The Veterans Affairs Implantable Insulin Pump Study: effect on cardiovascular risk factors

OBJECTIVE: To determine whether implantable insulin pump (IIP) and multiple-dose insulin (MDI) therapy have different effects on cardiovascular risk factors in insulin-requiring patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A randomized clinical trial was conducted at seven Veterans Affairs medical centers in 121 male patients with type 2 diabetes between the ages of 40 and 69 years receiving at least one injection of insulin per day and with HbA1c, levels of > or =8% at baseline. Weights, blood pressures, insulin use, and glucose monitoring data were obtained at each visit. Lipid levels were obtained at 0, 4, 8, and 12 months, and free and total insulin levels were obtained at 0, 6, and 12 months. All medications being taken were recorded at each visit. RESULTS: No difference in absolute blood pressure, neither systolic nor diastolic, was seen between patients receiving MDI or IIP therapy, but significantly more MDI patients required anti-hypertensive medications. When blood pressure was modeled against weight and time, IIP therapy was significantly better than MDI therapy for systolic blood pressure in patients with BMI <33 and for diastolic blood pressure in patients with BMI >34 kg/m2. Total cholesterol levels decreased in the overall sample, but IIP patients exhibited significantly higher levels than MDI patients. Triglyceride levels increased over time for both groups, with IIP patients having significantly higher levels than patients in the MDI group. BMI was a significant predictor of, and inversely proportional to, HDL cholesterol level. No difference in lipid-lowering drug therapy was seen between the two groups. Free insulin and insulin antibodies tended to decrease in the IIP group as compared with the MDI group. C-peptide levels decreased in both groups. CONCLUSIONS: IIP therapy in insulin-requiring patients with type 2 diabetes has advantages over MDI therapy in decreasing the requirement for antihypertensive therapy and for decreasing total and free insulin and insulin antibodies. Both therapies reduce total cholesterol and C-peptide levels.     

How should drugs for anxiety be prescribed?

For a tumor classification scheme to be useful, it must be reproducible and it must show clinical significance. Classification of neuroendocrine lung tumors is a difficult problem with little information about interobserver reproducibility. We sought to evaluate the classification of typical carcinoid (TC), atypical carcinoid (AC), large-cell neuroendocrine carcinoma (LCNEC), and small-cell carcinoma (SCC) tumors as proposed by W.D. Travis et al (Am J Surg Pathol 15:529, 1991). Forty neuroendocrine tumors were retrieved from the Armed Forces Institute of Pathology (AFIP) files and independently evaluated by five lung pathologists and classified as TC, AC, LCNEC, or SCC (pure SCC, mixed small cell/large cell, and combined SCC). A single hematoxylin and eosin-stained slide from each case was reviewed. Each participant was provided a set of tables summarizing the criteria for separation of the four major categories. Agreement was regarded as unanimous if all five pathologists agreed, a majority if four agreed, and a consensus if three or more pathologists agreed. The kappa statistic was calculated to measure the degree of agreement between two observers. A consensus diagnosis was achieved in all 40 cases (100%), a majority agreement in 31 of 40 (78%), and unanimous agreement in 22 of 40 (55%) of cases. Unanimous agreement occurred in seven of SCC (70%), seven of TC (58%), four of AC (50%), and four of LCNEC (40%). A majority diagnosis was achieved in 11 of 12 (92%) of TC, 9 of 10 (90%) of SCC, 6 of 8 (75%) of AC, and 5 of 10 (50%) of LCNEC. Most of the kappa values were 0.70 or greater, falling into the substantial agreement category. The most common disagreements fell between LCNEC and SCC, followed by TC and AC, and AC and LCNEC. The highest reproducibility occurred for SCC and TC, with disagreement in 8% and 10% of the diagnoses, respectively. For TC, 10% of the diagnoses rendered were AC. For AC, 15% of the diagnoses were rendered as TC, with 2.5% called LCNEC and 2.5% called SCC. For LCNEC, 18% and 4% of the diagnoses were called SCC and AC, respectively. For SCC, 4% of the diagnoses were called AC and 4% were called LCNEC. Thus, using the classification scheme tested, a consensus diagnosis can be achieved for virtually all neuroendocrine lung tumors with substantial agreement between experienced lung pathologists. Classification of NE tumors is most reproducible for classification of TC and SCC but less reproducible for AC and LCNEC. These results indicate a need for more careful definition and application of criteria for TC versus AC and SCC versus LCNEC.     

Modified radial head--capitellum projection in elbow trauma

A new technique is described for evaluating trauma to the elbow. The modified radial head--capitellum view is an alternative radiological projection to that described by Greenspan and Norman (the radial head--capitellum view). This new projection is useful in demonstrating minimally displaced or non-displaced fractures of the radial head, capitellum and coronoid process.     

The influence of surveillance methods on surgical wound infection rates in a tertiary care spinal surgery service

We studied 13 consecutive infants admitted to our Neonatal Intensive Care Unit over 37 months from 1 June 1994 to 30 June 1997, who were diagnosed with severe persistent pulmonary hypertension (PPHN) meeting extracorporeal membrane oxygenation (ECMO) criteria as defined by Bartlett and/or Short. They were managed with conservative ventilation strategy, with emphasis on the use of moderate ventilatory pressures whilst avoiding paralysis. Peak inspiratory pressure (PIP) on intermittent mandatory ventilation was adjusted according to adequate chest excursion. High PIP was avoided. Two main ventilatory techniques were used: 1) low ventilatory rate < or = 40/min, PIP 20 to 30 cmH2O, inspiratory time (IT) 0.5 seconds, positive end-expiratory pressure (PEEP) 5 cmH2O, and 2) high ventilatory rate 100/min, PEEP 0 cmH2O, IT 0.3 seconds. The aim was to keep preductal PaO2 > or = 50 mmHg. We did not sought to achieve alkalotic pH or low PaCO2. When PIP requirements exceeded 30 to 35 cmH2O, the use of an alternative rescue therapy such as pulmonary vasodilator, high frequency ventilation and/or surfactant were considered. Only 1 infant died of PPHN. Low mortality due to PPHN can be achieved using this strategy. There is a need for a randomised controlled trial to compare this strategy with other alternative treatment strategies.     

Impact of chronic cough on quality of life

STUDY DESIGN: The biomechanical influence of in situ setting hydroxyapatite cement was examined for use in pedicle screw revision surgery. Pull-out testing of control and pedicle screws augmented with hydroxyapatite cement was performed in human cadaver vertebrae. OBJECTIVES: To determine the immediate effect of using hydroxyapatite cement to augment revision pedicle screws after failure of the primary pedicle screw fixation. SUMMARY OF BACKGROUND DATA: The potential problems associated with using polymethylmethacrylate to augment revision pedicular instrumentation have prompted the search for other solutions. The introduction of resorbable hydroxyapatite pastes may have provided new biocompatible solutions for pedicle screw revision. METHODS: Ten human cadaver vertebrae were instrumented with 6.0-mm pedicle screws in each pedicle. The screws were loaded to failure in axial tension (pull-out). The failed pedicles then were instrumented with 7.0-mm pedicle screws, either augmented with hydroxyapatite cement or nonaugmented, which also were loaded to failure. Finally, the nonaugmented 7.0-mm screw hole was reinstrumented with a hydroxyapatite cement-augmented, 7.0-mm pedicle screw and loaded to failure. RESULTS: The pull-out strength of the 7.0-mm, hydroxyapatite cement-augmented screws was 325% (P = 2.9 x 10(-5)) of that of the 6.0-mm control screws, whereas the strength of the 7.0-mm nonaugmented screws was only 73% (P = 2.0 x 10(-2)) of that of the 6.0-mm control screws. The 7.0-mm screws augmented with hydroxyapatite cement also were able to salvage 7.0-mm pull-out sites to 384% (P = 6.9E-5) of the pull-out strength of the 7.0-mm nonaugmented screws. CONCLUSIONS: Hydroxyapatite cement may be a mechanically viable alternative to polymethyl methacrylate for augmenting revision pedicular instrumentation and should be considered for future experimental, animal, and clinical testing.     

Recovery of memory after posthypnotic amnesia

Notes that documentation of the reversibility of posthypnotic amnesia has been hampered by the correlation of hypnotizability with the initial level of response to amnesia suggestions. 691 college students were placed in groups differing in hypnotic susceptibility that could be matched for initial amnesia recall, thereby eliminating the ceiling effect. At virtually every point along the distribution of initial amnesia response, hypnotizable Ss were significantly better able than insusceptible Ss to recapture the previously blocked memories after the amnesia suggestion was lifted. Conversely, those Ss who showed reversibility of amnesia were more responsive overall to hypnosis than those who did not. It is concluded that reversibility is of value in distinguishing between amnesia and pseudoamnesia and between partial amnesia and nonamnesia. Furthermore, reversibility helps define posthypnotic amnesia as a process involving the disruption of retrieval processes in memory. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)