral bone thickness amounted to 2.90 (CXBB) and 3.00 (ABB), respectively. Secondary endpoints demonstrated similar results for CXBB and ABB in terms of possibility to place an implant, need to perform a secondary bone augmentation at implant placement and rate of complications. Early implant failure was 20% for CXBB and 10% for ABB, with no difference between the groups. Pain scores and postoperative consumption of analgesics were significantly lower in the CXBB group than in the ABB group, especially during the first days post-surgery.

CONCLUSION

CXBB is non-inferior to ABB for horizontal alveolar ridge augmentation and two-stage implant placement. This article is protected by copyright. All rights reserved.

Clustering of Parkinson subtypes reveals strong influence of DRD2 polymorphism and gender

Most classification approaches for idiopathic Parkinson’s disease subtypes primarily focus on motor and non-motor symptoms. Besides these characteristics, other features, including gender or genetic polymorphism of dopamine receptors are potential factors influencing the disease’s phenotype. By utilizing a kmeans-clustering algorithm we were able to identify three subgroups mainly characterized by gender, DRD2 Taq1A (rs1800497) polymorphism—associated with changes in dopamine signaling in the brain—and disease progression. A subsequent regression analysis of these subgroups further suggests an influence of their characteristics on the daily levodopa dosage, an indicator for medication response. These findings could promote further enhancements in individualized therapies for idiopathic Parkinson’s disease.

Effects of Lee Silverman Voice Treatment BIG and conventional physiotherapy on non-motor and motor symptoms in Parkinson's disease: a randomized controlled study comparing three exercise models

Background:

Parkinson’s disease (PD) patients experience disabling motor dysfunctions as well as non-motor symptoms (NMSs) that can highly impact their perceived quality of life. Besides pharmacological treatment options, active intervention programs have set some attention in managing these symptoms. However, previous studies mainly assessed the effectiveness of active intervention programs on functional mobility and motor symptoms.

Objective:

This study aimed to investigate the effect of Lee Silverman Voice Treatment (LSVT) BIG, an intensified and personalized physiotherapy (INTENSIVE), and a conventional physiotherapy (NORMAL) on NMSs in PD.

Method:

Forty-four patients with mild to moderate PD were randomly assigned to one of the three treatment groups. LSVT BIG and INTENSIVE were delivered one-on-one in 16 1-hour sessions within 4 weeks (4×/week). Patients assigned to NORMAL received 16 individual 1-hour sessions within 8 weeks (2×/week). The primary outcome measure was the difference in change from baseline in the non-motor symptom assessment scale for Parkinson’s disease (NMSS) between treatment groups to follow up at week 8. Patients were blinded for the NMSS being the primary outcome, but not the different treatment groups.

Results:

ANCOVA (Analysis of Covariance) showed reduced NMSS scores for all groups, with INTENSIVE being superior to NORMAL (p = 0.033). For secondary outcome measures (stride length, gait velocity and chair rising test) LSVT BIG and INTENSIVE were both superior to NORMAL.

Conclusions:

The study provides evidence that all three exercise programs are effective techniques to improve NMSs as well as motor function in PD.

DRKS registration number:

DRKS00008732

Network degeneration in Parkinson’s disease: multimodal imaging of nigro-striato-cortical dysfunction

The spreading hypothesis of neurodegeneration assumes an expansion of neural pathologies along existing neural pathways. Multimodal neuroimaging studies have demonstrated distinct topographic patterns of cerebral pathologies in neurodegeneration. For Parkinson’s disease the hypothesis so far rests largely on histopathological evidence of α-synuclein spreading in a characteristic pattern and progressive nigrostriatal dopamine depletion. Functional consequences of nigrostriatal dysfunction on cortical activity remain to be elucidated. Our goal was to investigate multimodal imaging correlates of degenerative processes in Parkinson’s disease by assessing dopamine depletion and its potential effect on striatocortical connectivity networks and cortical metabolism in relation to parkinsonian symptoms. We combined 18F-DOPA-PET, 18F-fluorodeoxyglucose (FDG)-PET and resting state functional MRI to multimodally characterize network alterations in Parkinson’s disease. Forty-two patients with mild-to-moderate stage Parkinson’s disease and 14 age-matched healthy control subjects underwent a multimodal imaging protocol and comprehensive clinical examination. A voxel-wise group comparison of 18F-DOPA uptake identified the exact location and extent of putaminal dopamine depletion in patients. Resulting clusters were defined as seeds for a seed-to-voxel functional connectivity analysis. 18F-FDG metabolism was compared between groups at a whole-brain level and uptake values were extracted from regions with reduced putaminal connectivity. To unravel associations between dopaminergic activity, striatocortical connectivity, glucose metabolism and symptom severity, correlations between normalized uptake values, seed-to-cluster β-values and clinical parameters were tested while controlling for age and dopaminergic medication. Aside from cortical hypometabolism, 18F-FDG-PET data for the first time revealed a hypometabolic midbrain cluster in patients with Parkinson’s disease that comprised caudal parts of the bilateral substantia nigra pars compacta. Putaminal dopamine synthesis capacity was significantly reduced in the bilateral posterior putamen and correlated with ipsilateral nigral 18F-FDG uptake. Resting state functional MRI data indicated significantly reduced functional connectivity between the dopamine depleted putaminal seed and cortical areas primarily belonging to the sensorimotor network in patients with Parkinson’s disease. In the inferior parietal cortex, hypoconnectivity in patients was significantly correlated with lower metabolism (left P = 0.021, right P = 0.018). Of note, unilateral network alterations quantified with different modalities corresponded with contralateral motor impairments. In conclusion, our results support the hypothesis that degeneration of nigrostriatal fibres functionally impairs distinct striatocortical connections, disturbing the efficient interplay between motor processing areas and impairing motor control in patients with Parkinson’s disease. The present study is the first to reveal trimodal evidence for network-dependent degeneration in Parkinson’s disease by outlining the impact of functional nigrostriatal pathway impairment on striatocortical functional connectivity networks and cortical metabolism.

Overlapping and distinct neural metabolic patterns related to impulsivity and hypomania in Parkinson's disease

Impulsivity and hypomania are common non-motor features in Parkinson's disease (PD). The aim of this study was to find the overlapping and distinct neural correlates of these symptoms in PD. Symptoms of impulsivity and hypomania were assessed in 24 PD patients using the Barratt Impulsiveness Scale (BIS-11) and Self-Report Manic Inventory (SRMI), respectively. In addition, fluorodeoxyglucose positron emission tomography (FDG-PET) imaging for each individual was performed. We conducted two separate multiple regression analyses for BIS-11 and SRMI scores with FDG-PET data to identify the brain regions that are associated with both impulsivity and hypomania scores, as well as those exclusive to each symptom. Then, seed-based functional connectivity analyses on healthy subjects identified the areas connected to each of the exclusive regions and the overlapping region, used as seeds. We observed a positive association between BIS-11 and SRMI scores and neural metabolism only in the prefrontal areas. Conjunction analysis revealed an overlapping region in the middle frontal gyrus. Regions exclusive to impulsivity were found in the medial part of the right superior frontal gyrus and regions exclusive to hypomania were in the right superior frontal gyrus, right precentral gyrus and right paracentral lobule. Connectivity patterns of seeds exclusively related to impulsivity were different from those for hypomania in healthy brains. These results provide evidence of both overlapping and distinct regions linked with impulsivity and hypomania scores in PD. The exclusive regions for each characteristic are connected to specific intrinsic functional networks.

SUN-095 Attenuation of Inflammation by a Novel Small Molecule Prevents High Fat Diet-Induced Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of both metabolic and inflammatory diseases, and it has become pervasive worldwide. Inflammation, including inflammation resulting from free fatty acid (FFA) activation of toll-like receptor (TLR) signaling, has been suggested to be an essential component of the pathophysiology of both insulin resistance and NAFLD. High fat (HF) diets promote an increased uptake and storage of FFAs and triglycerides in hepatocytes, which initiates inflammation and steatosis that induces lipotoxicity and an exacerbation of inflammation. In previous studies, we have established the efficacy of phenylmethimazole, a TLR3/4 inhibitor, to prevent and reverse HF diet-induced NAFLD, inflammation, and insulin resistance. A new library of small molecule compounds, including COB-214, was generated to identify even more potent inhibitors of inflammation. The objectives of this study were to evaluate the efficacy of COB-214 to delay and/or prevent hepatic steatosis, inflammation, and insulin resistance in a HF diet-induced model of NAFLD. C57BL/6J male mice were fed a HF diet (60 % fat, 20% protein, 70% carbohydrate) and divided into 3 groups (N=8 for each group): sham injection (stress control), DMSO (vehicle control), COB-214. Each treatment was administered once daily at a dosage of 1mg/kg for 16 weeks. Histological examination of liver sections from these mice using hematoxylin and eosin (H&E) revealed less hepatic lipid accumulation in mice treated with COB-214 when compared to mice in the sham- and DMSO-treated groups. Transcription of pro-inflammatory cytokines was down-regulated in both liver and mesenteric adipose tissue isolated from COB-214-treated mice when compared to sham- and DMSO-treated mice. Treatment with COB-214 prevented HF diet-induced insulin resistance measured by a 3-hour intraperitoneal glucose tolerance test (IPGTT) and 1.5-hour intraperitoneal insulin tolerance test (IPITT). Future directions include determining the efficacy of COB-214 to reverse HF diet-induced NAFLD, inflammation, and insulin resistance. At the conclusion of this study, we hope to have established the role of a novel class of small molecule inhibitors of inflammation in the treatment and prevention of NAFLD.

Mitigating Undesignated Trail Use: The Efficacy of Messaging and Direct Site Management Actions in an Urban-Proximate Open Space Context

The use and creation of undesignated recreational trails can lead to erosion, vegetation damage, unsafe trail conditions, and impacts to local wildlife. The mitigation of undesignated trail use is typically addressed indirectly through minimum-impact visitor education programs such as Leave No Trace, or directly through closures or sanctions. In this study, researchers collaborated with City of Boulder, Colorado Open Space and Mountain Parks (OSMP) staff to develop a quasi-experimental field study that examined the effectiveness of indirect (messaging) and direct (barriers) management approaches to mitigating undesignated trail use. The study applied a Theory of Planned Behavior framework, utilized Leave No Trace messaging, and employed a method to pair survey and direct observation data. A total of 2232 visitor parties were observed, and 147 surveys were collected. The combined direct (barrier) and indirect (messaging) intervention was the most effective at mitigating undesignated trail use. Implications for management and future research are discussed.

Using LSTMs to learn physiological models of blood glucose behavior

For people with type 1 diabetes, good blood glucose control is essential to keeping serious disease complications at bay. This entails carefully monitoring blood glucose levels and taking corrective steps whenever they are too high or too low. If blood glucose levels could be accurately predicted, patients could take proactive steps to prevent blood glucose excursions from occurring. However, accurate predictions require complex physiological models of blood glucose behavior. Factors such as insulin boluses, carbohydrate intake, and exercise influence blood glucose in ways that are difficult to capture through manually engineered equations. In this paper, we describe a recursive neural network (RNN) approach that uses long short-term memory (LSTM) units to learn a physiological model of blood glucose. When trained on raw data from real patients, the LSTM networks (LSTMs) obtain results that are competitive with a previous state-of-the-art model based on manually engineered physiological equations. The RNN approach can incorporate arbitrary physiological parameters without the need for sophisticated manual engineering, thus holding the promise of further improvements in prediction accuracy.

Phenylmethimazole abrogates diet-induced inflammation, glucose intolerance and NAFLD

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of both metabolic and inflammatory diseases and has become the leading chronic liver disease worldwide. High-fat (HF) diets promote an increased uptake and storage of free fatty acids (FFAs) and triglycerides (TGs) in hepatocytes, which initiates steatosis and induces lipotoxicity, inflammation and insulin resistance. Activation and signaling of Toll-like receptor 4 (TLR4) by FFAs induces inflammation evident in NAFLD and insulin resistance. Currently, there are no effective treatments to specifically target inflammation associated with this disease. We have established the efficacy of phenylmethimazole (C10) to prevent lipopolysaccharide and palmitate-induced TLR4 signaling. Because TLR4 is a key mediator in pro-inflammatory responses, it is a potential therapeutic target for NAFLD. Here, we show that treatment with C10 inhibits HF diet-induced inflammation in both liver and mesenteric adipose tissue measured by a decrease in mRNA levels of pro-inflammatory cytokines. Additionally, C10 treatment improves glucose tolerance and hepatic steatosis despite the development of obesity due to HF diet feeding. Administration of C10 after 16 weeks of HF diet feeding reversed glucose intolerance, hepatic inflammation, and improved hepatic steatosis. Thus, our findings establish C10 as a potential therapeutic for the treatment of NAFLD.

Resting-state functional reorganization in Parkinson's disease: An activation likelihood estimation meta-analysis

Parkinson's disease (PD) is a common progressive neurodegenerative disorder. Studies using resting-state functional magnetic resonance imaging (fMRI) to investigate underlying pathophysiology of motor and non-motor symptoms in PD yielded largely inconsistent results. This quantitative neuroimaging meta-analysis aims to identify consistent abnormal intrinsic functional patterns in PD across studies. We used PubMed to retrieve suitable resting-state studies and stereotactic data were extracted from 28 individual between-group comparisons. Convergence across their findings was tested using the activation likelihood estimation (ALE) approach. We found convergent evidence for intrinsic functional disturbances in bilateral inferior parietal lobule (IPL) and the supramarginal gyrus in PD patients compared to healthy subjects. In follow-up task-based and task-independent functional connectivity (FC) analyses using two independent healthy subject data sets, we found that the regions showing convergent aberrations in PD formed an interconnected network mainly with the default mode network (DMN). Behavioral characterization of these regions using the BrainMap database suggested associated dysfunction of perception and executive processes. Taken together, our findings highlight the role of parietal cortex in the pathophysiology of PD.

Program ACTIVE II: Design and Methods for a Multi-Center Community-Based Depression Treatment for Rural and Urban Adults with Type 2 Diabetes

Objective

Depression affects one in four adults with type 2 diabetes (T2DM) and is associated with worsened diabetes complications, increased health care costs and early mortality. Rural and low-income urban areas, including the Appalachian region, represent an epicenter of the T2DM epidemic. Program ACTIVE II is a comparative effectiveness treatment trial designed to test whether a combination of cognitive behavioral therapy (CBT) and community-based exercise (EXER) will offer greater improvements in diabetes and depression outcomes compared to individual treatment approaches and usual care (UC). The secondary aims are to assess changes in cardiovascular risk factors across groups and to conduct a cost-effectiveness analysis of predicted incidence of cardiovascular complications across groups.

Methods

The study is a 2-by-2 factorial randomized controlled trial consisting of 4 treatment groups: CBT alone, EXER alone, combination of CBT and EXER, and UC. Adults with T2DM for > 1 year and who meet DSM-IVTR criteria for Major Depressive Disorder (MDD) are eligible to participate at two rural Appalachian sites (southeastern Ohio and West Virginia) and one urban site (Indianapolis). This type II behavioral translation study uses a community-engaged research (CEnR) approach by incorporating community fitness centers and mental health practices as interventionists.

Conclusions

This is the first study to evaluate the comparative effectiveness of combined CBT and exercise in the treatment of depression using community-based intervention delivery. This approach may serve as a national model for expanding depression treatment for patients with T2DM.

Dopaminergic correlates of metabolic network activity in Parkinson's disease

Parkinson's disease (PD) is associated with distinct metabolic covariance patterns that relate to the motor and cognitive manifestations of the disorder. It is not known, however, how the expression of these patterns relates to measurements of nigrostriatal dopaminergic activity from the same individuals. To explore these associations, we studied 106 PD subjects who underwent cerebral PET with both (18) F-fluorodeoxyglucose (FDG) and (18) F-fluoro-L-dopa (FDOPA). Expression values for the PD motor- and cognition-related metabolic patterns (PDRP and PDCP, respectively) were computed for each subject; these measures were correlated with FDOPA uptake on a voxel-by-voxel basis. To explore the relationship between dopaminergic function and local metabolic activity, caudate and putamen FDOPA PET signal was correlated voxel-wise with FDG uptake over the entire brain. PDRP expression correlated with FDOPA uptake in caudate and putamen (P < 0.001), while PDCP expression correlated with uptake in the anterior striatum (P < 0.001). While statistically significant, the correlations were only of modest size, accounting for less than 20% of the overall variation in these measures. After controlling for PDCP expression, PDRP correlations were significant only in the posterior putamen. Of note, voxel-wise correlations between caudate/putamen FDOPA uptake and whole-brain FDG uptake were significant almost exclusively in PDRP regions. Overall, the data indicate that PDRP and PDCP expression correlates significantly with PET indices of presynaptic dopaminergic functioning obtained in the same individuals. Even so, the modest size of these correlations suggests that in PD patients, individual differences in network activity cannot be explained solely by nigrostriatal dopamine loss.

Predictors of Hypoglycemia in the ASPIRE In-Home Study and Effects of Automatic Suspension of Insulin Delivery

BACKGROUND

Hypoglycemia varies between patients with type 1 diabetes and is the main obstacle to therapy intensification. We investigated known and potential risk factors for hypoglycemia in subjects with type 1 diabetes.

METHOD

In the ASPIRE In-Home study (NCT01497938), a randomized trial of the threshold suspend (TS) feature of sensor-augmented insulin pump (SAP) therapy, subjects' propensity to nocturnal hypoglycemia (NH) was established in a 2-week run-in phase and assessed in a 3-month study phase via continuous glucose monitoring. Categorical variables were tested for association with NH rates in both phases.

RESULTS

Elevated rates of NH were significantly associated with baseline A1C ≤7%, with bolus insulin deliveries unassisted by the bolus estimation calculator, and with assignment to the control group during the study phase.

CONCLUSIONS

Routine use of the TS feature and the bolus estimation calculator are strategies that may reduce the risk of NH.

Lipodystrophy: Syndrome of severe insulin resistance

CONTEXT

Lipodystrophy (LD) is a relatively rare complex collection of diseases that can be congenital or acquired. It is commonly missed in the clinical setting. Thus, the spectrum of disease presentation mandates clinician expertise in the pathophysiology and management of all forms of LD, obesity, and insulin resistance.

METHODS AND MATERIALS

An extensive literature search of clinical trials, systematic reviews, and narrative reviews was completed in PubMed for the years 1970 to 2013. The search terms were lipodystrophy, congenital LD, acquired LD, HIV-associated LD, severe insulin resistance, adiposity, obesity, and dyslipidemia.

EVIDENCE SYNTHESIS

Lipodystrophies are a heterogeneous group of disorders with abnormal adipose tissue distribution, utilization, and metabolism. Adipose tissue can undergo significant changes in composition (hypertrophy and atrophy) in response to a nutritional state. Paradoxically, both excess and deficient adipose tissue is associated with insulin resistance and the metabolic syndrome. Bone density scan (DEXA) for body fat composition analysis or magnetic resonance imaging are optimal modalities for the assessment of abnormal adipose tissue distribution. Ongoing clinical studies suggest thiazolidinediones, insulin like growth factor-1, leptin, and growth hormone-releasing hormone as possible treatment for LPD; however, none of them is approved to reverse fat loss or treat severe insulin resistance due to LPD.

CONCLUSION

The underlying mechanisms for LPD causing insulin resistance may be lipotoxicity and derangements in adipose tissue-derived proteins (adipocytokines). However, the lack of evidence to support this model means that clinicians are on their own as they navigate through the phenotypic presentation of lipodystrophies, obesity, insulin resistance, and the metabolic syndrome.

Parkinson's disease subtypes show a specific link between dopaminergic and glucose metabolism in the striatum

BACKGROUND

Previous studies have shown different clinical and imaging pattern in tremordominant and akinetic-rigid Parkinson's disease (PD) subtypes. The association between dopaminergic and glucose metabolism has in contrast not been investigated yet. Therefore, this study compared PD subtypes with respect to clinical and imaging findings with the aim of establishing a relationship between clinical subtypes, dopamine and glucose metabolism.

METHODS

Two groups of a total of 64 idiopathic PD patients (42 male, 22 female, mean age 56 ± 10.9 years) were analysed: akinetic-rigid (AR, n = 32) and tremor-dominant (TD, n = 32) patients. Both were compared with respect to differential involvement of local striatal dopamine and glucose metabolism using [18F]-fluoro-L-dopa (F-dopa) and [18F]-fluorodeoxyglucose (FDG)-PET.

RESULTS

The analysis of PD subgroups showed significant differences in the F-dopa uptake in the anterior putamen. Using the results of the local striatal dopamine difference as a volume of interest for the FDG-analysis, analysis of AR patients revealed a significantly lower normalised cerebral metabolic rate of glucose (nCMRGlc) within the ventral striatum.

CONCLUSIONS

The dual tracer study illlustrates clear differences between TD and AR subtypes in the ventral striatum. In accordance with previous FP-CIT-SPECT studies, it discloses congruent results for the presynaptic dopaminergic system and extends the knowledge about an additional involvement of local metabolic activity in the caudate and anterior putamen. The findings corroborate the specific role of distinct PD subtypes within the cerebello-thalamo-cortical-circuits. Multitracer PET imaging may thus enhance the knowledge about the clinical segregation into subtypes.

Diabetes, depressive symptoms, and inflammation in older adults: results from the Health, Aging, and Body Composition Study

OBJECTIVE

Up-regulated levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) are common to both type 2 diabetes mellitus (T2DM) and elevated depressive symptoms, yet little attention has been given to the biological mechanisms associated with these co-morbidities. This study examined the association between inflammation and both T2DM and elevated depressive symptoms.

METHODS

Baseline data were analyzed from 3009 adults, aged 70-79, participating in the Health, Aging, and Body Composition Study. Diabetes was assessed per self-report, medication use, fasting glucose and/or glucose tolerance tests. Elevated depressive symptoms were categorized using the Center for Epidemiologic Studies Depression scale (cut-score≥20). Log-transformed IL-6, TNF-α, and CRP were analyzed using ANCOVA.

RESULTS

Participants with T2DM and elevated depressive symptoms (T2DM+DEP n=14) demonstrated significantly (p<.05) higher IL-6 compared to (T2DM Only n=628), (DEP Only n=49), and (No T2DM or DEP n=2067) groups following covariate adjustment. Similarly, participants with T2DM+DEP (n=14) had significantly (p<.05) higher CRP, after covariate adjustment, compared to DEP Only (n=50) and No T2DM or DEP groups (n=2153). No association was observed for TNF-α.

CONCLUSIONS

These findings provide evidence that inflammation is associated with T2DM and elevated depressive symptoms. Participants with T2DM+DEP demonstrated the highest IL-6 levels compared to all other groups. Greater CRP levels were also observed in T2DM, but not elevated depressive symptoms, which may suggest that differential associations between T2DM and depressive symptoms exist for various inflammatory markers. Further investigation into these associations could aid in understanding the biological pathways underlying both T2DM and depressive symptoms.

Toll-like receptor 3 involvement in Coxsackievirus B 4 acceleration of type 1 diabetes. (P6134)

Viruses are important in the pathogenesis of type 1 diabetes mellitus (T1DM). A pancreatrophic strain of coxsackievirus, CVB4, which is associated with the development of T1DM in humans, accelerates the development of T1DM in NOD mice. Toll-Like Receptor 3 (TLR3) is activated by viral dsRNA and is broadly expressed by NOD mice and human pancreatic beta cells, suggesting that TLR3 signaling may be important in CVB4 acceleration of T1DM. We used NOD mice deficient in TLR3 (TLR3 KO) to test the hypothesis that TLR3 signaling is important in CVB4 acceleration of T1DM in NOD mice. We report that TLR3 KO NOD mice are markedly protected from CVB4 acceleration of T1DM compared to wild type (WT) NOD mice. Similarly, we have observed that phenylmethimazole (C10), which has recently been shown to inhibit dsRNA-triggered TLR3 signaling, also delays CVB4 acceleration of T1DM in NOD mice. In preliminary experiments to investigate the mechanism by which TLR3 deficiency provides protection from T1DM in this model, we observed marked differences in T regulatory cell populations between TLR3 KO and WT NOD mice, and a significant enhancement of viral clearance in C10-treated NOD mice. These results indicate the distinct importance of TLR3 signaling in environmental (i.e. viral) induction of T1DM and that C10 could potentially protect β cells from virus-induced insulitis.

Can lifestyle interventions do more than reduce diabetes risk? Treating depression in adults with type 2 diabetes with exercise and cognitive behavioral therapy

The epidemic of metabolic syndrome, prediabetes, and type 2 diabetes is global in scope and comprehensive in its impact on individuals, health care systems, and societies. One in four patients with diabetes will experience depression in their lifetime. Comorbid depression is associated with poorer outcomes, greater functional disability, and early mortality. Prior studies have demonstrated beneficial effects of exercise as an efficacious form of treatment for depression in the general population. Few studies have evaluated this strategy in patients with prediabetes or type 2 diabetes. Program ACTIVE (Appalachians Coming Together to Increase Vital Exercise) was designed to treat depression among adults with type 2 diabetes by pairing aerobic activity with individual cognitive behavioral therapy. This combination treatment approach has been shown to be feasible to implement in a rural environment and promising in terms of depression, diabetes, and cardiovascular outcomes. Data from this study suggest that exercise can be used to achieve multiple benefits for adults with type 2 diabetes. Future work to compare this approach to singular treatment strategies for adults at risk for type 2 diabetes is needed.

Emerging Applications for Intelligent Diabetes Management

Diabetes management is a difficult task for patients, who must monitor and control their blood glucose levels in order to avoid serious diabetic complications. It is a difficult task for physicians, who must manually interpret large volumes of blood glucose data to tailor therapy to the needs of each patient. This paper describes three emerging applications that employ AI to ease this task: (1) case-based decision support for diabetes management; (2) machine learning classification of blood glucose plots; and (3) support vector regression for blood glucose prediction. The first application provides decision support by detecting blood glucose control problems and recommending therapeutic adjustments to correct them. The second provides an automated screen for excessive glycemic variability. The third aims to build a hypoglycemia predictor that could alert patients to dangerously low blood glucose levels in time to take preventive action. All are products of the 4 Diabetes Support SystemTM project, which uses AI to promote the health and wellbeing of people with type 1 diabetes. These emerging applications could potentially benefit 20 million patients who are at risk for devastating complications, thereby improving quality of life and reducing health care cost expenditures.

New Criteria for Assessing the Accuracy of Blood Glucose Monitors meeting, October 28, 2011

Glucose meters (GMs) are routinely used for self-monitoring of blood glucose by patients and for point-of-care glucose monitoring by health care providers in outpatient and inpatient settings. Although widely assumed to be accurate, numerous reports of inaccuracies with resulting morbidity and mortality have been noted. Insulin dosing errors based on inaccurate GMs are most critical. On October 28, 2011, the Diabetes Technology Society invited 45 diabetes technology clinicians who were attending the 2011 Diabetes Technology Meeting to participate in a closed-door meeting entitled New Criteria for Assessing the Accuracy of Blood Glucose Monitors. This report reflects the opinions of most of the attendees of that meeting. The Food and Drug Administration (FDA), the public, and several medical societies are currently in dialogue to establish a new standard for GM accuracy. This update to the FDA standard is driven by improved meter accuracy, technological advances (pumps, bolus calculators, continuous glucose monitors, and insulin pens), reports of hospital and outpatient deaths, consumer complaints about inaccuracy, and research studies showing that several approved GMs failed to meet FDA or International Organization for Standardization standards in postapproval testing. These circumstances mandate a set of new GM standards that appropriately match the GMs' analytical accuracy to the clinical accuracy required for their intended use, as well as ensuring their ongoing accuracy following approval. The attendees of the New Criteria for Assessing the Accuracy of Blood Glucose Monitors meeting proposed a graduated standard and other methods to improve GM performance, which are discussed in this meeting report.

Risk of femoral shaft and subtrochanteric fractures among users of bisphosphonates and raloxifene

Prior studies have suggested an association between bisphosphonate use and subtrochanteric fractures. This cohort study showed an increased risk of subtrochanteric and femoral shaft fractures both before and after the start of drugs against osteoporosis including bisphosphonates. This may suggest an effect of the underlying disease rather than the drugs used.

INTRODUCTION

The objective of this study is to determine the association between drugs against osteoporosis and the risk of femoral shaft and subtrochanteric fractures. No separation was made between atypical and typical fractures.

METHODS

Nationwide cohort study from Denmark with all users of bisphosphonates and other drugs against osteoporosis between 1996 and 2006 (n = 103,562) as exposed group and three age- and gender-matched controls from the general population (n = 310,683). Adjustments were made for prior fracture, use of systemic hormone therapy, and use of systemic corticosteroids.

RESULTS

After initiation of therapy, an increased risk of subtrochanteric fractures was seen for alendronate (hazard ratio (HR) = 2.41, 95% confidence interval (CI) 1.78-3.27), etidronate (HR = 1.96, 95% CI 1.62-2.36), and clodronate (HR = 20.0, 95% CI 1.94-205), but not for raloxifene (HR = 1.06, 95% CI 0.34-3.32). However, an increased risk of subtrochanteric fractures was also present before the start of alendronate (OR = 2.36, 95% CI 2.05-2.72), etidronate (OR = 3.05, 95% CI 2.59-3.58), clodronate (OR = 10.8, 95% CI 1.14-103), raloxifene (OR = 1.90, 95% CI 1.07-3.40), and strontium ranelate (OR = 2.97, 95% CI 1.07-8.27). Similar trends were seen for femoral shaft fractures and overall fracture risk. After the start of etidronate, no dose-response relationship was present (p for trend, 0.54). For alendronate, a decreasing risk was present with increasing average daily dose (p for trend, <0.01).

CONCLUSIONS

Although an increased risk of femoral shaft and subtrochanteric fractures are seen with the use of several types of bisphosphonates, the increased risk before the start of the drugs may point at an effect of the underlying disease being treated. The increased risk may, thus, perhaps be due to confounding by indication.

Saxagliptin: A Selective DPP-4 Inhibitor for the Treatment of Type 2 Diabetes Mellitus

The prevalence of type 2 diabetes mellitus is high and growing rapidly. Suboptimal glycemic control provides opportunities for new treatment options to improve the morbidity and mortality of this progressive disease. Saxagliptin, a selective DPP-4 inhibitor, increases endogenous incretin levels and incretin acitivty. In controlled clinical trials saxagliptin reduces both fasting and postprandial glucose and works in monotherapy and in combination with metformin, TZDs and sulfonylureas. Saxagliptin has a very favourable side effect profile and may have other beneficial non-glycemic effects. The authors review the current available evidence for the safety, efficacy and saxagliptin's place in therapy for type 2 diabetes mellitus. As understanding of the incretin hormones (GLP-1, GIP) expand we may see additional important non-glycemic effects that may affect the chronic management of type 2 diabetes mellitus.

Continuous glucose monitoring system in a rural intensive care unit: a pilot study evaluating accuracy and acceptance

BACKGROUND

Glucose management in an intensive care unit (ICU) is labor-intensive. A continuous glucose monitoring system (CGMS) has the potential to improve efficiency and safety in this setting. The goal of this study was to determine if the Medtronic Guardian REAL-Time CGMS was accurate and tolerated by patients in a rural hospital ICU unit.

METHOD

Differences between individual finger stick blood glucose (FSBG) and CGMS values were compared to American Diabetes Association (ADA) and International Organization for Standardization (ISO) standards. Continuous glucose monitoring system accuracy was evaluated over four ranges: <75, 75-140, 140-200, and >200 mg/dl. Other accuracy measures [mean absolute deviation (MAD), mean absolute relative difference (MARD), and coefficient of linear regression of CGMS on FSBG] were calculated. Nursing staff and patients were surveyed regarding use of the CGMS in the ICU.

RESULTS

Twenty-nine participants had 320 FSBG and corresponding CGMS readings. Sixty-two percent of participants were admitted with diabetic ketoacidosis (DKA). Two hundred and thirteen (66.6%) were accurate within the ISO standard, whereas only 70 out of 320 (21.9%) were within the 5% ADA standard. The CGMS was most accurate in euglycemia. Technical difficulties, such as adequate time for "wetting" and calibration of electrodes, arose with the sensors. The MAD was 28.3 mg/dl, the MRAD was 17.4%, and the linear regression coefficient of CGMS on FSBG was 0.834 (p < 0.001).

CONCLUSIONS

The CGMS is well tolerated by ICU patients but, at present, is not sufficiently accurate to be used for therapeutic decisions in the acute setting, particularly in patients with diabetic ketoacidosis. There is a need to find resolution to the technical issues regarding electrode "wetting" and calibration if CGMS use in the ICU setting is to provide an effective means of diabetes care and management.

Depression Among Adults With Diabetes: Prevalence, Impact, and Treatment Options

In Brief

Patients with type 1 or type 2 diabetes are two times more likely to experience depression than their peers without diabetes. Comorbid depression results in deleterious effects on glycemic control, worsened diabetes complications, functional disability, and premature mortality. Once identified, depression can be effectively treated with antidepressant medications, psychotherapy, or a combination of both. Patients and providers should monitor depressive symptoms to identify their recurrence and work collaboratively to address barriers to care that exist in both urban and rural areas.

High self-reported prevalence of diabetes mellitus, heart disease, and stroke in 11 counties of rural Appalachian Ohio

CONTEXT/PURPOSE: There is an epidemic of obesity and diabetes in the United States, especially in economically at-risk populations such as rural Appalachia. This survey determined the self-reported prevalence of obesity, diabetes mellitus, and associated macrovascular complications in 11 rural counties of Appalachian Ohio. The impacts of lifestyle, cardiovascular risk factors, income, and access to medical care were also determined.

METHODS

A telephone survey identical to the 2004 Behavioral Risk Factor Surveillance System (BRFSS) survey was conducted. Surveys were collected from 3,927 randomly selected residents 18 years of age and older in 11 counties of Appalachian Ohio and compared to published aggregate Ohio and national 2004 BRFSS data.

FINDINGS

The self-reported prevalence of diabetes (11.3%) was markedly higher in Appalachian Ohio counties surveyed compared to aggregate Ohio (7.8%) or national (7.2%) 2004 BRFSS data (P < .044). The prevalence of heart disease (7.6%) and stroke (4.1%) in these counties was slightly higher than aggregate Ohio or national 2004 BRFSS data. In persons with diabetes, the prevalence of heart disease was 2-fold higher (20.0%) and stroke 3-fold higher (11.4%) than among nondiabetics (P < .042) in the region and higher than aggregate Ohio and National 2004 BRFSS data. Lower-income levels and decreased access to medications and glucose monitoring supplies correlated with the increased risk for cardiovascular complications in this rural population (P < .042).

CONCLUSION

The self-reported prevalence of diabetes mellitus and its associated macrovascular complications are much higher in rural Appalachian Ohio compared to aggregate Ohio and National 2004 BRFSS data.

A Model of Community-Based Behavioral Intervention for Depression in Diabetes: Program ACTIVE

Depression affects one in four people with diabetes and significantly affects diabetes health. Earlier studies of the treatment of depression have documented that cognitive behavioral therapy (CBT) and exercise have each been found to be effective in treating depression in people with and without diabetes in the context of medical settings. Individuals in rural areas lack regular access to medical centers and require treatment options that may be adapted for local communities. To date, no studies have combined CBT and exercise for people with diabetes. This article presents a translational behavioral depression intervention study designed for individuals with type 2 diabetes in a rural Appalachian region as a model of an interdisciplinary approach to the treatment of depression in diabetes.

Evaluation of diabetes management in a rural community hospital

OBJECTIVE

To evaluate the effectiveness of implementing standardized insulin protocols in a small, rural community hospital.

METHODS

This retrospective review was performed on charts of 300 inpatients who received insulin treatment while hospitalized between January 1, 2006, and June 30, 2006. For patients who met the inclusion criteria, the collected information included the following: serum glucose level at hospital admission, glucose level that initiated the treatment protocol, time-to-fasting euglycemia, time-to-random euglycemia, and method of insulin administration. Comparisons were performed between the effectiveness of the new insulin protocols and routine insulin treatment orders.

RESULTS

A total of 168 patients met the study inclusion criteria. The mean glucose concentration that triggered initiation of insulin treatment was 262 mg/dL, which is significantly higher (P<.001) than levels recommended by the American Diabetes Association (ADA) and the American College of Endocrinology (ACE). There was a statistically significant relationship (P = .007) between time-to-fasting euglycemia and length of hospital stay. Implementation of the standardized insulin protocol did not improve the achievement of fasting euglycemia (P = .753). Most patients never reached the target glucose level goals despite the use of standardized protocol.

CONCLUSION

Significant delays in initiating the insulin protocol and frequent failure in achieving target glucose levels demonstrate delayed recognition of hyperglycemia by hospital staff as well as ineffective use of standardized insulin protocols. Protocol improvement and increased hospital staff education concerning appropriate hospital target glucose levels are required to achieve ADA/ACE recommendations in small community hospitals.

DPPIV inhibitors extend GLP-2 mediated tumour promoting effects on intestinal cancer cells

BACKGROUND

The glucagon-like peptides-1 and -2 (GLP-1 and -2) are co-secreted after food intake from intestinal L cells. Since both peptides are rapidly degraded by dipeptidyl peptidase-IV (DPPIV), research is focused on the development of DPPIV inhibitors or DPPIV resistant.

AIMS

In this study we investigated, whether the inhibition of DPPIV activity and the resulting increased half-life of DPPIV substrates may influence cancer development and progression.

METHODS

We examined proliferation and migratory activity of two human colon cancer cell lines (SW480, HT29) after stimulation with GLP-2 in combination with or without DPPIV inhibitors.

RESULTS

Migratory activity was increased by 25% from 20% matrix induced activity to a maximum of 45% (100 nM GLP-2). In cells expressing CD26, migration was prolonged by addition of DPPIV inhibitors in a concentration dependent manner. After treatment with GLP-2 doubling time decreased from 2.4 to 1.5 days - and addition of DPPIV inhibitors enhanced the effect of GLP-2.

CONCLUSIONS

The use of DPPIV inhibitors together with GLP-2 led to increased proliferation as well as elevated migratory activity. Therefore, the use of DPPIV inhibitors could increase the risk of promoting an already existing intestinal tumour and may support the potential of colon cancer cells to metastasize.

Maternal component in the familial aggregation of hypertension

To assess maternal versus paternal contributions to the familial aggregation of hypertension, we examined family history data from 344 hypertensive probands (69 African American, 153 US Caucasian, 122 Greek Caucasian) ascertained without respect to parental hypertension status. The proportion of hypertensive mothers (81.7, 65.0 and 84.8% for African Americans, US Caucasians and Greek Caucasians, respectively) of these probands was significantly greater than the proportion of hypertensive fathers (50.0, 44.9 and 48.3%, respectively) in all three ethnic groups. The lifetime risk of hypertension was significantly greater for mothers compared with fathers of these hypertensive probands (p<0.001). Examination of the proband's siblings indicated that maternal history of hypertension was associated with greater lifetime risk for hypertension than paternal history (p<0.01). In conclusion, we observe a consistent maternal component in the inheritance of hypertension. Although we cannot separate a maternal genetic from epigenetic or environmental effect, our findings suggest that genetic research should include studies of the mitochondrial as well as nuclear genome. Furthermore, when assessing a patient's risk for hypertension, particular attention should be paid to the maternal family history.

Detection of human herpesvirus-8 DNA in kidney allografts prior to the development of Kaposi's sarcoma

Human herpesvirus-8 (HHV-8) DNA was identified in kidney allografts in 2 of 3 transplant recipients prior to the development of Kaposi's sarcoma, and increase in viral antibody titer was found in the third. Combined genotypic and serologic analyses could be used to identify patients at risk and suggest that the kidney may be a site of HHV-8 latency.

Multisite regional telephone care

A multisite, regional telephone-care program staffed by advance practice and critical care nurses has improved patient care and reduced unnecessary clinic and emergency room visits. It allows patients to access the health care system and receive expert advice through the use of the telephone, 24 hours per day, 7 days per week. Computerized patient medical records from eight hospitals and 31 clinics are available to a registered nurse so that informed decisions can be made. The RN records the patient's concern and intervention directly into the patient's medical record, which is transmitted to the primary care provider in real time.

Mitochondrial DNA mutations in patients with orthostatic hypotension

We determined the entire sequence of the mitochondrial genome in affected individuals from three families with idiopathic orthostatic hypotension. The disorder in two of these families was recently linked to chromosome arm 18q, while the third family remains unlinked. In all three families, orthostatic hypotension is inherited through the females, suggesting the existence of additional contributing factors, such as genomic imprinting or a mitochondrial modifier. We now report the presence of multiple point mutations in the mitochondrial DNA (mtDNA) in all three families. While most of the changes are common polymorphisms, several novel mutations were found that merit further consideration. In one individual, we detected a T-to-C transition at position 1243 in the 12SrRNA, a change from threonine to alanine at position 67 of the ND1 protein, and from valine to isoleucine at position 197 of the ND2 protein. A second individual harbored a novel substitution of threonine with serine at position 536 of the ND5 protein. Two previously unreported amino acid replacements were detected in a third individual: amino acid 193 of cytochrome b was changed from alanine to threonine, and amino acid 88 of COIII was changed from threonine to alanine. Further studies are required to assess the role of these mutations in blood pressure homeostasis.

Identification of a polymorphic glutamic acid stretch in the alpha2B-adrenergic receptor and lack of linkage with essential hypertension

Essential hypertension, a clinically significant elevation in blood pressure with no recognizable cause, is believed to be attributable to the collective effect of genetic predisposing factors in combination with specific environmental factors, such as diet and stress. Of the genetic causes, genes coding for proteins involved in blood pressure regulation, such as the alpha- and beta-adrenergic receptors, are obvious candidates. The alpha2-adrenergic receptor plays a key role in the sympathetic nervous system by mediating the effects of epinephrine and norepinephrine. To evaluate the potential role between the alpha2B receptor and essential hypertension, we scanned the alpha2B-receptor gene for genetic variation in 108 affected sibling pairs. The screening revealed two major forms of the receptor. They differ by the presence of either 9 or 12 glutamic acid residues in the acidic domain of the third cytoplasmic loop of the protein. Investigation of the pattern of this variation in hypertensive sibling pairs suggests that the alpha2B receptor locus does not contribute substantially to genetic susceptibility for essential hypertension.

Evidence for linkage between essential hypertension and a putative locus on human chromosome 17

Several clinical and animal studies indicate that essential hypertension is inherited as a multifactorial trait with a significant genetic and environmental component. In the stroke-prone spontaneously hypertensive rat model, investigators have found evidence for linkage to blood pressure regulatory genes (quantitative trait loci) on rat chromosomes 2, 10, and X. In 1 human study of French and UK sib pairs, evidence for linkage has been reported to human chromosome 17q, the syntenic region of the rat chromosome 10 quantitative trait loci (QTL). Our study confirms this linkage (P=0.0005) and refines the location of the blood pressure QTL.

Autosomal dominant orthostatic hypotensive disorder maps to chromosome 18q

Familial orthostatic hypotensive disorder is characterized by light-headedness on standing, which may worsen to syncope, palpitations, and blue-purple ankle discoloration, and is accompanied by a marked decrease in systolic blood pressure, an increase in diastolic pressure, and tachycardia, all of which resolve when supine. We ascertained three families in which this disorder is inherited as an autosomal dominant trait with reduced penetrance. A genomewide scan was conducted in the two largest families, and three regions with multipoint LOD scores >1.5 were identified. Follow-up of these regions with additional markers in all three families yielded significant evidence of linkage at chromosome 18q. A maximum multipoint LOD score of 3.21 in the three families was observed at D18S1367, although the smallest family had negative LOD scores in the entire region. There was significant evidence of linkage in the presence of heterogeneity at 18q, with a maximum LOD score of 3.92 at D18S1367 in the two linked families. Identification of the gene responsible for orthostatic hypotensive disorder in these families may advance understanding of the general regulatory pathways involved in the continuum, from hypotension to hypertension, of blood pressure.

The 239AB gene on chromosome 22: a novel member of an ancient gene family

A novel family of genes expressed in human brain has recently been identified. Gene 239FB, transcribed extensively in fetal brain, was isolated from the chromosome 11p13 region associated with mental retardation component of the WAGR (Wilms tumor, aniridia, genitourinary anomalies, mental retardation) syndrome. This report presents a cDNA sequence and expression profile of a related gene, 239AB, isolated from adult brain library, that was mapped to chromosome 22. While similar in structure, the two genes differ in their expression pattern and may have different roles in central nervous system development and function. In contrast to the 239FB, which is expressed predominantly in fetal brain, the 239AB gene is transcribed in adult tissues. Both human genes encode novel proteins of unknown function that are highly conserved from Caenorhabditis elegans to birds and mammals. Phylogenetic analysis suggested that the two lineages of the ancient gene family represented by 239FB and 239AB have been in existence prior to the emergence of modern animals.

EGb 761 in control of acute mountain sickness and vascular reactivity to cold exposure

METHOD

We recruited 44 subjects to participate in a study of the preventive effect of Ginko biloba extract (EGb 761) on acute mountain sickness (AMS) and vasomotor changes of the extremities during a Himalayan expedition. After giving their written informed consent, the subjects were randomized to two groups. One group received 160 mg of EGb 761 per day in two divided doses and the other group received placebo. Assessment was based on the course of the Environmental Symptom Questionnaire (ESQ) score and the cold gradient measured by photoplethysmography.

RESULTS

The prophylactic efficacy of treatment with EGb 761 was clearly demonstrated in this study. In terms of factor 1 (AMS-Cerebral), no subject in the EGb 761 group developed acute mountain sickness versus 40.9% of subjects in the placebo group; this difference was very significant (p < or = 1.4 x 10(-3)). In terms of factor 2 (AMS-Respiratory), 3 subjects (13.6%) in the EGb 761 group developed acute mountain sickness versus 18 (81.8%) in the placebo group; this difference was very significant (p = 1.2 x 10(-5)).

CONCLUSION

Due to its multiple pharmacological actions, EGb 761 provides an interesting response to the prevention of mountain sickness for moderate altitude (5400 m) with gradual exposure. It also decreased vasomotor disorders of the extremities, as demonstrated by plethysmography (p < 10(-8)) and a specific questionnaire (p < 10(-9)).

Improving self-efficacy in nursing research

THE PURPOSE OF this project was to increase research activities of practicing nurses at one large healthcare facility. The members of the nursing research committee at this institution planned a participatory learning experience with the goal of increasing the nurses' self-efficacy toward conducting research. Increased self-efficacy was the impetus for stimulating increased research activities by the nurses. Measurable outcomes of this project included a significant increase in the participants' self-efficacy and implementation of a number of research projects. The Delphi technique proved useful in identifying nursing research priorities as well as in stimulating nurses to initiate and conduct clinical research. Project implementation and evaluation are described to help practicing nurses and their employers in pursuit of the same goal.