More patient portals and electronic health records should enable users to create "proxy" accounts for nurses and home aids to prevent unintentional sharing of personal health details, researchers said Monday.
Interferon beta, a drug originally developed to treat chronic obstructive pulmonary disease, or COPD, is being explored as a possible cure for the severe lung infections caused by COVID-19, media reports confirmed Monday
Pediatric vaccination against measles has declined by as much as 60 percent nationally since the start of the COVID-19 outbreak, according to new data released Friday by the Centers for Disease Control and Prevention.
To address the intersecting challenges facing European societies—from population aging and labor-market change, to immigration and political upheaval—governments need to hone new strategies for helping both newcomers and long-term residents succeed amid diversity. This report explores some of the most promising approaches, drawing on input from policymakers, the private sector, civil society, and others.
In the three years since the European migration and refugee crisis vividly captured public attention, a wave of innovative initiatives has emerged to help newcomers settle into receiving societies. Now, as the sense of crisis abates, this report explores what these initiatives will need to do to outlast the hype and produce lasting change on key integration issues such as housing, economic inclusion, and community building.
To investigate the association of the cardiovascular risk factor lipoprotein (Lp)(a) and vascular complications in patients with type 1 diabetes.
Patients with type 1 diabetes receiving regular care were recruited in this observational cross-sectional study and divided into four groups according to their Lp(a) levels in nmol/L (very low <10, low 10–30, intermediate 30–120, high >120). Prevalence of vascular complications was compared between the groups. In addition, the association between metabolic control, measured as HbA1c, and Lp(a) was studied.
The patients (n = 1,860) had a median age of 48 years, diabetes duration of 25 years, and HbA1c of 7.8% (61 mmol/mol). The median Lp(a) was 19 (interquartile range 10–71) nmol/L. No significant differences between men and women were observed, but Lp(a) levels increased with increasing age. Patients in the high Lp(a) group had higher prevalence of complications than patients in the very low Lp(a) group. The age- and smoking-status–adjusted relative risk ratio of having any macrovascular disease was 1.51 (95% CI 1.01–2.28, P = 0.048); coronary heart disease, 1.70 (95% CI 0.97–3.00, P = 0.063); albuminuria, 1.68 (95% CI 1.12–2.50, P = 0.01); and calcified aortic valve disease, 2.03 (95% CI 1.03–4.03; P = 0.042). Patients with good metabolic control, HbA1c <6.9% (<52 mmol/mol), had significantly lower Lp(a) levels than patients with poorer metabolic control, HbA1c >6.9% (>52 mmol/mol).
Lp(a) is a significant risk factor for macrovascular disease, albuminuria, and calcified aortic valve disease in patients with type 1 diabetes. Poor metabolic control in patients with type 1 diabetes is associated with increased Lp(a) levels.
We examined detailed renal and cardiovascular (CV) outcomes after gastric bypass (GBP) surgery in people with obesity and type 2 diabetes mellitus (T2DM), across several renal function categories, in a nationwide cohort study.
We linked data from the National Diabetes Register and the Scandinavian Obesity Surgery Register with four national databases holding information on socioeconomic variables, medications, hospitalizations, and causes of death and matched 5,321 individuals with T2DM who had undergone GBP with 5,321 who had not (age 18–65 years, mean BMI >40 kg/m2, mean follow-up >4.5 years). The risks of postoperative outcomes were assessed with Cox regression models.
During the first years postsurgery, there were small reductions in creatinine and albuminuria and stable estimated glomerular filtration rate (eGFR) in the GBP group. The incidence rates of most outcomes relating to renal function, CV disease, and mortality were lower after GBP, being particularly marked for heart failure (hazard ratio [HR] 0.33 [95% CI 0.24, 0.46]) and CV mortality (HR 0.36 [(95% CI 0.22, 0.58]). The risk of a composite of severe renal disease or halved eGFR was 0.56 (95% CI 0.44, 0.71), whereas nonfatal CV risk was lowered less (HR 0.82 [95% CI 0.70, 0.97]) after GBP. Risks for key outcomes were generally lower after GBP in all eGFR strata, including in individuals with eGFR <30 mL/min/1.73 m2.
Our data suggest robust benefits for renal outcomes, heart failure, and CV mortality after GBP in individuals with obesity and T2DM. These results suggest that marked weight loss yields important benefits, particularly on the cardiorenal axis (including slowing progression to end-stage renal disease), whatever the baseline renal function status.
To study whether the effects of intensive glycemic control on major vascular outcomes (a composite of major macrovascular and major microvascular events), all-cause mortality, and severe hypoglycemia events differ among participants with different levels of 10-year risk of atherosclerotic cardiovascular disease (ASCVD) and hemoglobin A1c (HbA1c) at baseline.
We studied the effects of more intensive glycemic control in 11,071 patients with type 2 diabetes (T2D), without missing values, in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial, using Cox models.
During 5 years’ follow-up, intensive glycemic control reduced major vascular events (hazard ratio [HR] 0.90 [95% CI 0.83–0.98]), with the major driver being a reduction in the development of macroalbuminuria. There was no evidence of differences in the effect, regardless of baseline ASCVD risk or HbA1c level (P for interaction = 0.29 and 0.94, respectively). Similarly, the beneficial effects of intensive glycemic control on all-cause mortality were not significantly different across baseline ASCVD risk (P = 0.15) or HbA1c levels (P = 0.87). The risks of severe hypoglycemic events were higher in the intensive glycemic control group compared with the standard glycemic control group (HR 1.85 [1.41–2.42]), with no significant heterogeneity across subgroups defined by ASCVD risk or HbA1c at baseline (P = 0.09 and 0.18, respectively).
The major benefits for patients with T2D in ADVANCE did not substantially differ across levels of baseline ASCVD risk and HbA1c.
To evaluate the efficacy and safety of fast-acting insulin aspart (faster aspart) compared with insulin aspart (IAsp), both with insulin degludec with or without metformin, in adults with type 2 diabetes not optimally controlled with a basal-bolus regimen.
This multicenter, double-blind, treat-to-target trial randomized participants to faster aspart (n = 546) or IAsp (n = 545). All available information, regardless of treatment discontinuation or use of ancillary treatment, was used for evaluation of effect.
Noninferiority for the change from baseline in HbA1c 16 weeks after randomization (primary end point) was confirmed for faster aspart versus IAsp (estimated treatment difference [ETD] –0.04% [95% CI –0.11; 0.03]; –0.39 mmol/mol [–1.15; 0.37]; P < 0.001). Faster aspart was superior to IAsp for change from baseline in 1-h postprandial glucose (PPG) increment using a meal test (ETD –0.40 mmol/L [–0.66; –0.14]; –7.23 mg/dL [–11.92; –2.55]; P = 0.001 for superiority). Change from baseline in self-measured 1-h PPG increment for the mean over all meals favored faster aspart (ETD –0.25 mmol/L [–0.42; –0.09]); –4.58 mg/dL [–7.59; –1.57]; P = 0.003). The overall rate of treatment-emergent severe or blood glucose (BG)–confirmed hypoglycemia was statistically significantly lower for faster aspart versus IAsp (estimated treatment ratio 0.81 [95% CI 0.68; 0.97]).
In combination with insulin degludec, faster aspart provided effective overall glycemic control, superior PPG control, and a lower rate of severe or BG-confirmed hypoglycemia versus IAsp in adults with type 2 diabetes not optimally controlled with a basal-bolus regimen.
To confirm the presence of subclinical cardiovascular dysfunction in working-age adults with type 2 diabetes (T2D) and determine whether this is improved by a low-energy meal replacement diet (MRP) or exercise training.
This article reports on a prospective, randomized, open-label, blinded end point trial with nested case-control study. Asymptomatic younger adults with T2D were randomized 1:1:1 to a 12-week intervention of 1) routine care, 2) supervised aerobic exercise training, or 3) a low-energy (~810 kcal/day) MRP. Participants underwent echocardiography, cardiopulmonary exercise testing, and cardiac magnetic resonance (CMR) at baseline and 12 weeks. The primary outcome was change in left ventricular (LV) peak early diastolic strain rate (PEDSR) as measured by CMR. Healthy volunteers were enrolled for baseline case-control comparison.
Eighty-seven participants with T2D (age 51 ± 7 years, HbA1c 7.3 ± 1.1%) and 36 matched control participants were included. At baseline, those with T2D had evidence of diastolic dysfunction (PEDSR 1.01 ± 0.19 vs. 1.10 ± 0.16 s–1, P = 0.02) compared with control participants. Seventy-six participants with T2D completed the trial (30 routine care, 22 exercise, and 24 MRP). The MRP arm lost 13 kg in weight and had improved blood pressure, glycemia, LV mass/volume, and aortic stiffness. The exercise arm had negligible weight loss but increased exercise capacity. PEDSR increased in the exercise arm versus routine care (β = 0.132, P = 0.002) but did not improve with the MRP (β = 0.016, P = 0.731).
In asymptomatic working-age adults with T2D, exercise training improved diastolic function. Despite beneficial effects of weight loss on glycemic control, concentric LV remodeling, and aortic stiffness, a low-energy MRP did not improve diastolic function.
The association between high glycemic variability and all-cause mortality has been widely investigated in epidemiological studies but rarely validated in glucose-lowering clinical trials. We aimed to identify the prognostic significance of visit-to-visit HbA1c variability in treated patients in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial population.
We studied the risk of all-cause mortality in relation to long-term visit-to-visit HbA1c variability, expressed as coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV), from the 8th month to the transition. Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratio (HR) and 95% CI.
Compared with the standard therapy group (n = 4,728), the intensive therapy group (n = 4,755) had significantly lower mean HbA1c (6.6% [49 mmol/mol] vs. 7.7% [61 mmol/mol], P < 0.0001) and lower CV, VIM, and ARV (P < 0.0001). In multivariate adjusted analysis, all three HbA1c variability indices were significantly associated with total mortality in all patients as well as in the standard- and intensive-therapy groups analyzed separately. The hazard ratios for a 1-SD increase in HbA1c variability indices for the all-cause mortality were 1.19 and 1.23 in intensive and standard therapy, respectively. Cross-tabulation analysis showed the third tertile of HbA1c mean and VIM had significantly higher all-cause mortality (HR 2.05; 95% CI, 1.17–3.61; P < 0.01) only in the intensive-therapy group.
Long-term visit-to-visit HbA1c variability was a strong predictor of all-cause mortality. HbA1c VIM combined with HbA1c mean conferred an increased risk for all-cause mortality in the intensive-therapy group.
In 2017, the American Academy of Pediatrics introduced a new guideline (2017 Clinical Practice Guideline of the American Academy of Pediatrics [AAP 2017]) to diagnose arterial hypertension (HTN) in children that included revised, lower normative blood pressure (BP) values and cut points for diagnosing high BP in adolescents. We studied the impact of the new AAP 2017 guideline on prevalence of HTN in children with type 1 diabetes mellitus (T1DM).
Up to September 2018, 1.4 million office BP measurements in 79,849 children and adolescents (aged 5–20 years) with T1DM have been documented in the DPV (Diabetes Prospective Follow-up) registry. BP values of the most recent year were aggregated, and BP values of 74,677 patients without antihypertensive medication were analyzed (median age 16 years and diabetes duration 5.3 years and 52.8% boys). BP values were classified according to AAP 2017 and the references of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) (2011) and the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (fourth report) (2004).
Of the patients, 44.1%, 29.5%, and 26.5% were hypertensive according to AAP 2017, KiGGS, and fourth report, respectively. Differences in prevalence of HTN were strongly age dependent: <10 years, AAP 2017 31.4%, KiGGS 30.7%, fourth report 19.6%; 10 to <15 years, AAP 2017 30.9%, KiGGS 31.2%, fourth report 22.4%; and ≥15 years, AAP 2017 53.2%, KiGGS 28.4%, fourth report 30.0%. Among teenagers ≥15 years, 59.1% of boys but only 46.3% of girls were classified as hypertensive by AAP 2017 but only 21.1%/26% of boys and 36.7%/34.4% of girls by KiGGS/fourth report, respectively.
Classification of BP as hypertension depends strongly on the normative data used. Use of AAP 2017 results in a significant increase in HTN in teenagers ≥15 years with T1DM, particularly in boys. AAP 2017 enhances the awareness of elevated BP in children, particularly in patients with increased risk for cardiovascular disease.
The vast number of antihyperglycemic medications and growing amount of evidence make clinical decision making difficult. The aim of this study was to investigate the safety of antihyperglycemic dual and triple therapies for type 2 diabetes management with respect to major adverse cardiovascular events, severe hypoglycemia, and all-cause mortality in a real-life clinical setting.
Cox regression models were constructed to analyze 20 years of data from the Danish National Patient Registry with respect to effect of the antihyperglycemic therapies on the three end points.
A total of 66,807 people with type 2 diabetes were treated with metformin (MET) including a combination of second- and third-line therapies. People on MET plus sulfonylurea (SU) had the highest risk of all end points, except for severe hypoglycemia, for which people on MET plus basal insulin (BASAL) had a higher risk. The lowest risk of major adverse cardiovascular events was seen for people on a regimen including a glucagon-like peptide 1 (GLP-1) receptor agonist. People treated with MET, GLP-1, and BASAL had a lower risk of all three end points than people treated with MET and BASAL, especially for severe hypoglycemia. The lowest risk of all three end points was, in general, seen for people treated with MET, sodium–glucose cotransporter 2 inhibitor, and GLP-1.
Findings from this study do not support SU as the second-line treatment choice for patients with type 2 diabetes. Moreover, the results indicate that adding a GLP-1 for people treated with MET and BASAL could be considered, especially if those people suffer from severe hypoglycemia.
Although blood pressure variability is increasingly appreciated as a risk factor for cardiovascular disease, its relationship with heart failure (HF) is less clear. We examined the relationship between blood pressure variability and risk of HF in two cohorts of type 2 diabetes participating in trials of glucose and/or other risk factor management.
Data were drawn from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial and the Veterans Affairs Diabetes Trial (VADT). Coefficient of variation (CV) and average real variability (ARV) were calculated for systolic (SBP) and diastolic blood pressure (DBP) along with maximum and cumulative mean SBP and DBP during both trials.
In ACCORD, CV and ARV of SBP and DBP were associated with increased risk of HF, even after adjusting for other risk factors and mean blood pressure (e.g., CV-SBP: hazard ratio [HR] 1.15, P = 0.01; CV-DBP: HR 1.18, P = 0.003). In the VADT, DBP variability was associated with increased risk of HF (ARV-DBP: HR 1.16, P = 0.001; CV-DBP: HR 1.09, P = 0.04). Further, in ACCORD, those with progressively lower baseline blood pressure demonstrated a stepwise increase in risk of HF with higher CV-SBP, ARV-SBP, and CV-DBP. Effects of blood pressure variability were related to dips, not elevations, in blood pressure.
Blood pressure variability is associated with HF risk in individuals with type 2 diabetes, possibly a consequence of periods of ischemia during diastole. These results may have implications for optimizing blood pressure treatment strategies in those with type 2 diabetes.
A recent publication questioned the integrity of insulin purchased from U.S. retail pharmacies. We sought to independently validate the method used, isotope dilution solid-phase extraction (SPE) liquid chromatography mass spectrometry (LC-MS), and expand analysis to two U.S. Pharmacopeia (USP) methods (high-performance LC with ultraviolet detection and LC-MS).
Each method was used to evaluate nine insulin formulations, purchased at four pharmacies, within five geographic locations in the U.S.
All human and analog insulins measured by the USP methods (n = 174) contained the expected quantity of active insulin (100 ± 5 units/mL). When using isotope dilution SPE-LC-MS, units-per-milliliter values were well below product labeling due to unequal recovery of the internal standard compared with target insulin.
Insulin purchased from U.S. pharmacies is consistent with product labeling.
The objective of this study was to examine whether altered heart rate variability (HRV) could predict the risk of diabetes in Asians.
A cohort study was conducted in 54,075 adults without diabetes who underwent 3-min HRV measurement during health checkups between 2011 and 2014 at Kangbuk Samsung Hospital. We analyzed the time domain (SD of the normal-to-normal interval [SDNN] and root mean square differences of successive normal-to-normal interval [RMSSD]) and the frequency domain (total power, normalized low-frequency power [LF], and normalized high-frequency power [HF] and LF/HF ratio). We compared the risk of diabetes until 2017 according to tertiles of heart rate and HRV variables, with tertile 1 serving as the reference group.
During 243,758.2 person-years, 1,369 subjects were diagnosed with diabetes. Both time and frequency domain variables were lower in the group with diabetes, with the exception of those with normalized LF and LF/HF ratio. In Cox analysis, as SDNN, RMSSD, and normalized HF tertiles increased, the risk of diabetes decreased (hazard ratios [95% CIs] of tertile 3: 0.81 [0.70–0.95], 0.76 [0.65–0.90], and 0.78 [0.67–0.91], respectively), whereas the risk of diabetes increased in the case of heart rate, normalized LF, and LF/HF ratio (hazard ratios [95% CIs] of tertile 3: 1.41 [1.21–1.65], 1.32 [1.13–1.53], and 1.31 [1.13–1.53), respectively) after adjusting for age, sex, BMI, smoking, drinking, systolic blood pressure, lipid level, CRP, and HOMA of insulin resistance.
Abnormal HRV, especially decreased vagal activity and deviation in sympathovagal imbalance to sympathetic activity, might precede incident diabetes.
To determine the risk of cardiovascular disease (CVD), microvascular complications, and mortality in patients with type 2 diabetes who subsequently develop obstructive sleep apnea (OSA) compared with patients with type 2 diabetes without a diagnosis of OSA.
This age-, sex-, BMI-, and diabetes duration–matched cohort study used data from a U.K. primary care database from 1 January 2005 to 17 January 2018. Participants aged ≥16 years with type 2 diabetes were included. Exposed participants were those who developed OSA after their diabetes diagnosis; unexposed participants were those without diagnosed OSA. Outcomes were composite CVD (ischemic heart disease [IHD], stroke/transient ischemic attack [TIA], heart failure [HF]), peripheral vascular disease (PVD), atrial fibrillation (AF), peripheral neuropathy (PN), diabetes-related foot disease (DFD), referable retinopathy, chronic kidney disease (CKD), and all-cause mortality. The same outcomes were explored in patients with preexisting OSA before a diagnosis of type 2 diabetes versus diabetes without diagnosed OSA.
A total of 3,667 exposed participants and 10,450 matched control participants were included. Adjusted hazard ratios for the outcomes were as follows: composite CVD 1.54 (95% CI 1.32, 1.79), IHD 1.55 (1.26, 1.90), HF 1.67 (1.35, 2.06), stroke/TIA 1.57 (1.27, 1.94), PVD 1.10 (0.91, 1.32), AF 1.53 (1.28, 1.83), PN 1.32 (1.14, 1.51), DFD 1.42 (1.16, 1.74), referable retinopathy 0.99 (0.82, 1.21), CKD (stage 3–5) 1.18 (1.02, 1.36), albuminuria 1.11 (1.01, 1.22), and all-cause mortality 1.24 (1.10, 1.40). In the prevalent OSA cohort, the results were similar, but some associations were not observed.
Patients with type 2 diabetes who develop OSA are at increased risk of CVD, AF, PN, DFD, CKD, and all-cause mortality compared with patients without diagnosed OSA. Patients with type 2 diabetes who develop OSA are a high-risk population, and strategies to detect OSA and prevent cardiovascular and microvascular complications should be implemented.
This study evaluated the ability of the Building, Relating, Assessing, and Validating Outcomes (BRAVO) risk engine to accurately project cardiovascular outcomes in three major clinical trials—BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), Canagliflozin Cardiovascular Assessment Study (CANVAS), and Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction (DECLARE-TIMI 58) trial—on sodium–glucose cotransporter 2 inhibitors (SGLT2is) to treat patients with type 2 diabetes.
Baseline data from the publications of the three trials were obtained and entered into the BRAVO model to predict cardiovascular outcomes. Projected benefits of reducing risk factors of interest (A1C, systolic blood pressure [SBP], LDL, or BMI) on cardiovascular events were evaluated, and simulated outcomes were compared with those observed in each trial.
BRAVO achieved the best prediction accuracy when simulating outcomes of the CANVAS and DECLARE-TIMI 58 trials. For the EMPA-REG OUTCOME trial, a mild bias was observed (~20%) in the prediction of mortality and angina. The effect of risk reduction on outcomes in treatment versus placebo groups predicted by the BRAVO model strongly correlated with the observed effect of risk reduction on the trial outcomes as published. Finally, the BRAVO engine revealed that most of the clinical benefits associated with SGLT2i treatment are through A1C control, although reductions in SBP and BMI explain a proportion of the observed decline in cardiovascular events.
The BRAVO risk engine was effective in predicting the benefits of SGLT2is on cardiovascular health through improvements in commonly measured risk factors, including A1C, SBP, and BMI. Since these benefits are individually small, the use of the complex, dynamic BRAVO model is ideal to explain the cardiovascular outcome trial results.
In patients with type 2 diabetes (T2D) and critical limb ischemia (CLI), migration of circulating CD34+ cells predicted cardiovascular mortality at 18 months after revascularization. This study aimed to provide long-term validation and mechanistic understanding of the biomarker.
The association between CD34+ cell migration and cardiovascular mortality was reassessed at 6 years after revascularization. In a new series of T2D-CLI and control subjects, immuno-sorted bone marrow CD34+ cells were profiled for miRNA expression and assessed for apoptosis and angiogenesis activity. The differentially regulated miRNA-21 and its proapoptotic target, PDCD4, were titrated to verify their contribution in transferring damaging signals from CD34+ cells to endothelial cells.
Multivariable regression analysis confirmed that CD34+ cell migration forecasts long-term cardiovascular mortality. CD34+ cells from T2D-CLI patients were more apoptotic and less proangiogenic than control subjects and featured miRNA-21 downregulation, modulation of several long noncoding RNAs acting as miRNA-21 sponges, and upregulation of the miRNA-21 proapoptotic target PDCD4. Silencing miR-21 in control subject CD34+ cells phenocopied the T2D-CLI cell behavior. In coculture, T2D-CLI CD34+ cells imprinted naïve endothelial cells, increasing apoptosis, reducing network formation, and modulating the TUG1 sponge/miRNA-21/PDCD4 axis. Silencing PDCD4 or scavenging reactive oxygen species protected endothelial cells from the negative influence of T2D-CLI CD34+ cells.
Migration of CD34+ cells predicts long-term cardiovascular mortality in T2D-CLI patients. An altered paracrine signaling conveys antiangiogenic and proapoptotic features from CD34+ cells to the endothelium. This damaging interaction may increase the risk for life-threatening complications.
To examine whether low baseline diastolic blood pressure (DBP) modifies the effects of intensive systolic blood pressure (SBP) lowering on cardiovascular outcomes in type 2 diabetes mellitus (T2DM).
The Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP), a two-by-two factorial randomized controlled trial, examined effects of SBP (<120 vs. <140 mmHg) and glycemic (HbA1c <6% vs. 7.0–7.9% [<42 vs. 53–63 mmol/mol]) control on cardiovascular events in T2DM (N = 4,731). We examined whether effects of SBP control on cardiovascular composite were modified by baseline DBP and glycemic control.
Intensive SBP lowering decreased the risk of the cardiovascular composite (hazard ratio [HR] 0.76 [95% CI 0.59–0.98]) in the standard glycemic arm but not in the intensive glycemic arm (HR 1.06 [95% CI 0.81–1.40]). Spline regression models relating the effects of the intervention on the cardiovascular composite across the range of baseline DBP did not show evidence of effect modification by low baseline DBP for the cardiovascular composite in the standard or intensive glycemic arms. The relation between the effect of the intensive SBP intervention and baseline DBP was similar between glycemic arms for the cardiovascular composite three-way interaction (P = 0.83).
In persons with T2DM, intensive SBP lowering decreased the risk of cardiovascular composite end point irrespective of baseline DBP in the setting of standard glycemic control. Hence, low baseline DBP should not be an impediment to intensive SBP lowering in patients with T2DM treated with guidelines recommending standard glycemic control.
The LEADER trial (ClinicalTrials.gov reg. no.
We performed exploratory analyses to identify potential mediators of the effect of liraglutide on major adverse CV events (MACE; composite of CV death, nonfatal myocardial infarction, or nonfatal stroke) from the following candidates: glycated hemoglobin (HbA1c), body weight, urinary albumin-to-creatinine ratio (UACR), confirmed hypoglycemia, sulfonylurea use, insulin use, systolic blood pressure, and LDL cholesterol. These candidates were selected as CV risk factors on which liraglutide had an effect in LEADER such that a reduction in CV risk might result. We used two methods based on a Cox proportional hazards model and the new Vansteelandt method designed to use all available information from the mediator and to control for confounding factors.
Analyses using the Cox methods and Vansteelandt method indicated potential mediation by HbA1c (up to 41% and 83% mediation, respectively) and UACR (up to 29% and 33% mediation, respectively) on the effect of liraglutide on MACE. Mediation effects were small for other candidates.
These analyses identify HbA1c and, to a lesser extent, UACR as potential mediators of the CV effects of liraglutide. Whether either is a marker of an unmeasured factor or a true mediator remains a key question that invites further investigation.
Despite evidence of a relationship among obstructive sleep apnea (OSA), metabolic dysregulation, and diabetes, it is uncertain whether OSA treatment can improve metabolic parameters. We sought to determine effects of long-term continuous positive airway pressure (CPAP) treatment on glycemic control and diabetes risk in patients with cardiovascular disease (CVD) and OSA.
Blood, medical history, and personal data were collected in a substudy of 888 participants in the Sleep Apnea Cardiovascular End Points (SAVE) trial in which patients with OSA and stable CVD were randomized to receive CPAP plus usual care, or usual care alone. Serum glucose and glycated hemoglobin A1c (HbA1c) were measured at baseline, 6 months, and 2 and 4 years and incident diabetes diagnoses recorded.
Median follow-up was 4.3 years. In those with preexisting diabetes (n = 274), there was no significant difference between the CPAP and usual care groups in serum glucose, HbA1c, or antidiabetic medications during follow-up. There were also no significant between-group differences in participants with prediabetes (n = 452) or in new diagnoses of diabetes. Interaction testing suggested that women with diabetes did poorly in the usual care group, while their counterparts on CPAP therapy remained stable.
Among patients with established CVD and OSA, we found no evidence that CPAP therapy over several years affects glycemic control in those with diabetes or prediabetes or diabetes risk over standard-of-care treatment. The potential differential effect according to sex deserves further investigation.
Classroom observations occur to document behaviors and to help provide insight to teachers. Teachers are teaching and are typically focused on the overall learning of the entire class. It is not possible for a teacher to catch all of the details of classroom while teaching. An outside observer, often a School Psychologist, can sit in the classroom and observe a student or the entire class. These insights can be used to help provide better instruction, create behavioral or academic interventions, or to document behaviors.
When do classroom observations occur?
- During a special education evaluation The classroom observation is a required component in a special education evaluation. It provides data and insight to the eligibility committee.
- Before a Behavior Intervention Plan or Functional Behavioral Assessment Classroom observations are important before implementing a Functional Behavioral Assessment or a Behavior Intervention Plan. It helps to clarify the current behaviors, identify possible triggers of the behavior, and determine the frequency of the behaviors.
- When a teacher is worried about a particular student Often a teacher will have a concern about a student and ask the School Psychologist to conduct an observation. After the observation the teacher and psychologist will meet to discuss and brainstorm strategies to assist in instruction.
I spend most days of my life working with various students who are at different parts in the sped referral process. I attend Child Study Meetings where we decide if we are going to evaluate a student. I observe and screen children and talk with parents and teachers to help the committee make a good decision about whether we should do a special education evaluation. I evaluate those students (this includes Psychological testing, observations, talking with student/teacher/parent, doing rating scales, etc.). I attend eligibility meetings where we determine if the student is eligible for for special education services. All of this is second nature to me and sometimes I need to stop and remember when a parent comes in, that this is NEW.
When I talk to parents, I find that many parents do not fully understand the special education referral process, even when they nod and act like they do. We as school staff need to do a better job of helping the parents understand the process. Parents also need to speak up and ask questions when there is not understanding.
This is a guide for parents to understand the process of special education testing, the testing components, and some of the test data. It is important to note that schools systems and states will vary to some degree. If you have any questions about the process in your school system, ask your school psychologist, teacher, or principal. Parents have every right to ask questions and usually school personnel are happy to help make this process less anxiety-provoking for you. It is important for parents to understand their rights during the special education process.
Special Education Process
After data shows that interventions have been attempted and if a student is suspected of having a disability, a referral is made to evaluate him or her for special education testing. Once the parents sign the Permission for Testing Forms, timelines begin and the schools have 65 business days to complete the assessments and hold the eligibility meeting. Some states may have a different timeline.
During these 65 days, several testing components will be completed with you and your child. The evaluators will write reports and a copy will be given to parents at the eligibility meeting. However, schools are required to have a copy available for parents to pick up two days before the eligibility meeting. It is advised, that parents take advantage of this and read reports before the meeting to help get familiar with the information and to formulate questions. The reports hold a lot of information that can be overwhelming if you are not familiar with this type of testing. Read Understanding Test Scores to understand the types of tests used and what the scores mean.
Additionally, the meeting is likely to bring forth strong emotions as your child’s difficulties are discussed openly. It can be overwhelming for parents, especially when not prepared. When parents do not read the reports prior to the eligibility meeting, they are the only people at the table who come to the meeting not knowing what to expect.
What if My Child is Found ELIGIBLE for Special Education Services?
Once a child is eligible for special education services, the schools have 30 days to develop an Individualized Education Plan (IEP) for the student. This will consist of accommodations, goals, and describe the services offered. Parents are part of a committee to help create this document. Once it is signed, schools are legally required to follow it. It is reviewed once a year, unless parents or teachers feel that changes are necessary. Every three years, the committee will determine if the student should be reevaluated. This is called a triennial evaluation. Sometimes another full evaluation will be conducted, other times a review of records and updated teacher information is used.
What if My Child is Found INELIGIBLE for Special Education Services?
If your child was found ineligible for special education services and you agree with the eligibility findings, then your child will not receive special education. He or she was evaluated because of a problem that still needs to be addressed within regular education. Ask for a separate meeting with your teacher or a team to determine what accommodations or strategies can be used to help.
If you believe that your child requires special education services and has a disability, but was found ineligible for services, make an appointment to meet with the special education director. If an agreement cannot be reached, you may be able to have an Independent Evaluation at the expense of the school. The results of that testing will be brought back to an eligibility meeting. A child MUST have 2 things before they can receive special education services: They must have a disability and there must be a documented educational impact that the student requires special education services to be successful.
California, Iowa, Pennsylvania and Rhode Island are among states that are loosening coronavirus restrictions Friday to gradually revive their economies.
The warty comb jelly is native to the western Atlantic, but in recent decades, it has invaded the waters of Eurasia. New research suggests cannibalism is key to the species' ability to move into new environs.
Televangelist Jim Bakker is recovering at his North Carolina home after having a stroke, his wife said Friday.
Director Rachel Lee Goldenberg discusses how her "Valley Girl" musical remake puts a twist on the hit music of the '80s.
Netflix shared a premiere date and teaser trailer for its "Baby-Sitters Club" series, based on the Ann M. Martin book series.
The Trump administration’s plan to create a "merit-based" U.S. immigration system, lessening the longstanding focus on family reunification in favor of more economic migrants, has met with a lackluster response from Democrats and Republicans alike. This Policy Beat article explores how the Trump proposal would reshape immigration to the United States, and how it compares to selection systems in other countries and past debates about changing the U.S. system.
I am torn, I know it is time to upgrade my phone, but I don't know whether to upgrade to just accept the larger phone size and go with the 2nd gen SE or go with an android. I'd be interested to know what the closest equivalent android device there is to the 1st gen SE. I am open to a bigger screen size, but not a bigger phone. So, if there was an andriod that was all screen on the front, but was similar size to the original SE, I would be open to that.
The state leads the nation in poverty and homelessness while it's socialist elites live in absolute luxury. It's like some third world nation the US is obligated to invade on the basis of humanitarianism.
Over the past decade, state and local policymakers have increasingly stepped into the void left by Washington over legislative reform of the immigration system and have enacted their own policies, particularly in regard to illegal immigration. This article explores this trend of increased activism and examines whether restrictive state immigration laws have had an effect on the size of immigrant populations at the state level.
Wall or no wall, deeply intertwined social, economic, business, cultural, and personal relationships mean the U.S.-Mexico border is more like a seam than a barrier, weaving together two economies and cultures, as MPI President Andrew Selee sketches in this book, which draws from his travels and discussions with people from all walks of life in Mexico and the United States.
Since regaining its independence in 1989, the Czech Republic has transformed from a country of emigration to one of rising immigration, amid growing labor market needs. Even as Czechia received few asylum seekers during the 2015-16 European migration crisis, the country has taken a harder line on immigration, and public opinion and political stances have grown more negative towards immigrants and refugees.
If you happen to stop by a Victoria's Secret store this Wednesday evening, on the eve of Valentine's Day, you will learn something fascinating about human nature that will tell you a lot about people and relationships.
One hundred forty-three years ago, women's suffrage advocate Elizabeth Cady Stanton faced a conundrum: With the Civil War over, Stanton had to decide whether to support the 14th and 15th amendments to the Constitution, which enabled black men to vote -- at a time when white women such as herself...
Across Europe, grassroots efforts have emerged in the wake of crisis that draw members of the public into the process of receiving refugees and supporting their integration. This policy brief examines the many forms community-based or private sponsorship can take, what benefits such approaches may hold for European communities, and the tradeoffs policymakers face in their implementation.
European policymakers are fixated on reform of the Dublin Regulation, the contentious rules that carve up responsibility for asylum claims between EU states. They see it not only as a long-term prophylactic against future fluctuations in irregular migration, but as a marker of the success or failure of solidarity in Europe overall. Yet rather than doggedly working to salvage Dublin, policymakers need to stop and consider why they regard it as so integral to European cooperation, as this commentary explores.
Fostering the social and economic inclusion of refugees has long been the domain of governments and NGOs. In the wake of the 2015–16 European migration and refugee crisis, however, new actors have emerged and taken on important roles in integrating newcomers. This report describes key discussions and takeaways from an MPI Europe conference on these developments.
WASHINGTON — Asylum seekers and refugees who arrived in Germany in the leadup to and during the 2015-16 European migration crisis have integrated into the labor market at a slightly faster rate than previous refugee cohorts, a Migration Policy Institute (MPI) report finds.
Brussels and Gütersloh, 05.03.2020 — Anticipated reform of the Common European Asylum System (CEAS), which was high on the agenda as nearly 2 million asylum seekers arrived at Europe’s door in 2015-16, quickly fell victim to EU Member State competing views on what constitutes equal burden-sharing, domestic politics around migration and the urgency of first addressing overtaxed national asylum systems.
I love Christmas my all time favourite time of year. It's also a great time for awesome summer sweet produce. Muscovado brown sugar is a treacle like flavour and makes a welcome texture to a traditional pavlova.
This recipe features on Foodie Tuesday, a weekly segment with Raf Epstein on Drive , 774, 3.30pm, courtesy of Alice Zaslavsky.
I love a carrot cake . Usually walnuts are used however who doesn't want to take advantage of the local new season pecans at our local markets . Happy baking!
This recipe features on Foodie Tuesday, a weekly segment on 774 Drive with Raf Epstein, 3.30PM, shared by the Dinner Ladies (Katherine Westwood & Sophie Gilliatt)
Nothing like a Pavlova and fresh seasonal fruit. The coconut ice cream provides a refreshing finish.
Exotic, different, really cool flavours, pared-back dessert and it's not too sweet. Enjoy!
Cassava leaves and Ugali - a traditional Congolese dish ... and much, much more. Gigi Mapatano
Over the last decade, a number of governments have launched start-up visa programs in the hopes of attracting talented immigrant entrepreneurs with innovative business ideas. With the track record for these programs a mixed one, this report explains how embedding start-up visas within a broader innovation strategy could lead to greater success.