The relationship of individual comorbid chronic conditions to diabetes care quality.

ObjectiveMultimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions.Research design and methodsThis is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18-75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors.ResultsThe 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality.ConclusionsFuture interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities

Randomized double-blind study comparing the efficacy and safety of lamotrigine and amitriptyline in painful diabetic neuropathy

WSTĘP. Celem niniejszej pracy było porównanie skuteczności oraz bezpieczeństwa stosowania lamotryginy i amitryptyliny w opanowywaniu przewlekłego bólu spowodowanego obwodową neuropatią u chorych na cukrzycę. MATERIAŁ I METODY. Badanie kliniczne z randomizacją przeprowadzono w układzie naprzemiennym metodą podwójnie ślepej próby, z grupą kontrolną otrzymującą terapię standardową. W badaniu wzięły udział 53 osoby. Zastosowano różne dawki leków. Amitryptylinę stosowano w 3 dawkach doustnie: 10, 25 lub 50 mg, jednorazowo na noc przez 2 tygodnie, a lamotryginę - doustnie, 2 × na dobę, w 3 dawkach: 25, 50 lub 100 mg; każdą z dawek stosowano przez 2 tygodnie. Między zamianą leków zastosowano 2-tygodniową przerwę, podczas której chorzy otrzymywali placebo. Oceniano wpływ terapii na zmniejszenie bólu, ogólne polepszenie stanu zdrowia oraz wystąpienie działań niepożądanych. WYNIKI. W ogólnej ocenie pacjentów zniesienie bólu w dużym, umiarkowanym i małym stopniu zanotowano odpowiednio u 19 (41%), 6 (13%) i 7 (15%) osób przyjmujących lamotryginę oraz u 13 (28%), 5 (11%) i 15 (33%) osób stosujących amitryptylinę. Ogólna ocena przeprowadzona przez pacjentów i lekarzy, kwestionariusz McGilla i skala bólu Likerta nie wykazały różnic istotnych statystycznie. Poprawę obserwowano już po 2 tygodniach stosowania obu leków. Odnotowano 44 przypadki działań niepożądanych, 33 (75%) dotyczyły amitryptyliny, z czego najczęściej stwierdzano działanie nasenne (19 pacjentów, 43%); 11 przypadków (25%) dotyczyło lamotryginy, najczęściej była to wysypka (3 chorych, 7%) i podwyższenie stężenia kreatyniny (4 osoby, 9%). Preferowana dawka lamotryginy to 25 mg 2 × na dobę. WNIOSKI. Mimo że wykazano niewiele różnic w skuteczności obu leków, wybór lamotryginy w dawce 25 mg 2 × na dobę wydaje się lepszy, ze względu na mniejszą liczbę działań niepożądanych wywołanych w badanej populacji.AIMS. To compare the efficacy and safety of lamotrigine and amitriptyline in controlling chronic painful peripheral neuropathy in diabetic patients. METHODS. A randomized, double-blind, crossover, active-control, clinical trial with variable dose titration was carried out (n = 53). Amitriptyline orally, at doses of 10, 25 and 50 mg at night-time, each dose for 2 weeks, and lamotrigine orally, at doses of 25, 50 and 100 mg twice daily, each dose for 2 weeks, by optional titration were used. There was a placebo washout period for 2 weeks between the two drugs. Assessment for pain relief, overall improvement and adverse events were carried out. RESULTS. Good, moderate and mild pain relief were noted in 19 (41%), six (13%) and seven (15%) patients on lamotrigine and 13 (28%), five (11%) and 15 (33%) patients on amitriptyline, respectively, by patient’s global assessment of efficacy and safety. Patient and physicians global assessment, McGill pain questionnaire and Likert pain scale showed no significant difference between the treatments, although improvement with both treatments was seen from 2 weeks. Of the 44 adverse events reported, 33 (75%) were with amitriptyline, sedation being the commonest [in 19 (43%) patients]. Lamotrigine caused adverse events in 11 (25%), of which rash in three (7%) and elevations of creatinine in four (9%) were the most common. The preferred lamotrigine dose was 25 mg twice daily. CONCLUSIONS. As there are few differences between the two treatments in efficacy, lamotrigine 25 mg twice daily might be the first choice as it is associated with fewer adverse effects in our population

Faraday rotation measures of northern-hemisphere pulsars using CHIME/Pulsar

Using commissioning data from the first year of operation of the Canadian Hydrogen Intensity Mapping Experiment's (CHIME) Pulsar backend system, we conduct a systematic analysis of the Faraday Rotation Measure (RM) of the northern hemisphere pulsars detected by CHIME. We present 55 new RMs as well as obtain improved RM uncertainties for 25 further pulsars. CHIME's low observing frequency and wide bandwidth between 400-800 MHz contribute to the precision of our measurements, whereas the high cadence observation provide extremely high signal-to-noise co-added data. Our results represent a significant increase of the pulsar RM census, particularly regarding the northern hemisphere. These new RMs are for sources that are located in the Galactic plane out to 10 kpc, as well as off the plane to a scale height of ~16 kpc. This improved knowledge of the Faraday sky will contribute to future Galactic large-scale magnetic structure and ionosphere modelling.Comment: 13 pages, 7 figures, accepted by MNRA

Secondary syphilis presenting as leucoderma syphiliticum: case report and review

ABSTRACT Leucoderma syphiliticum (LS), originally described as syphilide pigmentaire, encompasses a spectrum of dyschromic lesions that emerge during the course of secondary syphilis. Very few case reports are available in modern biomedical databases. We present the case of a 57-year-old HIV-infected male patient who presented with several round to oval, non-scaling, slightly raised and well-demarcated hypochromic lesions scattered over the trunk, abdomen, dorsum, and arms. Prior non-treponemal tests were negative for syphilis, but novel studies yielded positive results at high titers. Skin lesions slowly regressed and the hypochromic areas repigmented a few weeks after benzathine penicillin G treatment. This is the first report of LS in an HIV-infected patient. A review of modern and ancient literature was performed. The present case report emphasizes the need for clinicians to have a heightened awareness of the varied and unusual clinical phenotypes of syphilis

Wegener's granulomatosis in India: clinical features, treatment and outcome of twenty-five patients

Objective: To report our clinical experience on Wegener's granulomatosis (WG). Methods: A retrospective review of case records of all patients with WG in our Rheumatology Clinic during the period July 1988 to June 2000 was carried out and the details of demography, clinical and laboratory data, treatment and outcome were obtained and analysed. Results: Twenty-five patients (16 females and 9 males) were found eligible for inclusion in the study. The mean age and duration of symptoms at presentation were 33.5 years and 5.5 months, respectively. Two patients had limited WG. Twenty-two patients with generalized WG were treated with standard regimen comprising oral prednisolone (1 mg/kg/day) and oral cyclophosphamide (2 mg/kg/day). Cyclophosphamide was continued for at least one year after the patient attained remission. One patient was treated with intravenous cyclophosphamide regimen. The two patients with limited WG were treated with oral prednisolone and methotrexate (10-12.5 mg as a single dose per week). Remission was achieved in 24 patients after a median time of six months. The median follow-up of patients was five years (range 4 months-11 years). Five patients were lost to follow-up. Eight patients suffered a relapse. The mean time for relapse was 34 months after the initial remission. Seven out of eight patients remitted again after reinstitution of the initial induction regimen. One patient died of diffuse pulmonary haemorrhage despite early institution of therapy. Conclusion: WG is being increasingly diagnosed in India now because of greater awareness and diagnostic aids. Although remissions are easy to achieve, relapses continue to pose a challenge to the treating physician

Comparison of Outcomes Following Thrombolytic Therapy Among Patients With Prior Stroke and Diabetes in the Virtual International Stroke Trials Archive (VISTA)

OBJECTIVE - The use of alteplase in patients who have had a prior stroke and concomitant diabetes is not approved in Europe To examine the influence of diabetes and prior stroke on outcomes we compared data on thrombolysed patients with nonthrombolysed comparators RESEARCH DESIGN AND METHODS - We selected patients with ischemic stroke on whom we had data on age pretreatment baseline National Institutes of Health Stroke Scale (b-NIHSS) and 90-day outcome measures (functional modified Rankin score [mRS]) and neurological measures [NIHSS]) in the Virtual International Stroke Trials Archive We compared outcomes between thrombolysed patients and nonthrombolysed comparators in those with and without diabetes those who have had a prior stroke or both and report findings using the Cochran Mantel-Haenszel (CMH) test and proportional odds logistic regression analyses We report an age adjusted and b NIHSS adjusted CMH P value and odds ratio (OR) RESULTS - Rankin data were available for 5 817 patients 1 585 thrombolysed patients and 4 232 nonthrombolysed comparators A total 1 334 (24 1%) patients had diabetes 1 898 (33 7%) patients have had a prior stroke and 491 (8%) patients had both Diabetes and non-diabetes had equal b-NIHSS (median 13 P = 0 3) but patients who have had a prior stroke had higher b-NIHSS than patients who have not had a prior stroke (median 13 vs 12 P < 0 0001) Functional outcomes were better for thrombolysed patients versus nonthrombolysed comparators among both nondiabetic (P < 0 0001 OR 1 4 vertical bar 95% CI 1 3-1 6]) and diabetic (P = 0 1 1 3 [1 05-1 6 ]) subjects Similarly outcomes were better for thrombolysed patients versus nonthrombolysed comparators among who have not had a prior stroke (P < 0 0001 1 4 [1 2-1 6]) and those who have (P = 002 1 3 [1 04-1 6]) There was no interaction of diabetes and prior stroke with treatment (P = 0 8) Neurological outcomes were consistent with the mRS CONCLUSIONS - Outcomes from thrombolysis are better among patients with diabetes and/or those who have had a prior stroke than in control subjects Withholding thrombolytic treatment from otherwise eligible patients may not be justifie

Minority Status and Diabetes Screening in an Ambulatory Population

Abstract available at publisher's web site

Microbleed Prevalence and Burden in Anticoagulant-Associated Intracerebral Bleed

Prior studies suggest an association between Vitamin K antagonists (VKA) and cerebral microbleeds (CMBs); less is known about nonvitamin K oral anticoagulants (NOACs). In this observational study we describe CMB profiles in a multicenter cohort of 89 anticoagulation-related intracerebral hemorrhage (ICH) patients. CMB prevalence was 51% (52% in VKA-ICH, 48% in NOAC-ICH). NOAC-ICH patients had lower median CMB count [2(IQR:1–3) vs. 7(4–11); P \u3c 0.001]; ≥5 CMBs were less prevalent in NOAC-ICH (4% vs. 31%, P = 0.006). This inverse association between NOAC exposure and high CMB count persisted in multivariable logistic regression models adjusting for potential confounders (OR 0.10, 95%CI: 0.01–0.83; P = 0.034)

Establishing chronic condition concordance and discordance with diabetes: a Delphi study

Background The vast majority of patients with diabetes have multiple chronic conditions, increasing complexity of care; however, clinical practice guidelines, interventions, and public reporting metrics do not adequately address the interaction of these multiple conditions. To advance the understanding of diabetes clinical care in the context of multiple chronic conditions, we must understand how care overlaps, or doesn’t, between diabetes and its co-occurring conditions. This study aimed to determine which chronic conditions are concordant (share care goals with diabetes) and discordant (do not share care goals) with diabetes care, according to primary care provider expert opinion. Methods Using the Delphi technique, we administered an iterative, two-round survey to 16 practicing primary care providers in an academic practice in the Midwestern USA. The expert panel determined which specific diabetes care goals were also care goals for other chronic conditions (concordant) and which were not (discordant). Our diabetes care goals were those commonly used in quality reporting, and the conditions were 62 ambulatory-relevant condition categories. Results Sixteen experts participated and all completed both rounds. Consensus was reached on the first round for 94% of the items. After the second round, 12 conditions were concordant with diabetes care and 50 were discordant. Of the concordant conditions, 6 overlapped in care for 4 of 5 diabetes care goals and 6 overlapped for 3 of 5 diabetes care goals. Thirty-one discordant conditions did not overlap with any of the diabetes care goals, and 19 overlapped with only 1 or 2 goals. Conclusions This study significantly adds to the number of conditions for which we have information on concordance and discordance for diabetes care. The results can be used for future studies to assess the impact of concordant and discordant conditions on diabetes care, and may prove useful in developing multimorbidity guidelines and interventions

Alignment of dense molecular core morphology and velocity gradients with ambient magnetic fields

Studies of dense core morphologies and their orientations with respect to gas flows and the local magnetic field have been limited to only a small sample of cores with spectroscopic data. Leveraging the Green Bank Ammonia Survey alongside existing sub-millimeter continuum observations and Planck dust polarization, we produce a cross-matched catalogue of 399 dense cores with estimates of core morphology, size, mass, specific angular momentum, and magnetic field orientation. Of the 399 cores, 329 exhibit 2D $\mathrm{v}_\mathrm{LSR}$ maps that are well fit with a linear gradient, consistent with rotation projected on the sky. We find a best-fit specific angular momentum and core size relationship of $J/M \propto R^{1.82 \pm 0.10}$, suggesting that core velocity gradients originate from a combination of solid body rotation and turbulent motions. Most cores have no preferred orientation between the axis of core elongation, velocity gradient direction, and the ambient magnetic field orientation, favouring a triaxial and weakly magnetized origin. We find, however, strong evidence for a preferred anti-alignment between the core elongation axis and magnetic field for protostellar cores, revealing a change in orientation from starless and prestellar populations that may result from gravitational contraction in a magnetically-regulated (but not dominant) environment. We also find marginal evidence for anti-alignment between the core velocity gradient and magnetic field orientation in the L1228 and L1251 regions of Cepheus, suggesting a preferred orientation with respect to magnetic fields may be more prevalent in regions with locally ordered fields.Comment: 33 pages, 28 figures, accepted to MNRA