The Partnership to Improve Diabetes Education Trial: a Cluster Randomized Trial Addressing Health Communication in Diabetes Care

BACKGROUND

Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings.

OBJECTIVE

The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients.

DESIGN

Cluster randomized controlled trial.

PATIENTS

Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN.

INTERVENTIONS

A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics).

MAIN MEASURES

Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care.

KEY RESULTS

Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses.

CONCLUSIONS

Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting.

Degenerative left shift as a prognostic tool in cats

Background

A degenerative left shift (DLS) is reported to be a poor prognostic indicator in dogs and cats. Limited data in dogs and no studies in cats have been published to investigate this claim.

Hypothesis/Objectives

To characterize the feline population affected by DLS and to determine if the presence and severity of DLS are associated with increased risk of euthanasia or death.

Animals

One hundred and eight cats with DLS (cases) and 322 cats without DLS (controls) presented to the University of California, Davis Veterinary Medical Teaching Hospital between April 1, 1995 and April 1, 2010.

Methods

Retrospective case–control study. All cases had a CBC performed within 24 hours of presentation in which immature granulocytic precursors exceeded mature neutrophils. Controls were matched by year of presentation and primary diagnosis. Survival analysis was used to determine risk of death or euthanasia from DLS and other potential predictors of outcome.

Results

Cases were more likely to die or be euthanized in hospital compared to controls (60/108 [56%] versus 107/322 [33%]). DLS was a significant predictor of death or euthanasia in hospitalized cats in both univariate and multivariate analysis (hazard ratio, 1.57; 95% confidence interval, 1.13–2.18). Trend analysis showed an increasing trend in the hazard of euthanasia or death with increasing severity of DLS.

Conclusions and Clinical Importance

Cats with DLS are 1.57 times more likely to die or be euthanized in hospital than cats without DLS. In addition, increasing severity of DLS is associated with increased likelihood of death or euthanasia.

The prognostic utility of degenerative left shifts in dogs

BACKGROUND

A degenerative left shift (DLS) in dogs is reported to be a poor prognostic indicator, but no studies have been reported to verify this claim.

HYPOTHESIS/OBJECTIVES

To characterize the canine population affected by DLS and to determine if the presence and severity of the DLS are associated with increased risk of euthanasia or death.

ANIMALS

Three-hundred and nineteen dogs with DLS (cases) and 918 dogs without DLS (controls) presented to the University of California, Davis Veterinary Medical Teaching Hospital between April 1, 1995 and April 1, 2010.

METHODS

Retrospective case-control study. All cases had a CBC performed within 24 hours of presentation that showed an immature neutrophil count higher than the mature neutrophil count. Controls were matched by year of presentation and primary diagnosis. Survival analysis was used to determine the risk of death or euthanasia associated with DLS and other potential predictors.

RESULTS

Half of cases versus 76% of controls were alive at discharge. Median in-hospital survival time was 7 days for cases and 13 days for controls. DLS was a significant predictor of death or euthanasia in both univariate and multivariate analysis (hazard ratio, HR, 1.9; 95% CI 1.54-2.34).

CONCLUSIONS AND CLINICAL IMPORTANCE

DLS in dogs is associated with an increased risk of death or euthanasia. This finding, however, varies with disease diagnosis and should be interpreted in light of the individual patient.

A randomized, double-blind study of larazotide acetate to prevent the activation of celiac disease during gluten challenge

OBJECTIVES

In patients with celiac disease, enteropathy is caused by the entry of gluten peptides into the lamina propria of the intestine, in which their immunogenicity is potentiated by tissue transglutaminase (tTG) and T-helper type 1-mediated immune responses are triggered. Tight junction disassembly and paracellular permeability are believed to have an important role in the transport of gluten peptides to the lamina propria. Larazotide acetate is a tight-junction regulator peptide that, in vitro, prevents the opening of intestinal epithelial tight junctions. The aim of this study was to evaluate the efficacy and tolerability of larazotide acetate in protecting against gluten-induced intestinal permeability and gastrointestinal symptom severity in patients with celiac disease.

METHODS

In this dose-ranging, placebo-controlled study, 86 patients with celiac disease controlled through diet were randomly assigned to larazotide acetate (0.25, 1, 4, or 8 mg) or placebo three times per day with or without gluten challenge (2.4 g/day) for 14 days. The primary efficacy outcome was the urinary lactulose/mannitol (LAMA) fractional excretion ratio. Secondary endpoints included gastrointestinal symptom severity, quality-of-life measures, and antibodies to tTG.

RESULTS

LAMA measurements were highly variable in the outpatient setting. The increase in LAMA ratio associated with the gluten challenge was not statistically significantly greater than the increase in the gluten-free control. Among patients receiving the gluten challenge, the difference in the LAMA ratios for the larazotide acetate and placebo groups was not statistically significant. However, larazotide acetate appeared to limit gluten-induced worsening of gastrointestinal symptom severity as measured by the Gastrointestinal Symptom Rating Scale at some lower doses but not at the higher dose. Symptoms worsened significantly in the gluten challenge-placebo arm compared with the placebo-placebo arm, suggesting that 2.4 g of gluten per day is sufficient to induce reproducible gluten toxicity. Larazotide acetate was generally well tolerated. No serious adverse events were observed. The most common adverse events were headache and urinary tract infection.

CONCLUSIONS

LAMA variability in the outpatient setting precluded accurate assessment of the effect of larazotide acetate on intestinal permeability. However, some lower doses of larazotide acetate appeared to prevent the increase in gastrointestinal symptom severity induced by gluten challenge.

Measuring symptoms in the irritable bowel syndrome: development of a framework for clinical trials

BACKGROUND

There is uncertainty about how to measure patient-reported outcomes (PROs) in IBS. The Food and Drug Administration (FDA) emphasizes that PROs must be couched in a conceptual framework, yet existing IBS PROs were not based on such a framework.

AIM

To perform qualitative analyses to inform a new conceptual framework for IBS symptoms.

METHODS

Following FDA guidance, we searched the literature for extant IBS questionnaires. We then performed interviews in IBS patients to learn about the illness experience in their own words. We cultivated vocabulary to inform a conceptual framework depicted with domains, sub-domains, and item categories, per FDA guidance.

RESULTS

We identified 13 questionnaires with items encompassing 18 symptoms. We recruited 123 IBS patients for cognitive interviews. Major themes included: pain and discomfort are different - asking about discomfort is nonspecific and should be avoided in future PROs; bowel urgency is multifaceted - PROs should measure bowel immediacy, controllability, and predictability; and PROs should divide bloating into how it feels vs. how it looks. Symptom experience may be determined by 35-item categories within five domains: (i) pain; (ii) gas/bloat; (iii) diarrhoea; (iv) constipation; and (v) extraintestinal symptoms.

CONCLUSIONS

We applied FDA guidance to develop a framework that can serve as the foundation for developing a PRO for IBS clinical trials.

Femme/Butch family romances

SUMMARY My essay theorizes femme/butch family romances against the grain of dominant feminist and lesbian thought that desexualizes the space of mother/daughter desire. I do so through a reading/recoding of the infringing incestuous mommie-boy desires that surface in an archetypal lesbian novel, Jane Rule's Desert of the Heart.

Preclinical studies to predict the disposition of Apo2L/tumor necrosis factor-related apoptosis-inducing ligand in humans: characterization of in vivo efficacy, pharmacokinetics, and safety

Apo2L/TRAIL (tumor necrosis factor-related apoptosis-inducing ligand) is a member of the tumor necrosis factor gene family known to induce apoptosis in a number of cancer cell lines and may have broad-spectrum activity against human malignancies. These studies have evaluated the potency of recombinant soluble human Apo2L/TRAIL in a mouse xenograft model and the disposition and safety of Apo2L/TRAIL in rodents and nonhuman primates. Mice with established COLO205 tumors were given daily i.v. injections of Apo2L/TRAIL (30-120 mg/kg/day). Control tumors doubled in size every 2 to 3 days, while time to tumor doubling in the treatment groups was significantly longer and related to dose (14-21 days). For pharmacokinetic studies, Apo2L/TRAIL was given as an i.v. bolus to mice (10 mg/kg), rats (10 mg/kg), cynomolgus monkeys (1, 5, and 50 mg/kg), and chimpanzees (1 and 5 mg/kg). Apo2L/TRAIL was rapidly eliminated from the serum of all species studied. Half-lives were approximately 3 to 5 min in rodents and approximately 23 to 31 min in nonhuman primates. Allometric scaling provided estimates of Apo2L/TRAIL kinetics in humans, suggesting that on a milligram per kilogram basis, doses significantly lower than those used in xenograft studies could be effective in humans. Apo2L/TRAIL clearance was highly correlated with glomerular filtration rate across species, indicating that the kidneys play a critical role in the elimination of this molecule. Safety evaluations in cynomolgus monkeys and chimpanzees revealed no abnormalities associated with Apo2L/TRAIL exposure. In conclusion, these studies have characterized the disposition of Apo2L/TRAIL in rodents and primates and provide information that will be used to predict the pharmacokinetics of Apo2L/TRAIL in humans.

Total quality improvement according to hospital nursing executives

Total quality management (TQM) is certainly a hot topic in health care today. The Department of Veterans Affairs is not alone in launching the quality movement in their hospitals. The question is, can it succeed. The success of total quality lies in the commitment of the organizations' leaders. Nursing leadership has yet to be studied regarding TQM implementation. Nursing performs a vital role in hospitals, and if nursing leaders are opposed to total quality, then it is highly unlikely that the philosophy will succeed. This study is designed to measure the attitudes and perceptions of VA nursing chiefs regarding the total quality improvement (TQI) process.

Purification, characterization, and localization of a protein antigen shared by thermophilic campylobacters

A protein antigen with an apparent molecular weight (Mr) of 31,000 was isolated from 0.2 M glycine hydrochloride (pH 2.2) extracts of a typical human fecal isolate, Campylobacter jejuni VC74. The protein was purified to homogeneity on a preparative scale by immunoaffinity chromatography followed by molecular sieving with a Superose 12 column. Isoelectric focusing under nondenaturing conditions indicated a pI of 9.3, and amino acid composition analysis showed that the protein was unusually rich in lysine, containing 14.9 mol% of this basic amino acid. Cysteine and tryptophan were absent. The protein also contained approximately 35% hydrophobic amino acid residues, and N-terminal amino acid analysis showed that 17 of the first 38 residues were hydrophobic. This amino-terminal sequence to residue 22 was virtually identical to that of an antigenically cross-reactive 31,000-Mr protein isolated from another C. jejuni strain belonging to a different heat-labile serogroup. Western blotting (immunoblotting) of glycine extracts of other C. jejuni, Campylobacter coli, and Campylobacter laridis strains belonging to different thermolabile and thermostable serotypes, as well as Campylobacter fetus, with a rabbit polyclonal antiserum raised against the purified C. jejuni VC74 protein showed that all C. jejuni, C. coli, and C. laridis strains tested contained a 31,000-Mr protein with epitopes which were antigenically cross-reactive with the C. jejuni VC74 protein. The antigenically cross-reactive epitopes of this protein were also readily detected by immunodot blot assay of glycine extracts of C. jejuni, C. coli, and C. laridis with monospecific polyclonal antisera to the 31,000-Mr protein, suggesting that this serological test could be a useful addition to those currently employed in the rapid identification of these important pathogens. Slide agglutination reactions, immunofluorescence assay, and immunogold electron microscopy with antisera to purified 31,000-Mr protein and trypsin treatment of whole cells indicated that the cross-reactive epitopes of the 31,000-Mr protein were not exposed on the cell surface. Cell fractionation analysis and immunogold electron microscopy located the protein on the outer surface of the cytoplasmic membrane. This finding suggests that the 31,000-Mr protein is not a good candidate for inclusion in a monovalent subunit Campylobacter vaccine.

Abdominal actinomycosis: evaluation by computed tomography

Actinomycosis causes disease in multiple organ systems and involves the abdomen approximately 20% of the time. We report a case of a 48-yr-old woman with a large abdominal mass secondary to actinomycosis. The patient demonstrates the clinical and pathologic features of this disease, as well as the role of evaluation by barium examination and computed tomography (CT). A discussion of abdominal actinomycosis is included.

Pre-employment screening: use or ornament?

Pre-employment screening (PES) in an occupational health department (OHD) in Inner London was evaluated by establishing its resource implications and devising methods to estimate its efficiency and effectiveness. The attitudes of those involved in PES were also examined. While coverage of student nurses applicants was in the region of 100 per cent, only 43 per cent of all other new employees were screened. Student nurse applicants were more likely to be referred to an occupational health nurse or doctor than other employees (45 per cent nurses, 18 per cent others), but only one person had been rejected on health grounds, as a result, during the previous 15 months. The majority of reasons for sickness absence or early retirement could not have been predicted by PES. Opinions as to the purpose of PES varied from employees who in general thought that PES was designed to protect their interests, to managers, who thought it was to protect theirs.

Antigenic variation of Campylobacter flagella

Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of flagella dissociated from strains of Campylobacter coli and Campylobacter jejuni belonging to the heat-labile serogroup LIO 8 showed that some strains were capable of producing flagellin subunits of two different molecular weights (MrS), 59,500 and 61,500. Immunoelectron microscopy of cultures of the type strain of this serogroup, C. coli VC167, showed the presence of two flagellum filaments of different antigenic specificity. Epitopes on the surface of one of these flagella bound antibodies in LIO 8 typing antiserum, and Western blotting (immunoblotting) and immunoprecipitation showed that the flagellum was composed of flagellin of Mr 61,500. The other flagellum antigenic type did not bind LIO 8 antibodies but did possess serospecific epitopes which bound a second polyclonal antiserum, LAH2. This second antigenic flagellum type was composed of the Mr 59,500 flagellin. Cells producing either of the flagellum antigenic types serotyped as LIO 8, indicating that flagella composed of the Mr 61,500 flagellin do not carry the serological determinants for this serogroup. The ability of C. coli VC167 to produce these flagella of different subunit MrS was shown to represent a bidirectional antigenic variation. When measured in culture medium, the phase 1-to-phase 2 transition occurred at a rate of approximately 2.0 x 10(-5) per cell per generation, and the phase 2-to-phase 1 transition occurred at a rate of 1.2 x 10(-6) per cell per generation.

Isolation and characterization of Campylobacter flagellins

Sequential acid pH dissociation, differential ultracentrifugation, and neutral pH reassociation were used to partially purify serotypically distinct flagella from three strains of Campylobacter jejuni and the two antigenic phases of flagella of Campylobacter coli VC167. Each C. jejuni flagellin and C. coli VC167 antigenic phase 1 flagellin were purified to homogeneity by reverse-phase high-performance liquid chromatography with a C8 Spheri-10 column. C. coli VC167 antigenic phase 2 was purified to homogeneity by ion-exchange chromatography with a Mono-Q column. Amino acid compositional analysis put the C. jejuni flagellin molecular weight in the range 63,200 to 63,800 and the C. coli antigenic phase 1 and 2 flagellins at 61,500 and 59,500, respectively. The amino acid compositions of the C. jejuni were similar to each other and to the C. coli VC167 antigenic phase 1 and phase 2 flagellins. One-dimensional peptide mapping of the C. jejuni flagellins by partial digestion with trypsin or chymotrypsin confirmed the structural similarities of the C. jejuni flagellins and the C. coli VC167 antigenic phase 1 flagellin and showed that C. coli VC167 antigenic phase 2 flagellin was structurally distinct from the phase 1 flagellin. The antigenic phase 2 flagellin was especially sensitive to digestion by chymotrypsin. Amino-terminal sequence analysis showed that the 20 N-terminal amino acids of the Campylobacter flagellins were highly conserved. The Campylobacter flagellins also shared limited sequence homology with the N-terminal sequences reported for Salmonella and Bacillus flagellins.

Presumptive antibiotics for penetrating abdominal wounds

The optimal antibiotic agent or agents for penetrating abdominal injuries remains undetermined. During the two year period ending April 1985, 150 consecutive patients undergoing celiotomy for penetrating abdominal trauma were prospectively randomized to receive either mezlocillin (4 grams every six hours) or clindamycin (600 milligrams every six hours) and gentamicin (loading dose of 2.0 milligrams per kilogram, then 1.5 milligrams per kilogram every eight hours). Antibiotics were begun in the emergency department with duration of coverage based upon the injury pattern--colon, five days; other hollow visceral injury, two days, and all others, one day. Ten patients were excluded due to breach in protocol and other patients died within 48 hours of presentation. The two study groups, comprised of the remaining 130 patients, were comparable with respect to age, sex, injury mechanism, incidence of colonic injuries, intraoperative blood replacement and abdominal trauma index. Overall incidence of septic morbidity was similar among the groups; ten of the 61 patients receiving mezlocillin and nine of those receiving clindamycin and gentamicin had infection develop. There was no significant difference with respect to extensive abdominal infection (10 versus 3 per cent). The pattern of postoperative infection and offending pathogens were similar in the study groups. Enterobacteriaceae, enterococcus and Bacteroides species were most frequently isolated. Infection was due to an organism resistant to the initial study regimen in one of the ten failures with mezlocillin and in two of the nine failures with clindamycin and gentamicin. Mezlocillin, a single agent broad spectrum penicillin, achieved comparable results with more expensive potentially toxic combination therapy for penetrating wounds.

Are consumers provided with adequate information on the actions and uses of ipecacuanha syrup?

The results of a study to assess the level of consumer information about the action and uses of Ipecacuanha Syrup (Emetic) Australian Pharmaceutical Formulary (APF) are reported. Of 40 community pharmacies selected at random from the 321 pharmacies in the Perth metropolitan area, four were unable to supply the syrup. Dosage information provided on the labels of branded products was, for the most part, comprehensive and in line with APF recommendations. Syrup samples dispensed under pharmacy labels provided much less detailed dose information and no information on contraindications on the labels. Counselling by pharmacists was mostly adequate, but information provided by pharmacy assistants was much less detailed. The active alkaloid content of about 77% of the samples of ipecacuanha syrup was within +/- 12% of the target concentration; the remainder had only 56%-58% of the required alkaloid concentration, which indicates a need for more stringent quality control.

Ecological validity of laboratory-type discrimination-learning tasks

Brooks and Baumeister (1977a, 1977b) have questioned the ecological validity of laboratory-type research on discrimination learning, memory, and other cognitive processes. Their criticisms were rebutted by House (1977). The present report established the relationship among learning and retention of two-choice discrimination tasks, "real-life" adaptive behavior in an institution, and IQ. These measures were substantially interrelated, and we concluded that laboratory-type discrimination-learning tasks have ecological validity.

Learning, memory, and transfer in profoundly, severely, and moderately mentally retarded persons

Discrimination learning, memory, and transfer capacity were assessed in representative samples of institutionalized retarded persons in order to provide information on trainability. The 56 subjects were selected from moderately, severely, and two levels of profoundly retarded adults. They learned and relearned three successive two-choice discrimination problems. Generally, the higher functioning subjects, defined by IQ and adaptive behavior learned more rapidly than did the lower functioning subjects. Forgetting was related to IQ/adaptive behavior level. Interproblem transfer was negligible at all levels of retardation, but ceiling effects may have obscured positive transfer in the higher functioning groups. Backward learning curves revealed large differences between lower and higher functioning persons in the presolution trials, but once learning began even profoundly retarded subjects solved these problems as rapidly as did the moderately retarded subjects. Ten of the 56 subjects failed to learn all three problems.

Schwarz'S lemma in normed linear spaces

In this paper we show that any Fréchet holomorphic function mapping the open unit ball of one normed linear space into the closed unit ball of another must be a linear mapping if the Fréchet derivative of the function at zero is a surjective isometry. From this fact we deduce a Banach-Stone theorem for operator algebras which generalizes that of R. V. Kadison.