OBJECTIVES: To test the hypothesis that individualized nutritional treatment during and after discharge from acute hospitalization will reduce mortality and improve nutritional outcomes.
DESIGN: ...Randomized, controlled trial.
SETTING: Internal medicine departments.
PARTICIPANTS: Two hundred fifty‐nine hospitalized adults aged 65 and older at nutritional risk were recruited and randomized according to hospitalization ward into one intervention and two control groups during hospitalization.
INTERVENTION: Group 1 (intervention group) received individualized nutritional treatment from a dietitian in the hospital and three home visits after discharge. Group 2 received one meeting with a dietitian in the hospital. Group 3 received standard care. Groups 2 and 3 were combined into a single group that served as the control group in the analysis.
MEASUREMENTS: Mortality, health status, nutritional outcomes, blood tests, cognition, emotional, and functional parameters were assessed at baseline and after 6 months. All participants were contacted monthly.
RESULTS: The overall dropout rate was 25.8%. After 6 months, rise in Mini Nutritional Assessment score, adjusted for education and hospitalization ward, was significantly higher in the intervention group than in the control groups (3.01 ± 2.65 vs 1.81 ± 2.97, P=.004) mainly on the subjective assessment part (0.34 ± 0.86 vs. −0.04 ± 0.87, P=.004). The only laboratory parameter for which a difference was observed between the groups was albumin; 9.7% of the intervention group had serum albumin levels of less than 3.5 g/dL, versus 22.9% of the control group (P=.03). Mortality was significantly lower in the intervention group (3.8%) than in the control group (11.6%, P=.046).
CONCLUSION: Lower mortality and moderate improvement in nutritional status were found in patients receiving individualized nutritional treatment during and after acute hospitalization.
Aim:
Epidemiological and mechanistic studies raised the possibility that cognitive function may be affected by brain responses to insulin. We systematically reviewed and analyzed existing clinical ...trials that assessed the potential beneficial effects of intranasal insulin administration on cognitive functions.
Methods:
Interventional studies measuring changes in cognitive functions in response to intranasal insulin were retrieved and included if they were in English and assessed cognitive functions before and after treatment. Cohen's effect size was calculated to allow comparison between studies.
Results:
Eight studies (328 participants) were analyzed. No significant side effects of intranasal insulin administration were reported. Seven studies included healthy subjects' response to intranasal insulin, and three evaluated the cognitive effect among patients with minimal cognitive impairment or overt Alzheimer's disease. In healthy people, Cohen's effect size calculations suggest that only 160 IU/d intranasal insulin induced potential beneficial effects. Although females, when compared head-to-head, exhibited greater improvements in cognitive tests than men, the composite analysis of all included studies did not support this trend. Among cognitively impaired patients, only lower doses of insulin were assessed, and 20 IU revealed potential beneficial effects on cognitive functions. This was significant in a single study assessing long-term intranasal insulin administration, whereas acute administration of 20 IU intranasal insulin tended to show a beneficial effect on immediate recall in Apo ε4(−), but not Apo ε4(+), patients.
Conclusions:
The current limited clinical experience suggests potential beneficial cognitive effects of intranasal insulin. Analyses provide clinical considerations for future research aimed at elucidating whether intranasal insulin may be used to improve cognitive functions.
Aims: To introduce a simple carb counting tool (CC) in patients with type 1 diabetes mellitus (T1DM) making CC easy and accessible, overcoming barriers such as age, education, gender or tutoring ...language.
Methods: In a randomized control trial 82 patients (pts.) received either 1-the common CC guidance using calculation of insulin sensitivity (IS), Carb:insulin ratio (C:I) or 2- a simple personalized tool consisting of 2 tables: A) correction values derived from the individual's IS, B) calculated insulin dose for carb content (personal C:I) for the most consumed carbs derived from the individual’s personal food diary. The intervention comprised 6 tutoring visits to a dietician, diabetes educator. The primary outcome was Hba1c post training.
Results: On the common tool were 39 pts. and 43 on the simple tool. Both groups showed significant statistical and clinical improvement; A1C declined -1.31% in the common tool and -1.59% in the simple method. The positive effects of CC using either method were unaffected by gender (-1.65% vs. -1.22% in males and females respectively P=0.43). We hypothesized that older age, language barrier or people with <12 years of education would benefit more from the simple tool compared to the common tool but no significant difference was found. Moreover, no significance was found among lower vs. higher education (>12 ys) (-1.32% vs. -1.64% respectively p=0.58). Newly diagnosed T1DM (≤1 year) in both groups had a significant decrease in HbA1c (-4.67%) compared to T1DM > 1 year (-.87%) (p<0.001). As expected, better compliance decreased the HbA1c. Those attending ≤ 2 meetings decreased by -.46% vs. -1.56% (p=0.051) in those attending 3-6 CC training sessions.
Discussion: CC was beneficial for all pts.; barriers such as age, gender, tutoring or spoken language didn’t hinder the benefits. Teaching CC close to diabetes diagnosis yielded better clinical results emphasizing the importance of early CC education. Our method provides an additional effective tool to better deliver patient -centered diabetes education.
Disclosure
S. Witkow: None. I.F. Liberty: Other Relationship; Self; AstraZeneca, Novo Nordisk Inc., Sanofi. I. Goloub: None. M. Kaminsky: None. O. Otto: None. Y. Abu Rabia: None. I. Harman Boehm: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Merck Sharp & Dohme Corp., Merck Sharp & Dohme Corp., Novartis AG, Novo Nordisk Inc., Novo Nordisk Inc., Sanofi. Speaker's Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novartis AG, Sanofi.
ABSTRACT
The morbidity and mortality caused by diabetic foot ulcer (DFU) are still significant. Conservative treatment of DFU is often ineffective. Treatment modalities using stem cells directly into ...the DFU or systematically have been introduced recently. Ischemic preconditioning (IPC) has been proved to be a cheap, simple, and safe method which can augment stem cells number in the peripheral blood circulation. This study's purpose was to test whether IPC can improve DFU healing. Forty diabetic patients were enrolled and divided into study and control groups. All patients received their regular treatment. The study group patients received in addition brief, transient cycles of IPC while the control group patients received a sham procedure only. The procedure was repeated every 2 weeks to complete a follow‐up period of 6 weeks. The ulcers were photographed to measure wound area, and the degree of granulation tissue was assessed. No serious adverse events were noted. Twenty‐two patients from the study group and 12 from the control group completed the entire follow‐up. The ratio of patients who reached complete healing of their ulcer was 9/22 (41%) in the study group compared with 0/12 (0%) in the control group, p = 0.01. Furthermore, the mean remaining ulcer area at the end of the follow‐up was significantly smaller in the study group, 25 ± 6% of the initial area vs. 61 ± 10% in the control group, p = 0.007. The degree of granulation increased after one cycle of treatment in 8/24 (33%) study patients compared to 3/16 (19%) in the control group, p = 0.47. Remote, repeated IPC significantly improves the healing of DFU. This simple, safe, inexpensive treatment method should be considered to be routinely applied to diabetic patients with DFU in addition to other regular treatment modalities.
Abstract Objectives To examine whether the degree of risk aversion is associated with adherence to disease self-management among adults with type 2 diabetes. Methods This was a cross-sectional study ...of patients with type 2 diabetes (n = 408) aged 21 to 70 years who presented for routine visits in the diabetes clinic at a university medical center in Beer-Sheva, Israel. The authors used validated questionnaires to estimate adherence, risk preferences, motivation, self-efficacy, impulsivity, perceptions about the disease and the interpersonal process of care, and demographic and socioeconomic characteristics, in addition to retrieving data from computerized patient medical records of clinical indicators of disease severity. Multivariable linear and ordered-logit models examined predictors of adherence to each self-care behavior. Results Multivariable analyses revealed that, compared with others, risk-seeking patients reported lower general adherence ( β = −0.32; P ≤ 0.05), and specifically, lower adherence to healthful eating plan ( β = −0.48; P ≤ 0.1), consumption of low-fat food ( β = −0.47; P ≤ 0.1), exercise ( β = −0.73; P ≤ 0.05), blood glucose monitoring ( β = −0.69; P ≤ 0.05), and foot care ( β = −0.36; P ≤ 0.1). Risk-seeking patients did not report lower consumption of fruits and vegetables ( β = −0.19; P > 0.1). Because 96% of the study population reported optimal adherence to medication, determinants of this behavior could not be analyzed. Conclusions Risk preference is associated with adherence to self-care behaviors. Identifying risk seekers may enable practitioners to target these patients with tailored strategies to improve adherence, thus more efficiently allocating scarce health care resources.
Undernutrition among older people is a continuing source of concern, particularly among acutely hospitalized patients. The purpose of the current study is to compare malnourished elderly patients ...with those at nutritional risk and identify factors contributing to the variability between the groups.
The study was carried out at the Soroka University Medical Center in the south of Israel. From September 2003 through December 2004, all patients 65 years-of-age or older admitted to any of the internal medicine departments, were screened within 72 hours of admission to determine nutritional status using the short version of the Mini Nutritional Assessment (MNA-SF). Patients at nutritional risk were entered the study and were divided into malnourished or 'at risk' based on the full version of the MNA. Data regarding medical, nutritional, functional, and emotional status were obtained by trained interviewers.
Two hundred fifty-nine elderly patients, 43.6% men, participated in the study; 18.5% were identified as malnourished and 81.5% were at risk for malnutrition according to the MNA. The malnourished group was less educated, had a higher depression score and lower cognitive and physical functioning. Higher prevalence of chewing problems, nausea, and vomiting was detected among malnourished patients. There was no difference between the groups in health status indicators except for subjective health evaluation which was poorer among the malnourished group. Lower dietary score indicating lower intake of vegetables fruits and fluid, poor appetite and difficulties in eating distinguished between malnourished and at-risk populations with the highest sensitivity and specificity as compare with the anthropometric, global, and self-assessment of nutritional status parts of the MNA. In a multivariate analysis, lower cognitive function, education <12 years and chewing problems were all risk factors for malnutrition.
Our study indicates that low food consumption as well as poor appetite and chewing problems are associated with the development of malnutrition. Given the critical importance of nutritional status in the hospitalized elderly, further intervention trials are required to determine the best intervention strategies to overcome these problems.
Autophagy genes' expression is upregulated in visceral fat in human obesity, associating with obesity-related cardio-metabolic risk. E2F1 (E2F transcription factor 1) was shown in cancer cells to ...transcriptionally regulate autophagy. We hypothesize that E2F1 regulates adipocyte autophagy in obesity, associating with endocrine/metabolic dysfunction, thereby, representing non-cell-cycle function of this transcription factor. E2F1 protein (N=69) and mRNA (N=437) were elevated in visceral fat of obese humans, correlating with increased expression of ATG5 (autophagy-related 5), MAP1LC3B/LC3B (microtubule-associated protein 1 light chain 3 β), but not with proliferation/cell-cycle markers. Elevated E2F1 mainly characterized the adipocyte fraction, whereas MKI67 (marker of proliferation Ki-67) was elevated in the stromal-vascular fraction of adipose tissue. In human visceral fat explants, chromatin-immunoprecipitation revealed body mass index (BMI)-correlated increase in E2F1 binding to the promoter of MAP1LC3B, but not to the classical cell cycle E2F1 target, CCND1 (cyclin D1). Clinically, omental fat E2F1 expression correlated with insulin resistance, circulating free-fatty-acids (FFA), and with decreased circulating ADIPOQ/adiponectin, associations attenuated by adjustment for autophagy genes. Overexpression of E2F1 in HEK293 cells enhanced promoter activity of several autophagy genes and autophagic flux, and sensitized to further activation of autophagy by TNF. Conversely, mouse embryonic fibroblast (MEF)-derived adipocytes from e2f1 knockout mice (e2f1
−/−
) exhibited lower autophagy gene expression and flux, were more insulin sensitive, and secreted more ADIPOQ. Furthermore, e2f1
−/−
MEF-derived adipocytes, and autophagy-deficient (by Atg7 siRNA) adipocytes were resistant to cytokines-induced decrease in ADIPOQ secretion. Jointly, upregulated E2F1 sensitizes adipose tissue autophagy to inflammatory stimuli, linking visceral obesity to adipose and systemic metabolic-endocrine dysfunction.
Diabetic ketoacidosis (DKA) occurs most often in patients with type 1 diabetes, however patients with type 2 diabetes are also susceptible to DKA under stressful conditions. The aims of our study ...were to evaluate and compare the clinical and biochemical characteristics and outcomes of type 1 versus type 2 diabetes mellitus (DM) patients with DKA.
A retrospective cohort study of adult patients hospitalized with DKA between January 1, 2003, and January 1, 2010. The clinical and biochemical characteristics of DKA patients with type-1 DM were compared with those of patients with type-2 DM. The primary outcome was in-hospital all-cause mortality.
The study cohort included 201 consecutive patients for whom the admission diagnosis was DKA: 166 patients (82.6%) with type-1 DM and 35 patients (17.4%) with type-2 DM. The patients with DKA and type-2 DM were significantly older than patients with type-1 DM (64.3 versus 37.3, P < 0.001). Significantly more patients with severe forms of DKA were seen in the group with type-2 DM (25.7% versus 9.0%, P = 0.018). The total in-hospital mortality rate of patients with DKA was 4.5%. The primary outcome was significantly worse in the group of patients with type-2 DM.
DKA in patients with type-2 DM is a more severe disease with worse outcomes compared with type-1 DM. Advanced age, mechanical ventilation and bed-ridden state were independent predictors of 30-day mortality.
Visceral adipose tissue foam cells are increased in human obesity, and were implicated in adipose dysfunction and increased cardio-metabolic risk. In the circulation, non-classical monocytes (NCM) ...are elevated in obesity and associate with atherosclerosis and type 2 diabetes. We hypothesized that circulating NCM correlate and/or are functionally linked to visceral adipose tissue foam cells in obesity, potentially providing an approach to estimate visceral adipose tissue status in the non-surgical obese patient.
We preformed ex-vivo functional studies utilizing sorted monocyte subclasses from healthy donors. Moreover, we assessed circulating blood monocyte subclasses and visceral fat adipose tissue macrophage (ATM) lipid content by flow-cytometry in paired blood and omental-fat samples collected from patients (n = 65) undergoing elective abdominal surgery.
Ex-vivo, NCM and NCM-derived macrophages exhibited lower lipid accumulation capacity compared to classical or intermediate monocytes/-derived macrophages. Moreover, of the three subclasses, NCM exhibited the lowest migration towards adipose tissue conditioned-media. In a cohort of n = 65, increased %NCM associated with higher BMI (r = 0.250,p<0.05) and ATM lipid content (r = 0.303,p<0.05). Among patients with BMI≥25Kg/m2, linear regression models adjusted for age, sex or BMI revealed that NCM independently associate with ATM lipid content, particularly in men.
Collectively, although circulating blood NCM are unlikely direct functional precursor cells for adipose tissue foam cells, their increased percentage in the circulation may clinically reflect higher lipid content in visceral ATMs.
The presence of a foot ulcer increases the self-treatment burden imposed on the individual with diabetes. Additionally, this condition increases the cognitive demands needed for adherence to medical ...recommendations. A potential gap could exist between medical recommendations and the individual's ability to implement them. Hence, the goal of this study was to examine whether the cognitive profile of people with diabetic foot ulcers differs from that of people with diabetes without this complication.
This was a case-control study. Ninety-nine individuals with diabetic foot ulcers (case patients) and 95 individuals with type 2 diabetes (control subjects) (age range 45-75 years), who were matched for diabetes duration and sex, underwent extensive neuropsychological evaluation using a NeuroTrax computerized battery, digit symbol, and verbal fluency tests. A global cognitive score after standardization for age and education was computed as well as scores in the following six cognitive domains: memory, executive function, reaction time, attention, psychomotor abilities, and estimated premorbid cognition.
Individuals with diabetic foot ulcers had significantly (P < 0.001) lower cognitive scores than individuals with diabetes without this complication, in all tested cognitive domains, excluding estimated premorbid cognition. Individuals with diabetic foot ulcers demonstrated a significant difference between precognitive and current cognitive abilities, as opposed to the nonsignificant difference among control subjects. The differences persisted in multivariable analysis after adjusting for depression and smoking.
Individuals with diabetic foot ulcers were found to possess fewer cognitive resources than individuals with diabetes without this complication. Thus, they appear to face more self-treatment challenges, while possessing significantly fewer cognitive resources.
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