A pragmatic cluster randomised controlled trial of a Diabetes REcall And Management system: the DREAM trial

BACKGROUND: Following the introduction of a computerised diabetes register in part of the northeast of England, care initially improved but then plateaued. We therefore enhanced the existing diabetes register to address these problems. The aim of the trial was to evaluate the effectiveness and efficiency of an area wide 'extended,' computerised diabetes register incorporating a full structured recall and management system, including individualised patient management prompts to primary care clinicians based on locally-adapted, evidence-based guidelines. METHODS: The study design was a pragmatic, cluster randomised controlled trial, with the general practice as the unit of randomisation. Set in 58 general practices in three Primary Care Trusts in the northeast of England, the study outcomes were the clinical process and outcome variables held on the diabetes register, patient-reported outcomes, and service and patient costs. The effect of the intervention was estimated using generalised linear models with an appropriate error structure. To allow for the clustering of patients within practices, population averaged models were estimated using generalized estimating equations. RESULTS: Patients in intervention practices were more likely to have at least one diabetes appointment recorded (OR 2.00, 95% CI 1.02, 3.91), to have a recording of a foot check (OR 1.87, 95% CI 1.09, 3.21), have a recording of receiving dietary advice (OR 2.77, 95% CI 1.22, 6.29), and have a recording of blood pressure (BP) (OR 2.14, 95% CI 1.06, 4.36). There was no difference in mean HbA1c or BP levels, but the mean cholesterol level in patients from intervention practices was significantly lower (-0.15 mmol/l, 95% CI -0.25, -0.06). There were no differences in patient-reported outcomes or in patient-reported use of drugs, or uptake of health services. The average cost per patient was not significantly different between the intervention and control groups. Costs incurred in administering the system at the register and in general practice were in addition to these. CONCLUSION: This study has shown benefits from an area-wide, computerised diabetes register incorporating a full structured recall and individualised patient management system. However, these benefits were achieved at a cost. In future, these costs may fall as electronic data exchange becomes a reliable reality. Trial registration: International Standard Randomised Controlled Trial Number (ISRCTN) Register, ISRCTN32042030

How does pregnancy affect the patients with pituitary adenomas: a study on 113 pregnancies from Turkey

Objective Data regarding pregnancies in relation to pituitary tumors are limited. The effects of pregnancy on pituitary adenomas and the effects of adenoma itself (hormonal activity, mass effects and pituitary insufficiency) and/or treatment on the ongoing gestation and developing fetus were evaluated

O papel da lipemia pós-prandial na gênese da aterosclerose: particularidades do diabetes mellitus

A aterosclerose é uma doença multifatorial e complexa, que determina eventos clínicos causadores de morbi-mortalidade significativa, representada pela ocorrência de infarto agudo do miocárdio, angina e morte súbita. Está associada a anormalidades lipídicas, ativação plaquetária, trombose, inflamação, disfunção endotelial, estresse oxidativo e alterações metabólicas da matriz, entre outros distúrbios. Todas essas anormalidades são mais comuns e acentuadas no paciente com diabetes, assim como no estado pós-prandial. Dentre os fatores de risco para doença arterial coronariana que ainda não são efetivamente empregados nas estratégias de prevenção da doença em grandes populações destaca-se a hiperlipemia pós-prandial, possível marcador precoce de anormalidades metabólicas e disfunção vascular não observadas em jejum. Recentes resultados mostram que as alterações que ocorrem após uma única sobrecarga lipídica se relacionam negativamente à função endotelial, sendo que as alterações na reatividade vascular estão fortemente associadas à progressão da aterosclerose e aos eventos cardiovasculares. Essas alterações podem revelar um estado de intolerância às gorduras que já são detectadas em indivíduos saudáveis, antes mesmo que anormalidades em jejum sejam percebidas. Esta revisão aborda a fisiopatologia envolvida na lipemia pós-prandial e sua relação com a aterogênese, com ênfase no diabetes mellitus.Atherosclerosis is a complex and multifactorial disease, which determines clinical events that cause significant morbi-mortality, represented by acute myocardial infarction, angina and sudden death. It is associated with lipid disturbances, platelet activation, thrombosis, endothelial dysfunction, inflammation, oxidative stress, altered matrix metabolism, among other disturbances. All these abnormalities are usual and more pronounced in diabetic patients, as well as in the post-prandial state. Among the coronary artery disease risk factors that are not usually employed in clinical practice in the whole population, postprandial hyperlipemia plays a major role, being a possible early marker of metabolic abnormalities and vascular dysfunction not yet seen in the fasting state. Recent results showed that post-oral lipid overload changes are negatively associated with endothelial dysfunction, and vascular reactivity abnormalities are strongly related to atherosclerosis progression and cardiovascular events. These abnormalities could disclose a lipid intolerance state that can be detected in apparently healthy subjects even before fasting abnormalities are seen. This review will deal with the pathophysiology changes involved in post-prandial hyperlipemia and its relationship with atherogenesis, with particular emphasis to diabetes mellitus