Clinical

NEW YORK - Inflammation may contribute to impaired cerebral vasoregulation in type 2 diabetes, research suggests.

In a two-year study, participants with type 2 diabetes experienced diminished regional and global vasoreactivity in the brain, as well as a decline in cognitive function and the ability to perform daily tasks.

Higher blood levels of inflammatory markers were correlated with decreases in cerebral vasoreactivity and vasodilation in the diabetic subjects, but not in controls.

"Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks," senior author Dr. Vera Novak, of Beth Israel Deaconess Medical Center in Boston, said in a news release. "People with type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills."

The study's final analysis involved 40 people, average age 69, including 19 with diabetes and 21 controls. The diabetes patients had been treated for the disease an average of 13 years. Smokers were excluded.

The researchers administered a number of cognition and memory tests, magnetic resonance imaging (MRI) scans and blood tests at the beginning of the study and at 24 months.

At the two-year visit, the diabetics had lower global gray matter volume, lower composite scores on learning and memory, lower regional and global cerebral vasoreactivity, and worse glycemic control, compared to baseline.

Among the diabetics, impaired cerebral vasoreactivity at baseline correlated with worse performance of daily activities. In addition, worsening vasodilation correlated with greater decreases in executive function, independent of age, education, and other factors.

"Higher serum soluble intercellular and vascular adhesion molecules, higher cortisol, and higher C-reactive protein levels at baseline were associated with greater decreases in cerebral vasoreactivity and vasodilation only in the (diabetes) group, independent of diabetes control and 24-hour blood pressure," the researchers wrote online July 8 in Neurology.

"Inflammation may further impair cerebral vasoregulation, which consequently accelerates decline in executive function and daily activities performance in older people with (diabetes)," they said.

"Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills," Dr. Novak said in the news release. She called for additional studies in a greater number of people and for a longer duration.

"We are currently starting a Phase 2-3 clinical trial to see if intranasal insulin could prevent/slow down cognitive decline," she told Reuters Health by email.

She also noted that while no specific treatment exists to prevent cognitive decline, healthy life styles help people to have less decline.

Large clinical trials have shown that even strict control of blood sugar does not prevent cognitive decline. The high fluctuation in blood glucose that occurs with diabetes damages the nerves of the brain, she said.

The study was funded by the National Institute on Aging, American Diabetes Association, Harvard Clinical and Translational Science Center and National Center for Research Resources.

NEW YORK - Inflammation may contribute to impaired cerebral vasoregulation in type 2 diabetes, research suggests.

In a two-year study, participants with type 2 diabetes experienced diminished regional and global vasoreactivity in the brain, as well as a decline in cognitive function and the ability to perform daily tasks.

Higher blood levels of inflammatory markers were correlated with decreases in cerebral vasoreactivity and vasodilation in the diabetic subjects, but not in controls.

"Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks," senior author Dr. Vera Novak, of Beth Israel Deaconess Medical Center in Boston, said in a news release. "People with type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills."

The study's final analysis involved 40 people, average age 69, including 19 with diabetes and 21 controls. The diabetes patients had been treated for the disease an average of 13 years. Smokers were excluded.

The researchers administered a number of cognition and memory tests, magnetic resonance imaging (MRI) scans and blood tests at the beginning of the study and at 24 months.

At the two-year visit, the diabetics had lower global gray matter volume, lower composite scores on learning and memory, lower regional and global cerebral vasoreactivity, and worse glycemic control, compared to baseline.

Among the diabetics, impaired cerebral vasoreactivity at baseline correlated with worse performance of daily activities. In addition, worsening vasodilation correlated with greater decreases in executive function, independent of age, education, and other factors.

"Higher serum soluble intercellular and vascular adhesion molecules, higher cortisol, and higher C-reactive protein levels at baseline were associated with greater decreases in cerebral vasoreactivity and vasodilation only in the (diabetes) group, independent of diabetes control and 24-hour blood pressure," the researchers wrote online July 8 in Neurology.

"Inflammation may further impair cerebral vasoregulation, which consequently accelerates decline in executive function and daily activities performance in older people with (diabetes)," they said.

"Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills," Dr. Novak said in the news release. She called for additional studies in a greater number of people and for a longer duration.

"We are currently starting a Phase 2-3 clinical trial to see if intranasal insulin could prevent/slow down cognitive decline," she told Reuters Health by email.

She also noted that while no specific treatment exists to prevent cognitive decline, healthy life styles help people to have less decline.

Large clinical trials have shown that even strict control of blood sugar does not prevent cognitive decline. The high fluctuation in blood glucose that occurs with diabetes damages the nerves of the brain, she said.

The study was funded by the National Institute on Aging, American Diabetes Association, Harvard Clinical and Translational Science Center and National Center for Research Resources.

NEW YORK - Inflammation may contribute to impaired cerebral vasoregulation in type 2 diabetes, research suggests.

In a two-year study, participants with type 2 diabetes experienced diminished regional and global vasoreactivity in the brain, as well as a decline in cognitive function and the ability to perform daily tasks.

Higher blood levels of inflammatory markers were correlated with decreases in cerebral vasoreactivity and vasodilation in the diabetic subjects, but not in controls.

"Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks," senior author Dr. Vera Novak, of Beth Israel Deaconess Medical Center in Boston, said in a news release. "People with type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills."

The study's final analysis involved 40 people, average age 69, including 19 with diabetes and 21 controls. The diabetes patients had been treated for the disease an average of 13 years. Smokers were excluded.

The researchers administered a number of cognition and memory tests, magnetic resonance imaging (MRI) scans and blood tests at the beginning of the study and at 24 months.

At the two-year visit, the diabetics had lower global gray matter volume, lower composite scores on learning and memory, lower regional and global cerebral vasoreactivity, and worse glycemic control, compared to baseline.

Among the diabetics, impaired cerebral vasoreactivity at baseline correlated with worse performance of daily activities. In addition, worsening vasodilation correlated with greater decreases in executive function, independent of age, education, and other factors.

"Higher serum soluble intercellular and vascular adhesion molecules, higher cortisol, and higher C-reactive protein levels at baseline were associated with greater decreases in cerebral vasoreactivity and vasodilation only in the (diabetes) group, independent of diabetes control and 24-hour blood pressure," the researchers wrote online July 8 in Neurology.

"Inflammation may further impair cerebral vasoregulation, which consequently accelerates decline in executive function and daily activities performance in older people with (diabetes)," they said.

"Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills," Dr. Novak said in the news release. She called for additional studies in a greater number of people and for a longer duration.

"We are currently starting a Phase 2-3 clinical trial to see if intranasal insulin could prevent/slow down cognitive decline," she told Reuters Health by email.

She also noted that while no specific treatment exists to prevent cognitive decline, healthy life styles help people to have less decline.

Large clinical trials have shown that even strict control of blood sugar does not prevent cognitive decline. The high fluctuation in blood glucose that occurs with diabetes damages the nerves of the brain, she said.

The study was funded by the National Institute on Aging, American Diabetes Association, Harvard Clinical and Translational Science Center and National Center for Research Resources.

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

(Reuters Health) - Overweight and obese people with type 2 diabetes may feel better after a meal if they start it off with vegetables or proteins and end with the carbs, suggests a new study of 11 people.

Finishing the broccoli and chicken before tucking into bread and fruit juice was tied to a lower rise in blood sugar levels over the next two hours, compared to eating the same foods in the opposite order, researchers report in Diabetes Care.

"When we saw the result, we were really encouraged that this is something that could potentially benefit people," said Dr.Louis Aronne, the study's senior author from Weill Cornell Medical College in New York.

Approximately 29 million Americans - about 9 percent of the U.S. population - have diabetes, according to the Centers for Disease Control and Prevention. About 30 percent of those people are undiagnosed.

Type 2 is the most common form of diabetes and is often linked to obesity. In type 2 diabetes, the body's cells are resistant to the hormone insulin, or the body doesn't make enough of it. Insulin helps the body's cells use glucose in the blood for fuel.

Drinking whey protein shakes before meals has been linked to lower blood sugar levels after eating, but little was known about the influence of foods, and the order in which they're consumed, on blood sugar levels following a meal, the researchers write.

Blood sugar normally rises after eating, but for people with diabetes it can spike dangerously. Diabetics are often told to avoid foods high on the glycemic index - a measure of how rapidly a food gets converted to glucose in the blood - like white breads and sugary drinks.

The new research suggests that people may benefit from timing their consumption of carbohydrates during a meal instead of simply avoiding certain foods.

The researchers recruited 11 people with type 2 diabetes who were all overweight or obese. They were also taking a drug called metformin, which helps to control blood sugar.

The participants all fasted for 12 hours overnight before consuming a 628 calorie meal with protein, carbohydrates and fat.

One week, they consumed the carbohydrates (ciabatta bread and orange juice) first. Then they ate skinless grilled chicken, a small salad and buttered steamed broccoli 15 minutes later.

The participants ate the same meal a week later, but the order of the foods was reversed, with the salad and broccoli first, then the chicken, then the carbs.

The researchers also took blood samples before the meals and 30, 60 and 120 minutes afterward.

When the participants ate vegetables and proteins first, their blood sugar levels were about 29 percent lower 30 minutes after starting the meal, compared to when they ate the carbs first. At 60 and 120 minutes after participants began eating, blood sugar levels were 37 percent and 17 percent lower, respectively, compared to when the carbs came first.

"It's possible what this is doing is delaying or tempering how fast the carbohydrates get absorbed," said Dr. Sethu Reddy, chief of the Adult Diabetes Section at the Joslin Diabetes Center in Boston.

"I think certainly it's an interesting study that says eating a good salad before your meal may help with glucose absorption," said Reddy, who was not involved with the new study.

The new study may not be the full story, Reddy told Reuters Health. For example, he said, it will be important to see what happens beyond two hours, and what's happening to the carbohydrates.

The researchers also say more studies with longer follow-up times are needed.

"We're doing the next study," Aronne told Reuters Health. "We're doing a longer study and we're looking at some of the other key hormones."

As of now, he said, the theory is that the absorption of the carbohydrates is somehow slowed down by eating vegetables, which are low on the glycemic index.

"This shows that the highly desired foods can be a part of a diet if we sneak them in there," Aronne said.

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

When Ruth Ann Crystal, MD, performed her residency at Stanford University Medical Center more than 15 years ago, she often worked side by side in the operating room with one of her favorite professors, Bert Johnson, MD, a skilled surgeon and obstetrician. While performing vaginal hysterectomies, Dr. Johnson would often share stories of when he was a resident back in the 1950s at the Chicago Maternity Center (CMC) and delivered babies for poor families on Chicago’s south side.

One of the stories Dr. Johnson told was about a time when he and another medical student were called to a home to “turn a baby that was stuck,” recalls Dr. Crystal, now a hospitalist at El Camino Hospital, which supports two campuses in Mountain View, Calif., and Los Gatos, Calif. They were going to administer ether, which is highly flammable, to the young mother to relax the uterus and help turn the baby, but then realized that a wood fire was burning. As the woman writhed in pain, they doused the flames with water.

“He said it was like Dante’s Inferno as smoke filled the room,” Dr. Crystal says. “It was quite the scene.”

Stories told by Dr. Johnson and other physicians who worked at the CMC during medical school or residency in the 1950s are legendary. They reflect a time in medicine when doctors not only made house calls, but also stayed in the family’s home until the baby was delivered, getting glimpses into the life of the poor. In an effort to preserve these stories, Dr. Crystal wanted to produce a one-hour PBS documentary called Catch the Baby. But financial realities set in, and she now plans to convert the stories into short vignettes that will be posted on a website by the same name for medical humanities classes.

“I thought, ‘Wow, this is an amazing part of history that shouldn’t be lost,’” says Dr. Crystal, who also supports a private practice. “The Chicago Maternity Center was an incredible place that, for almost 80 years, taught medical students how to be self-sufficient.

They learned “to count on their own skills and [find] ways of solving problems in very real situations when being sent out to these deliveries.”

Big Plans, No Budget

During her residency, Dr. Crystal videotaped approximately seven hours of interviews with Dr. Johnson about his experiences at CMC. She planned to write a book about the 80-something-year-old doctor, who still owns a ranch, ropes cattle, and, at one time, headed the California Beef Council; however, her job, growing family, and well, life, simply got in the way.

Then, in 2009, roughly a decade later, one of her patients mentioned that she knew a film crew who produced documentaries for PBS. Dr. Crystal asked for an introduction.

Members of the film crew were excited about the project. Their first task was to create a trailer for the documentary. They spent an entire day filming Dr. Johnson at his ranch telling stories about kitchen table deliveries in the slums and doing activities around the ranch, like roping cattle with a fellow cowboy—someone he actually delivered as a baby years ago. More film was later shot at the Santa Clara Valley Medical Center of Dr. Johnson performing a C-section and vaginal delivery with a resident and medical student.

The four-minute and 20-second trailer cost $37,000, she says, explaining that the money was mostly raised through donations from Dr. Johnson’s “cowboy friends” who also owned ranches in the area. It is still posted on the original website Dr. Crystal created: www.CatchTheBaby.com.

Now came the hard part—fundraising.

“I found out that I would have to raise between $650,000 and $700,000 to make a one-hour film,” Dr. Crystal says. “I tried, but I’m a doctor and don’t like asking people for money. I realized that probably wasn’t going to happen.”

But she wasn’t willing to abandon the project. So she turned her attention to YouTube, which, by then, had been online for four years. At the time, shorter videos were popular. Dr. Crystal had to develop a new plan.

Her current goal is to build a website that would highlight the CMC stories, which would be part of a medical humanities course at medical schools across the country. Medical students, residents, and other doctors could learn about the history of medicine and obstetrics. She says there are many lessons to be learned that don’t involve medical procedures, such as the impact of social and cultural issues on a physician’s ability to deliver healthcare.

“We need to look back on the important lessons the medical students learned at the CMC,” she says. “Not about how to do specific procedures, but how to interact with patients who may be very different from themselves.”

There seems to be plenty of interest in the topic; Dr. Crystal has since built a Twitter following of 5,700 people who read articles she tweets about medicine’s past, present, and future (@CatchTheBaby).

Still, she needs to build the website, edit the hours of film into short films, and then post them on the website with a study guide. The cost, she says, could run anywhere between $35,000 and $65,000.

“I don’t necessarily have to work with people who are PBS documentarians,” she says, adding that over recent years she has contacted several university film professors and students who turned down the project because it was too much to tackle. “I’d like to use a crowd-funding [platform like] Kickstarter or Indiegogo to raise the money, so I could edit the film.”

Meanwhile, Dr. Johnson is getting older and would enjoy seeing this project completed. So would his friends who helped pay for the trailer and original filming, says Dr. Crystal. Besides, she believes these stories can help new doctors better balance their focus between technology and face time with patients.

“Medical school education is changing quite a bit,” she says. “Despite advances in technology, we can’t forget we’re treating a human being first.”

Carol Patton is a freelance writer in Las Vegas.

When Ruth Ann Crystal, MD, performed her residency at Stanford University Medical Center more than 15 years ago, she often worked side by side in the operating room with one of her favorite professors, Bert Johnson, MD, a skilled surgeon and obstetrician. While performing vaginal hysterectomies, Dr. Johnson would often share stories of when he was a resident back in the 1950s at the Chicago Maternity Center (CMC) and delivered babies for poor families on Chicago’s south side.

One of the stories Dr. Johnson told was about a time when he and another medical student were called to a home to “turn a baby that was stuck,” recalls Dr. Crystal, now a hospitalist at El Camino Hospital, which supports two campuses in Mountain View, Calif., and Los Gatos, Calif. They were going to administer ether, which is highly flammable, to the young mother to relax the uterus and help turn the baby, but then realized that a wood fire was burning. As the woman writhed in pain, they doused the flames with water.

“He said it was like Dante’s Inferno as smoke filled the room,” Dr. Crystal says. “It was quite the scene.”

Stories told by Dr. Johnson and other physicians who worked at the CMC during medical school or residency in the 1950s are legendary. They reflect a time in medicine when doctors not only made house calls, but also stayed in the family’s home until the baby was delivered, getting glimpses into the life of the poor. In an effort to preserve these stories, Dr. Crystal wanted to produce a one-hour PBS documentary called Catch the Baby. But financial realities set in, and she now plans to convert the stories into short vignettes that will be posted on a website by the same name for medical humanities classes.

“I thought, ‘Wow, this is an amazing part of history that shouldn’t be lost,’” says Dr. Crystal, who also supports a private practice. “The Chicago Maternity Center was an incredible place that, for almost 80 years, taught medical students how to be self-sufficient.

They learned “to count on their own skills and [find] ways of solving problems in very real situations when being sent out to these deliveries.”

Big Plans, No Budget

During her residency, Dr. Crystal videotaped approximately seven hours of interviews with Dr. Johnson about his experiences at CMC. She planned to write a book about the 80-something-year-old doctor, who still owns a ranch, ropes cattle, and, at one time, headed the California Beef Council; however, her job, growing family, and well, life, simply got in the way.

Then, in 2009, roughly a decade later, one of her patients mentioned that she knew a film crew who produced documentaries for PBS. Dr. Crystal asked for an introduction.

Members of the film crew were excited about the project. Their first task was to create a trailer for the documentary. They spent an entire day filming Dr. Johnson at his ranch telling stories about kitchen table deliveries in the slums and doing activities around the ranch, like roping cattle with a fellow cowboy—someone he actually delivered as a baby years ago. More film was later shot at the Santa Clara Valley Medical Center of Dr. Johnson performing a C-section and vaginal delivery with a resident and medical student.

The four-minute and 20-second trailer cost $37,000, she says, explaining that the money was mostly raised through donations from Dr. Johnson’s “cowboy friends” who also owned ranches in the area. It is still posted on the original website Dr. Crystal created: www.CatchTheBaby.com.

Now came the hard part—fundraising.

“I found out that I would have to raise between $650,000 and $700,000 to make a one-hour film,” Dr. Crystal says. “I tried, but I’m a doctor and don’t like asking people for money. I realized that probably wasn’t going to happen.”

But she wasn’t willing to abandon the project. So she turned her attention to YouTube, which, by then, had been online for four years. At the time, shorter videos were popular. Dr. Crystal had to develop a new plan.

Her current goal is to build a website that would highlight the CMC stories, which would be part of a medical humanities course at medical schools across the country. Medical students, residents, and other doctors could learn about the history of medicine and obstetrics. She says there are many lessons to be learned that don’t involve medical procedures, such as the impact of social and cultural issues on a physician’s ability to deliver healthcare.

“We need to look back on the important lessons the medical students learned at the CMC,” she says. “Not about how to do specific procedures, but how to interact with patients who may be very different from themselves.”

There seems to be plenty of interest in the topic; Dr. Crystal has since built a Twitter following of 5,700 people who read articles she tweets about medicine’s past, present, and future (@CatchTheBaby).

Still, she needs to build the website, edit the hours of film into short films, and then post them on the website with a study guide. The cost, she says, could run anywhere between $35,000 and $65,000.

“I don’t necessarily have to work with people who are PBS documentarians,” she says, adding that over recent years she has contacted several university film professors and students who turned down the project because it was too much to tackle. “I’d like to use a crowd-funding [platform like] Kickstarter or Indiegogo to raise the money, so I could edit the film.”

Meanwhile, Dr. Johnson is getting older and would enjoy seeing this project completed. So would his friends who helped pay for the trailer and original filming, says Dr. Crystal. Besides, she believes these stories can help new doctors better balance their focus between technology and face time with patients.

“Medical school education is changing quite a bit,” she says. “Despite advances in technology, we can’t forget we’re treating a human being first.”

Carol Patton is a freelance writer in Las Vegas.

When Ruth Ann Crystal, MD, performed her residency at Stanford University Medical Center more than 15 years ago, she often worked side by side in the operating room with one of her favorite professors, Bert Johnson, MD, a skilled surgeon and obstetrician. While performing vaginal hysterectomies, Dr. Johnson would often share stories of when he was a resident back in the 1950s at the Chicago Maternity Center (CMC) and delivered babies for poor families on Chicago’s south side.

One of the stories Dr. Johnson told was about a time when he and another medical student were called to a home to “turn a baby that was stuck,” recalls Dr. Crystal, now a hospitalist at El Camino Hospital, which supports two campuses in Mountain View, Calif., and Los Gatos, Calif. They were going to administer ether, which is highly flammable, to the young mother to relax the uterus and help turn the baby, but then realized that a wood fire was burning. As the woman writhed in pain, they doused the flames with water.

“He said it was like Dante’s Inferno as smoke filled the room,” Dr. Crystal says. “It was quite the scene.”

Stories told by Dr. Johnson and other physicians who worked at the CMC during medical school or residency in the 1950s are legendary. They reflect a time in medicine when doctors not only made house calls, but also stayed in the family’s home until the baby was delivered, getting glimpses into the life of the poor. In an effort to preserve these stories, Dr. Crystal wanted to produce a one-hour PBS documentary called Catch the Baby. But financial realities set in, and she now plans to convert the stories into short vignettes that will be posted on a website by the same name for medical humanities classes.

“I thought, ‘Wow, this is an amazing part of history that shouldn’t be lost,’” says Dr. Crystal, who also supports a private practice. “The Chicago Maternity Center was an incredible place that, for almost 80 years, taught medical students how to be self-sufficient.

They learned “to count on their own skills and [find] ways of solving problems in very real situations when being sent out to these deliveries.”

Big Plans, No Budget

During her residency, Dr. Crystal videotaped approximately seven hours of interviews with Dr. Johnson about his experiences at CMC. She planned to write a book about the 80-something-year-old doctor, who still owns a ranch, ropes cattle, and, at one time, headed the California Beef Council; however, her job, growing family, and well, life, simply got in the way.

Then, in 2009, roughly a decade later, one of her patients mentioned that she knew a film crew who produced documentaries for PBS. Dr. Crystal asked for an introduction.

Members of the film crew were excited about the project. Their first task was to create a trailer for the documentary. They spent an entire day filming Dr. Johnson at his ranch telling stories about kitchen table deliveries in the slums and doing activities around the ranch, like roping cattle with a fellow cowboy—someone he actually delivered as a baby years ago. More film was later shot at the Santa Clara Valley Medical Center of Dr. Johnson performing a C-section and vaginal delivery with a resident and medical student.

The four-minute and 20-second trailer cost $37,000, she says, explaining that the money was mostly raised through donations from Dr. Johnson’s “cowboy friends” who also owned ranches in the area. It is still posted on the original website Dr. Crystal created: www.CatchTheBaby.com.

Now came the hard part—fundraising.

“I found out that I would have to raise between $650,000 and $700,000 to make a one-hour film,” Dr. Crystal says. “I tried, but I’m a doctor and don’t like asking people for money. I realized that probably wasn’t going to happen.”

But she wasn’t willing to abandon the project. So she turned her attention to YouTube, which, by then, had been online for four years. At the time, shorter videos were popular. Dr. Crystal had to develop a new plan.

Her current goal is to build a website that would highlight the CMC stories, which would be part of a medical humanities course at medical schools across the country. Medical students, residents, and other doctors could learn about the history of medicine and obstetrics. She says there are many lessons to be learned that don’t involve medical procedures, such as the impact of social and cultural issues on a physician’s ability to deliver healthcare.

“We need to look back on the important lessons the medical students learned at the CMC,” she says. “Not about how to do specific procedures, but how to interact with patients who may be very different from themselves.”

There seems to be plenty of interest in the topic; Dr. Crystal has since built a Twitter following of 5,700 people who read articles she tweets about medicine’s past, present, and future (@CatchTheBaby).

Still, she needs to build the website, edit the hours of film into short films, and then post them on the website with a study guide. The cost, she says, could run anywhere between $35,000 and $65,000.

“I don’t necessarily have to work with people who are PBS documentarians,” she says, adding that over recent years she has contacted several university film professors and students who turned down the project because it was too much to tackle. “I’d like to use a crowd-funding [platform like] Kickstarter or Indiegogo to raise the money, so I could edit the film.”

Meanwhile, Dr. Johnson is getting older and would enjoy seeing this project completed. So would his friends who helped pay for the trailer and original filming, says Dr. Crystal. Besides, she believes these stories can help new doctors better balance their focus between technology and face time with patients.

“Medical school education is changing quite a bit,” she says. “Despite advances in technology, we can’t forget we’re treating a human being first.”

Carol Patton is a freelance writer in Las Vegas.

An Australian team conducted a literature review of expected deaths in the hospital—where the majority of deaths in the developed world occur—and identified elements of end-of-life care that are important to patients and families.¹ Published in the British journal Palliative Medicine, the review of nine electronic data bases and 1859 articles released between 1990 and 2014 identified eight quantitative studies that met inclusion criteria.

The authors, led by Claudia Virdun, RN, of the faculty of health at the University of Technology in Sydney, found four end-of-life domains that were most important to both patients and families:

• Effective communication and shared decision-making;
• Expert care;
• Respectful and compassionate care; and
• Trust and confidence in clinicians.

Not all patients dying in hospitals receive best evidence-based palliative care, the authors note, adding that the “challenge for healthcare services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.”

Reference

1. Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important [published online ahead of print April 28, 2015]. Palliat Med.

An Australian team conducted a literature review of expected deaths in the hospital—where the majority of deaths in the developed world occur—and identified elements of end-of-life care that are important to patients and families.¹ Published in the British journal Palliative Medicine, the review of nine electronic data bases and 1859 articles released between 1990 and 2014 identified eight quantitative studies that met inclusion criteria.

The authors, led by Claudia Virdun, RN, of the faculty of health at the University of Technology in Sydney, found four end-of-life domains that were most important to both patients and families:

• Effective communication and shared decision-making;
• Expert care;
• Respectful and compassionate care; and
• Trust and confidence in clinicians.

Not all patients dying in hospitals receive best evidence-based palliative care, the authors note, adding that the “challenge for healthcare services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.”

Reference

1. Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important [published online ahead of print April 28, 2015]. Palliat Med.

An Australian team conducted a literature review of expected deaths in the hospital—where the majority of deaths in the developed world occur—and identified elements of end-of-life care that are important to patients and families.¹ Published in the British journal Palliative Medicine, the review of nine electronic data bases and 1859 articles released between 1990 and 2014 identified eight quantitative studies that met inclusion criteria.

The authors, led by Claudia Virdun, RN, of the faculty of health at the University of Technology in Sydney, found four end-of-life domains that were most important to both patients and families:

• Effective communication and shared decision-making;
• Expert care;
• Respectful and compassionate care; and
• Trust and confidence in clinicians.

Not all patients dying in hospitals receive best evidence-based palliative care, the authors note, adding that the “challenge for healthcare services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.”

Reference

1. Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important [published online ahead of print April 28, 2015]. Palliat Med.

Clinical question: What risk factors predict septic arthritis surgical debridement failure?

Background: Standard treatment of septic arthritis is debridement and antibiotics. Unfortunately, 23%-48% of patients fail single debridement. Data is limited on what factors correlate with treatment failure.

Study design: Retrospective, logistic regression analysis.

Setting: Billing database query of one academic medical center from 2000-2011.

Synopsis: After excluding patients with orthopedic comorbidities, multivariate logistic regression was performed on 128 patients greater than 18 years of age and treated operatively for septic arthritis, 38% of whom had failed a single debridement. Five significant independent clinical variables were identified as predictors for failure of a single surgical debridement:

• History of inflammatory arthropathy (OR, 7.3; 95% CI, 2.4 to 22.6; P<0.001);
• Involvement of a large joint (knee, shoulder, or hip; OR 7.0; 95% CI, 1.2-37.5; P=0.02);
• Synovial fluid nucleated cell count >85.0 x 109 cells/L (OR, 4.7; 95% CI, 1.8-17.7; P=0.002);
• S. aureus as an isolate (OR, 4.6; 95% CI, 1.8 to 11.9; P=0.002); and
• History of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; P=0.04).

Using these variables, a prognostic model was created with an ROC curve of 0.79.

The study’s limitations include its retrospective nature, reliance on coding and documentation, small sample size, and the fact that all patients were treated at a single center.

Bottom line: Risk factors for failing single debridement in septic arthritis include inflammatory arthropathy, large joint involvement, more than 85.0 x 109 nucleated cells, S. aureus infection, and history of diabetes.

Citation: Hunter JG, Gross JM, Dahl JD, Amsdell SL, Gorczyca JT. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558-564.

Clinical question: What risk factors predict septic arthritis surgical debridement failure?

Background: Standard treatment of septic arthritis is debridement and antibiotics. Unfortunately, 23%-48% of patients fail single debridement. Data is limited on what factors correlate with treatment failure.

Study design: Retrospective, logistic regression analysis.

Setting: Billing database query of one academic medical center from 2000-2011.

Synopsis: After excluding patients with orthopedic comorbidities, multivariate logistic regression was performed on 128 patients greater than 18 years of age and treated operatively for septic arthritis, 38% of whom had failed a single debridement. Five significant independent clinical variables were identified as predictors for failure of a single surgical debridement:

• History of inflammatory arthropathy (OR, 7.3; 95% CI, 2.4 to 22.6; P<0.001);
• Involvement of a large joint (knee, shoulder, or hip; OR 7.0; 95% CI, 1.2-37.5; P=0.02);
• Synovial fluid nucleated cell count >85.0 x 109 cells/L (OR, 4.7; 95% CI, 1.8-17.7; P=0.002);
• S. aureus as an isolate (OR, 4.6; 95% CI, 1.8 to 11.9; P=0.002); and
• History of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; P=0.04).

Using these variables, a prognostic model was created with an ROC curve of 0.79.

The study’s limitations include its retrospective nature, reliance on coding and documentation, small sample size, and the fact that all patients were treated at a single center.

Bottom line: Risk factors for failing single debridement in septic arthritis include inflammatory arthropathy, large joint involvement, more than 85.0 x 109 nucleated cells, S. aureus infection, and history of diabetes.

Citation: Hunter JG, Gross JM, Dahl JD, Amsdell SL, Gorczyca JT. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558-564.

Clinical question: What risk factors predict septic arthritis surgical debridement failure?

Background: Standard treatment of septic arthritis is debridement and antibiotics. Unfortunately, 23%-48% of patients fail single debridement. Data is limited on what factors correlate with treatment failure.

Study design: Retrospective, logistic regression analysis.

Setting: Billing database query of one academic medical center from 2000-2011.

Synopsis: After excluding patients with orthopedic comorbidities, multivariate logistic regression was performed on 128 patients greater than 18 years of age and treated operatively for septic arthritis, 38% of whom had failed a single debridement. Five significant independent clinical variables were identified as predictors for failure of a single surgical debridement:

• History of inflammatory arthropathy (OR, 7.3; 95% CI, 2.4 to 22.6; P<0.001);
• Involvement of a large joint (knee, shoulder, or hip; OR 7.0; 95% CI, 1.2-37.5; P=0.02);
• Synovial fluid nucleated cell count >85.0 x 109 cells/L (OR, 4.7; 95% CI, 1.8-17.7; P=0.002);
• S. aureus as an isolate (OR, 4.6; 95% CI, 1.8 to 11.9; P=0.002); and
• History of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; P=0.04).

Using these variables, a prognostic model was created with an ROC curve of 0.79.

The study’s limitations include its retrospective nature, reliance on coding and documentation, small sample size, and the fact that all patients were treated at a single center.

Bottom line: Risk factors for failing single debridement in septic arthritis include inflammatory arthropathy, large joint involvement, more than 85.0 x 109 nucleated cells, S. aureus infection, and history of diabetes.

Citation: Hunter JG, Gross JM, Dahl JD, Amsdell SL, Gorczyca JT. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am. 2015;97(7):558-564.

Clinical question: Does administration of prednisolone or pentoxifylline reduce mortality in patients hospitalized with severe alcoholic hepatitis?

Background: Alcoholic hepatitis is associated with high mortality. Studies have shown unclear mortality benefit with prednisolone and pentoxifylline. Despite multiple studies and meta-analyses, controversy about the use of these medications persists.

Study Design: Multicenter, double-blind, randomized trial with 2-by-2 design.

Setting: Sixty-five hospitals across the United Kingdom.

Synopsis: Approximately 1,100 patients with a clinical diagnosis of alcoholic hepatitis were randomized to four groups: placebo + placebo; prednisolone + pentoxifylline-matched placebo; prednisolone-matched placebo + pentoxifylline; or prednisolone + pentoxifylline. Groups received 28 days of treatment. The primary endpoint was 28-day mortality. Secondary endpoints were mortality or liver transplantation at 90 days and one year.

Neither intervention showed a significant reduction in 28-day mortality. Secondary analysis with adjustments for risk showed a reduction in 28-day mortality in the prednisolone groups. There was no difference between groups for mortality or liver transplantation at 90 days or one year.

Adverse events of death, infection, and acute kidney injury were reported in 42% of patients. Infection rates were higher in the prednisolone groups; however, attributable deaths were no different between groups.

Patients in this trial were younger, with a lower incidence of encephalopathy, infection, and acute kidney injury than those seen in similar trials, which could affect the rates of mortality seen here. Also, liver biopsy was not used, so patients may have been incorrectly included.

Bottom line: No difference was found in mortality or liver transplantation at 90 days and one year for prednisolone or pentoxifylline, although subanalysis showed there may be short-term benefit with prednisolone.

Citation: Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med. 2015;372(17):1619-1628.

Clinical question: Does administration of prednisolone or pentoxifylline reduce mortality in patients hospitalized with severe alcoholic hepatitis?

Background: Alcoholic hepatitis is associated with high mortality. Studies have shown unclear mortality benefit with prednisolone and pentoxifylline. Despite multiple studies and meta-analyses, controversy about the use of these medications persists.

Study Design: Multicenter, double-blind, randomized trial with 2-by-2 design.

Setting: Sixty-five hospitals across the United Kingdom.

Synopsis: Approximately 1,100 patients with a clinical diagnosis of alcoholic hepatitis were randomized to four groups: placebo + placebo; prednisolone + pentoxifylline-matched placebo; prednisolone-matched placebo + pentoxifylline; or prednisolone + pentoxifylline. Groups received 28 days of treatment. The primary endpoint was 28-day mortality. Secondary endpoints were mortality or liver transplantation at 90 days and one year.

Neither intervention showed a significant reduction in 28-day mortality. Secondary analysis with adjustments for risk showed a reduction in 28-day mortality in the prednisolone groups. There was no difference between groups for mortality or liver transplantation at 90 days or one year.

Adverse events of death, infection, and acute kidney injury were reported in 42% of patients. Infection rates were higher in the prednisolone groups; however, attributable deaths were no different between groups.

Patients in this trial were younger, with a lower incidence of encephalopathy, infection, and acute kidney injury than those seen in similar trials, which could affect the rates of mortality seen here. Also, liver biopsy was not used, so patients may have been incorrectly included.

Bottom line: No difference was found in mortality or liver transplantation at 90 days and one year for prednisolone or pentoxifylline, although subanalysis showed there may be short-term benefit with prednisolone.

Citation: Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med. 2015;372(17):1619-1628.

Clinical question: Does administration of prednisolone or pentoxifylline reduce mortality in patients hospitalized with severe alcoholic hepatitis?

Background: Alcoholic hepatitis is associated with high mortality. Studies have shown unclear mortality benefit with prednisolone and pentoxifylline. Despite multiple studies and meta-analyses, controversy about the use of these medications persists.

Study Design: Multicenter, double-blind, randomized trial with 2-by-2 design.

Setting: Sixty-five hospitals across the United Kingdom.

Synopsis: Approximately 1,100 patients with a clinical diagnosis of alcoholic hepatitis were randomized to four groups: placebo + placebo; prednisolone + pentoxifylline-matched placebo; prednisolone-matched placebo + pentoxifylline; or prednisolone + pentoxifylline. Groups received 28 days of treatment. The primary endpoint was 28-day mortality. Secondary endpoints were mortality or liver transplantation at 90 days and one year.

Neither intervention showed a significant reduction in 28-day mortality. Secondary analysis with adjustments for risk showed a reduction in 28-day mortality in the prednisolone groups. There was no difference between groups for mortality or liver transplantation at 90 days or one year.

Adverse events of death, infection, and acute kidney injury were reported in 42% of patients. Infection rates were higher in the prednisolone groups; however, attributable deaths were no different between groups.

Patients in this trial were younger, with a lower incidence of encephalopathy, infection, and acute kidney injury than those seen in similar trials, which could affect the rates of mortality seen here. Also, liver biopsy was not used, so patients may have been incorrectly included.

Bottom line: No difference was found in mortality or liver transplantation at 90 days and one year for prednisolone or pentoxifylline, although subanalysis showed there may be short-term benefit with prednisolone.

Citation: Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med. 2015;372(17):1619-1628.

Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?

Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.

Study design: Double-blind, multicenter, randomized, placebo-controlled trial.

Setting: Seven tertiary care hospitals in Switzerland.

Synopsis: Seven hundred eighty-four patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33, 95% CI 1.15-1.50, P<0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin.

Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.

Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.

Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518.

Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?

Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.

Study design: Double-blind, multicenter, randomized, placebo-controlled trial.

Setting: Seven tertiary care hospitals in Switzerland.

Synopsis: Seven hundred eighty-four patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33, 95% CI 1.15-1.50, P<0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin.

Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.

Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.

Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518.

Clinical question: Does corticosteroid treatment shorten systemic illness in patients admitted to the hospital for community-acquired pneumonia (CAP)?

Background: Pneumonia is the third-leading cause of death worldwide. Studies have yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of CAP.

Study design: Double-blind, multicenter, randomized, placebo-controlled trial.

Setting: Seven tertiary care hospitals in Switzerland.

Synopsis: Seven hundred eighty-four patients hospitalized for CAP were randomized to receive either oral prednisone 50 mg daily for seven days or placebo, with the primary endpoint being time to stable vital signs. The intention-to-treat analysis found that the median time to clinical stability was 1.4 days earlier in the prednisone group (hazard ratio 1.33, 95% CI 1.15-1.50, P<0.0001) and that length of stay and IV antibiotics were reduced by one day; this effect was valid across all PSI classes and was not dependent on age. Pneumonia-associated complications in the two groups did not differ at 30 days, though the prednisone group had a higher incidence of hyperglycemia requiring insulin.

Because all study locations were in a single, fairly homogenous northern European country, care should be taken when hospitalists apply these findings to their patient population, and the risks of hyperglycemia requiring insulin should be taken into consideration.

Bottom line: Systemic steroids may reduce the time to clinical stability in patients with CAP.

Citation: Blum CA, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518.