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Florida oral surgeon stays atop branding as practice expands

There is an art to conveying just who you are at every stage of your dental practice. One minute you could be a single-dentist practice with a hygienist and a receptionist, and then, the next thing you know, you could have a group practice and maybe even several locations.




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Former executive director of FDI World Dental Federation dies

Dr. Per Äke Zillen, executive director of the FDI World Dental Federation from 1989-2001, died Jan. 19 following a battle with cancer.




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New dentists, ADA officers and Board members meet Feb. 9 to exchange ideas

Dr. Emily Mattingly, chair, New Dentist Committee, 6th District, shares her experience as a new dentist in a rural Missouri town. Three other NDC members also shared new dentist perspectives.




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American Institute of Dental Public Health mentors next generation of service-oriented dentists

Dr. David P. Cappelli, Ph.D., acknowledges that as providers, we don’t often understand difficulties that some patients face to receive needed dental care.




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Narwhal exhibit to start U.S. tour March 28

Dr. Martin Nweeia began researching narwhals in 2000. He came to the conclusion that the prevailing research available about the narwhal’s tooth — such as Charles Darwin’s belief that the narwhal’s tooth was a secondary sexual characteristic like an antler or a horn — was only part of the story.




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New ADA resource supports expectant dentists

The ADA’s Council on Dental Practice, in collaboration with the New Dentist Committee and several external dental consultants, has developed the new Guidelines for Practice Success module on Managing Pregnancy, a resource that combines best practices with practical information to guide new dentists through the process of managing a new chapter in the lives and careers.




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Treasury, IRS delay federal tax filing, payments until July 15

Taxpayers do not need to file or pay their federal income taxes until July 15, after the U.S. Department of the Treasury and Internal Revenue Service extended both deadlines from April 15.




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April JADA compares zirconia-ceramic fixed dental prostheses with metal-ceramic

Posterior multiunit zirconia-ceramic restorations are slightly more susceptible to chipping of the veneering ceramic than metal-ceramic restorations, but they are considered a reliable treatment in the medium term, according to a systematic review and meta-analysis published in the April issue of The Journal of the American Dental Association.




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EPA releases expanded list of SARS-CoV-2 disinfectants

Washington — The Environmental Protection Agency announced March 13 that it was adding nearly 200 additional products that have qualified for use against SARS-CoV-2, the novel coronavirus that causes the disease COVID-19.




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HPI poll examines impact of COVID-19 on dental practices

The ADA Health Policy Institute launched an ongoing biweekly poll the week of March 23 that shows 76% of dentists surveyed had closed their offices to all but emergency patients during the COVID-19 pandemic. Another 19% indicated their offices are closed completely.




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Labor Department says employers with fewer than 50 employees may be exempt from new law

Employers with fewer than 50 employees, including dental practices, may be exempt from a provision in the Families First Coronavirus Response Act that requires them to provide emergency paid sick leave and expanded medical leave to employees in certain COVID-19 circumstances, the Department of Labor said April 1.




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New clinical dental licensure examination to launch in June

The Dental Licensure Objective Structured Clinical Examination, or DLOSCE, is expected to launch in June, the Joint Commission on National Dental Examinations announced April 2.




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ADA free webinar exploring radiographs, diagnostic imaging

In a time when teledentistry is gaining more attention during the COVID-19 pandemic, the ADA will stream a free webinar in May that takes a close look at the different types of images needed for diagnosis, treatment planning and operative procedures.




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ADA asks Congress to increase funding, extend dates for Small Business Administration loans

The ADA is urging Congress to continue supporting small businesses during the COVID-19 pandemic by increasing funding and streamlining the application process for Small Business Administration loans.




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Homeland Security issues alert on cybercriminals increasingly exploiting COVID-19 pandemic

The U.S. Department of Homeland Security issued an alert April 8 warning that cybercriminals are increasingly exploiting the COVID-19 pandemic to target individuals, small and medium businesses and large organizations.




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Index shows that dentists slowly but surely embracing electronic means of doing business

Despite the ADA Council on Dental Benefits’ efforts, the practice of using automated electronic means for verifying eligibility and benefits, checking claim status or receiving and reconciling payment remains underutilized by many dental providers according to an index, said Dr. Randall Markarian, council chair.




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Senate votes to expand small business aid

The Senate passed new coronavirus relief legislation April 21 calling for much-needed funding for depleted federal loan programs that could help businesses nationwide, including dentists and dental practices, recover from the economic fallout of the pandemic.




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May JADA discusses calcium hydroxide overfill risk during root canals

Overfill of medication or obturation materials in endodontic treatment can cause permanent neurologic injury, and there are steps clinicians can take to help prevent that, according to an article published in the May issue of The Journal of the American Dental Association.




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Agencies submit final rule extending ERISA deadlines during pandemic

The U.S. Department of Labor said April 28 that it is extending the Employee Retirement Income Security Act of 1974 filing deadlines for certain notice and disclosure requirements in the wake of the COVID-19 pandemic.




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ADA asks Congress to help dental community in next COVID-19 legislation

As Congress works on the next COVID-19 relief package, the ADA is asking lawmakers to include a number of provisions to assist the dental profession in recovery efforts.




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Organized dentistry asks Congress for flexibility in Paycheck Protection Program loans

The Organized Dentistry Coalition is asking Congress for flexibility in the Paycheck Protection Program to allow dentists to purchase personal protective equipment as states begin the reopening phase of the COVID-19 pandemic.




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Petrobras preempts three pre-salt areas ahead of sixth auction

Petrobras wants to exercise pre-emption rights for three areas ahead of the sixth bidding round of pre-salt offshore oil areas to be held later this year.




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Crude oil prices drop after API reported lower-than-expected draw

Oil prices fell early Wednesday, likely a result of lower-than-expected draws in an API with traders awaiting official EIA inventory data later in the day.




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EIA sees fuel prices below 2018 average for the next two years

U.S. retail fuel prices will drop this year and in 2020 from 2018, but in both cases higher than January levels due to mandated lower sulfur in marine fuel.




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Major corporations, cities buying into Texas' green energy boom

The U.S. wind industry is in a scramble to get a batch of turbine farms running in the next two years, before the federal government phases out a key tax credit.




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Petrobras sells Chevron $350M Texas plant bought for $1.2B

Chevron bought a Houston refinery for $350 million from Petrobras that had cost the Brazilian state oil company over $1.2 billion little over a decade earlier.




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Cancer patients on Medicaid might not benefit from experimental treatments, study finds

Cancer patients on Medicaid or who don't have insurance benefit less from experimental treatments, even if they get into clinical trials, a study published Thursday by JAMA Network Open has found.




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Patient portals need proxy options for better privacy protection, study finds

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.




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CDC: 40% of U.S. teens are sexually active

The CDC estimates that 40 percent of U.S. teens are sexually active -- 42 percent of females and 38 percent of males 15 and 19 years of age -- numbers that have dropped significantly since 1988.




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Poverty, poorer health make some in the Bronx more vulnerable to COVID-19

New York City has been the epicenter of the COVID-19 outbreak in the United States, with immigrant populations in areas such as the Bronx "disproportionately" affected, a commentary in JAMA Internal Medicine says.




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Exploring the Potential of Two-Generation Strategies in Refugee Integration

On this webinar, MPI researchers and Utah and Colorado refugee coordinators explore promising practices to better serve refugee families, including education services for refugee youth, innovative efforts to secure better jobs for adult refugees, and other services designed to aid integration over time. They also discuss the potential for implementing and supporting two-generation approaches to refugee integration at a time when the system’s funding and capacity are in peril.  




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Sustainable Reintegration: Strategies to Support Migrants Returning to Mexico and Central America

Reception and reintegration programs for deported and other returning migrants represent a long-term investment for migrant-origin and destination countries, holding the potential to reduce re-migration and permit communities of origin to benefit from the skills migrants learn abroad. This report offers recommendations to make reintegration programs more effective in Mexico and Central America.




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Exploring New Legal Migration Pathways: Lessons from Pilot Projects

As European countries launch ambitious new legal migration partnerships with several origin and transit countries in Africa, this report takes stock of the long and mixed history of such projects. To make the most of their potential to encourage skills development and fill pressing labor gaps, policymakers will need to think carefully about the partners and sectors they choose, among other key considerations.




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Trends in Uninsured Rates Before and After Medicaid Expansion in Counties Within and Outside of the Diabetes Belt

OBJECTIVE

To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged <65 years and to determine whether the Patient Protection and Affordable Care Act (ACA), which expanded Medicaid, impacted insurance coverage in the Diabetes Belt, a region across 15 southern and eastern states in which residents have high rates of diabetes.

RESEARCH DESIGN AND METHODS

Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50–64 years, the percentage of women, Distressed Communities Index value, and rurality.

RESULTS

In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states.

CONCLUSIONS

ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt.




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Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits

OBJECTIVE

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.

RESEARCH DESIGN AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.




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Reduced Myocardial Perfusion Reserve in Type 2 Diabetes Is Caused by Increased Perfusion at Rest and Decreased Maximal Perfusion During Stress

OBJECTIVE

To examine differences in myocardial blood flow (MBF) at rest and during stress between patients with type 2 diabetes and controls, and to identify potential predictors of changes in MBF at rest and during stress.

RESEARCH DESIGN AND METHODS

A cross-sectional study of 193 patients with type 2 diabetes and 20 age- and sex-matched controls. Cardiovascular magnetic resonance was used in order to evaluate left ventricular structure and function, and MBF at rest and during adenosine-induced stress. MBF was derived as the mean of the flow within all segments of a midventricular slice.

RESULTS

Patients with type 2 diabetes had higher global MBF at rest (0.81 ± 0.19 mL/min/g) and lower global MBF during stress (2.4 ± 0.9 mL/min/g) than did controls (0.61 ± 0.11 at rest, 3.2 ± 0.8 mL/min/g under stress; both P < 0.01). Patients with macroalbuminuria had lower MBF during stress (1.6 ± 0.5 mL/min/g) than did patients with microalbuminuria (2.1 ± 0.7 mL/min/g; P = 0.04), who in turn had lower MBF during stress than did normoalbuminuric patients (2.7 ± 0.9 mL/min/g; P < 0.01). Patients with severe retinopathy had lower MBF during stress (1.8 ± 0.6 mL/min/g) than did patients with simplex retinopathy (2.3 ± 0.7 mL/min/g; P < 0.05) and those who did not have retinopathy (2.6 ± 1.0 mL/min/g; P < 0.05). Albuminuria and retinopathy were associated with reduced MBF during stress in a multiple regression analysis. Stress-related MBF inversely correlated with myocardial extracellular volume (P < 0.001; R2 = 0.37), a measure of diffuse myocardial fibrosis. A trend toward lower basal MBF was observed in patients treated with sodium–glucose cotransporter 2 inhibitors (P = 0.07).

CONCLUSIONS

Patients with type 2 diabetes have higher global MBF at rest and lower maximal MBF during vasodilator-induced stress than do controls. Reduced MBF during stress is associated with diabetes complications (albuminuria and retinopathy) and is inversely correlated with diffuse myocardial fibrosis.




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Combination Therapy With Canagliflozin Plus Liraglutide Exerts Additive Effect on Weight Loss, but Not on HbA1c, in Patients With Type 2 Diabetes

OBJECTIVE

To examine the effect of combination therapy with canagliflozin plus liraglutide on HbA1c, endogenous glucose production (EGP), and body weight versus each therapy alone.

RESEARCH DESIGN AND METHODS

Forty-five patients with poorly controlled (HbA1c 7–11%) type 2 diabetes mellitus (T2DM) on metformin with or without sulfonylurea received a 9-h measurement of EGP with [3-3H]glucose infusion, after which they were randomized to receive 1) liraglutide 1.2 mg/day (LIRA); 2) canagliflozin 100 mg/day (CANA); or 3) liraglutide 1.2 mg plus canagliflozin 100 mg (CANA/LIRA) for 16 weeks. At 16 weeks, the EGP measurement was repeated.

RESULTS

The mean decrease from baseline to 16 weeks in HbA1c was –1.67 ± 0.29% (P = 0.0001), –0.89 ± 0.24% (P = 0.002), and –1.44 ± 0.39% (P = 0.004) in patients receiving CANA/LIRA, CANA, and LIRA, respectively. The decrease in body weight was –6.0 ± 0.8 kg (P < 0.0001), –3.5 ± 0.5 kg (P < 0.0001), and –1.9 ± 0.8 kg (P = 0.03), respectively. CANA monotherapy caused a 9% increase in basal rate of EGP (P < 0.05), which was accompanied by a 50% increase (P < 0.05) in plasma glucagon-to-insulin ratio. LIRA monotherapy reduced plasma glucagon concentration and inhibited EGP. In CANA/LIRA-treated patients, EGP increased by 15% (P < 0.05), even though the plasma insulin response was maintained at baseline and the CANA-induced rise in plasma glucagon concentration was blocked.

CONCLUSIONS

These results demonstrate that liraglutide failed to block the increase in EGP caused by canagliflozin despite blocking the rise in plasma glucagon and preventing the decrease in plasma insulin concentration caused by canagliflozin. The failure of liraglutide to prevent the increase in EGP caused by canagliflozin explains the lack of additive effect of these two agents on HbA1c.




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Effects of Low-Energy Diet or Exercise on Cardiovascular Function in Working-Age Adults With Type 2 Diabetes: A Prospective, Randomized, Open-Label, Blinded End Point Trial

OBJECTIVE

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.

RESEARCH DESIGN AND METHODS

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.

RESULTS

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).

CONCLUSIONS

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.




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Use of Antihyperglycemic Medications in U.S. Adults: An Analysis of the National Health and Nutrition Examination Survey

OBJECTIVE

1) To examine trends in the use of diabetes medications and 2) to determine whether physicians individualize diabetes treatment as recommended by the American Diabetes Association (ADA).

RESEARCH DESIGN AND METHODS

We conducted a retrospective, cross-sectional analysis of 2003–2016 National Health and Nutrition Examination Survey (NHANES) data. We included people ≥18 years who had ever been told they had diabetes, had an HbA1C >6.4%, or had a fasting plasma glucose >125 mg/dL. Pregnant women, and those aged <20 years receiving only insulin were excluded. We assessed trends in use of ADA’s seven preferred classes from 2003–2004 to 2015–2016. We also examined use by hypoglycemia risk (sulfonylureas, insulin, and meglitinides), weight effect (sulfonylureas, thiazolidinediones [TZDs], insulin, and meglitinides), cardiovascular benefit (canagliflozin, empagliflozin, and liraglutide), and cost (brand-name medications and insulin analogs).

RESULTS

The final sample included 6,323 patients. The proportion taking any medication increased from 58% in 2003–2004 to 67% in 2015–2016 (P < 0.001). Use of metformin and insulin analogs increased, while use of sulfonylureas, TZDs, and human insulin decreased. Following the 2012 ADA recommendation, the choice of drug did not vary significantly by older age, weight, or presence of cardiovascular disease. Patients with low HbA1C, or HbA1C <6%, and age ≥65 years were less likely to receive hypoglycemia-inducing medications, while older patients with comorbidities were more likely. Insurance, but not income, was associated with the use of higher-cost medications.

CONCLUSIONS

Following ADA recommendations, the use of metformin increased, but physicians generally did not individualize treatment according to patients’ characteristics. Substantial opportunities exist to improve pharmacologic management of diabetes.




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Efficacy and Safety of 1:1 Fixed-Ratio Combination of Insulin Glargine and Lixisenatide Versus Lixisenatide in Japanese Patients With Type 2 Diabetes Inadequately Controlled on Oral Antidiabetic Drugs: The LixiLan JP-O1 Randomized Clinical Trial

OBJECTIVE

To assess the efficacy and safety of a 1:1 fixed-ratio combination of insulin glargine and lixisenatide (iGlarLixi) versus lixisenatide (Lixi) in insulin-naive Japanese patients with type 2 diabetes mellitus (T2DM) inadequately controlled on oral antidiabetic drugs (OADs).

RESEARCH DESIGN AND METHODS

In this phase 3, open-label, multicenter trial, 321 patients with HbA1c≥7.5 to ≤10.0% (58–86 mmol/mol) and fasting plasma glucose (FPG) ≤13.8 mmol/L (250 mg/dL) were randomized 1:1 to iGlarLixi or Lixi for 52 weeks. The primary end point was change in HbA1c at week 26.

RESULTS

Change in HbA1c from baseline to week 26 was significantly greater with iGlarLixi (–1.58% [–17.3 mmol/mol]) than with Lixi (–0.51% [–5.6 mmol/mol]), confirming the superiority of iGlarLixi (least squares [LS] mean difference –1.07% [–11.7 mmol/mol], P < 0.0001). At week 26, significantly greater proportions of patients treated with iGlarLixi reached HbA1c <7% (53 mmol/mol) (65.2% vs. 19.4%; P < 0.0001), and FPG reductions were greater with iGlarLixi than Lixi (LS mean difference –2.29 mmol/L [–41.23 mg/dL], P < 0.0001). Incidence of documented symptomatic hypoglycemia (≤3.9 mmol/L [70 mg/dL]) was higher with iGlarLixi (13.0% vs. 2.5%) through week 26, with no severe hypoglycemic events in either group. Incidence of gastrointestinal events through week 52 was lower with iGlarLixi (36.0% vs. 50.0%), and rates of treatment-emergent adverse events were similar.

CONCLUSIONS

This phase 3 study demonstrated superior glycemic control and fewer gastrointestinal adverse events with iGlarLixi than with Lixi, which may support it as a new treatment option for Japanese patients with T2DM that is inadequately controlled with OADs.




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Acrylamide Exposure and Oxidative DNA Damage, Lipid Peroxidation, and Fasting Plasma Glucose Alteration: Association and Mediation Analyses in Chinese Urban Adults

OBJECTIVE

Acrylamide exposure from daily-consumed food has raised global concern. We aimed to assess the exposure-response relationships of internal acrylamide exposure with oxidative DNA damage, lipid peroxidation, and fasting plasma glucose (FPG) alteration and investigate the mediating role of oxidative DNA damage and lipid peroxidation in the association of internal acrylamide exposure with FPG.

RESEARCH DESIGN AND METHODS

FPG and urinary biomarkers of oxidative DNA damage (8-hydroxy-deoxyguanosine [8-OHdG]), lipid peroxidation (8-iso-prostaglandin-F2α [8-iso-PGF2α]), and acrylamide exposure (N-acetyl-S-[2-carbamoylethyl]-l-cysteine [AAMA], N-acetyl-S-[2-carbamoyl-2-hydroxyethyl]-l-cysteine [GAMA]) were measured for 3,270 general adults from the Wuhan-Zhuhai cohort. The associations of urinary acrylamide metabolites with 8-OHdG, 8-iso-PGF2α, and FPG were assessed by linear mixed models. The mediating roles of 8-OHdG and 8-iso-PGF2α were evaluated by mediation analysis.

RESULTS

We found significant linear positive dose-response relationships of urinary acrylamide metabolites with 8-OHdG, 8-iso-PGF2α, and FPG (except GAMA with FPG) and 8-iso-PGF2α with FPG. Each 1-unit increase in log-transformed level of AAMA, AAMA + GAMA (UAAM), or 8-iso-PGF2α was associated with a 0.17, 0.15, or 0.23 mmol/L increase in FPG, respectively (P and/or P trend < 0.05). Each 1% increase in AAMA, GAMA, or UAAM was associated with a 0.19%, 0.27%, or 0.22% increase in 8-OHdG, respectively, and a 0.40%, 0.48%, or 0.44% increase in 8-iso-PGF2α, respectively (P and P trend < 0.05). Increased 8-iso-PGF2α rather than 8-OHdG significantly mediated 64.29% and 76.92% of the AAMA- and UAAM-associated FPG increases, respectively.

CONCLUSIONS

Exposure of the general adult population to acrylamide was associated with FPG elevation, oxidative DNA damage, and lipid peroxidation, which in turn partly mediated acrylamide-associated FPG elevation.




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The Association of Energy and Macronutrient Intake at Dinner Versus Breakfast With Disease-Specific and All-Cause Mortality Among People With Diabetes: The U.S. National Health and Nutrition Examination Survey, 2003-2014

OBJECTIVE

This study aims to evaluate the association of energy and macronutrient intake at dinner versus breakfast with disease-specific and all-cause mortality in people with diabetes.

RESEARCH DESIGN AND METHODS

A total of 4,699 people with diabetes who enrolled in the National Health and Nutrition Examination Survey from 2003 to 2014 were recruited for this study. Energy and macronutrient intake was measured by a 24-h dietary recall. The differences () in energy and macronutrient intake between dinner and breakfast ( = dinner – breakfast) were categorized into quintiles. Death information was obtained from the National Death Index until 2015. Cox proportional hazards regression models were developed to evaluate the survival relationship between and diabetes, cardiovascular disease (CVD), and all-cause mortality.

RESULTS

Among the 4,699 participants, 913 deaths, including 269 deaths due to diabetes and 314 deaths due to CVD, were documented. After adjustment for potential confounders, compared with participants in the lowest quintile of in terms of total energy and protein, participants in the highest quintile were more likely to die due to diabetes (hazard ratio [HR]energy 1.92, 99% CI 1.08–3.42; HRprotein 1.92, 99% CI 1.06–3.49) and CVD (HRenergy 1.69, 99% CI 1.02–2.80; HRprotein 1.96, 99% CI 1.14–3.39). The highest quintile of total fat was related to CVD mortality (HR 1.67, 99% CI 1.01–2.76). Isocalorically replacing 5% of total energy at dinner with breakfast was associated with 4% and 5% lower risk of diabetes (HR 0.96, 95% CI 0.94–0.98) and CVD (HR 0.95, 95% CI 0.93–0.97) mortality, respectively.

CONCLUSIONS

Higher intake of energy, total fat, and protein from dinner than breakfast was associated with greater diabetes, CVD, and all-cause mortality in people with diabetes.




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Cardiovascular Risk Reduction With Liraglutide: An Exploratory Mediation Analysis of the LEADER Trial

OBJECTIVE

The LEADER trial (ClinicalTrials.gov reg. no. NCT01179048) demonstrated a reduced risk of cardiovascular (CV) events for patients with type 2 diabetes who received the glucagon-like peptide 1 receptor agonist liraglutide versus placebo. The mechanisms behind this CV benefit remain unclear. We aimed to identify potential mediators for the CV benefit observed with liraglutide in the LEADER trial.

RESEARCH DESIGN AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.




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Instability of Insulin Aspart Diluted in Dextrose




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Readers Respond About Your Own Experiences In the Schools

The readers of School Psychologist Blog Files were asked in February to share their own experiences and to vote on a poll "How do you feel about the level of education the school provides your child." It's important to understand that everyone's experience is unique. The readers come from different states, different school systems, and different grade levels. Laws and standards vary somewhat between states. Within any state, there are schools that do a better job suiting the needs of children than others. Within any school system, there are those star schools, and the schools that need more attention. Even within the best schools, there are still going to be individuals who have negative experiences. Within the worst schools, there will be those who have positive experiences. Regardless of your school or your situation, I believe that the readers of this blog care deeply about their child's education and have strong emotions about the education (positive or negative.)

The most popular response was "I generally feel good about the level of education, but have some complaints." I was glad to see that many of you are mostly satisfied. I hope that continues throughout your children's school career. Stay involved, speak up when needed, and compliment those who deserve it.

There was a strong outcry from those who endorsed "I feel as if the school is not supportive and I feel as though I am constantly fighting for his or her rights." This was the second most popular answer. While many feel comfortable with their schools, there are many parents out there who have the unsettling feeling of sending their child to a place they do not feel good about. Many of the readers are feeling that getting appropriate services only comes with a fight. Some of you are not having good experiences. I hope that you are able to find some support and insight here from others.

A few of you feel very thankful for the high level of education that your child is receiving. I am thankful to hear that some of the parents here feel exceptionally good about their child's school. Know this is a blessing that many others do not have.

Feel free to share your comments about experiences and offer some insight to others who may have similar experiences.




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Why is My Child Defiant or Explosive?

Dedicated to the lady at Walmart with the screaming kid and all of us "good parents" who have been that lady at Walmart.

One of the most difficult behaviors for parents or teachers to address is explosive behavior, a child who has little control over emotions and "melts down" in the classroom or at home.  It is frustrating, it is embarrassing, it is anxiety producing, it causes intense emotions in ourselves.  Parents agonize over why it happens or what they did wrong?  Often the parents are blamed or judged by bystanders in stores, family members, friends, or school staff.  However, I have seen parents with a variety of parenting styles have kids with poor emotional control, including those who are strict, those who are quick to give in, those who spank, those who use time out, those who take away privileges, and a whole lot of parents who feel like they have tried everything.  I know children with very little emotional control from homes that are falling apart, from homes that are loving and supportive, from poor families, from affluent families, from parents who have no clue how to parent, from parents with excellent skills, even from School Psychologists.  This is not to say that parenting styles do not have a role in this, but there IS more to it.  We have to stop judging each other and get to the root of the problem.  

What is the Root of the Problem?

The problem, the reason some children "explode" or act out with little emotional control, is because he or she is lacking a skill.  Emotional control is a skill.  Most kids will learn this skill through consistent discipline strategies, but some do not. 

Another way to look at it.

We don't tell our kids how to read and then expect them to do it.  We show them step by step.  Some kids will pick it up easy, others will need to be taught and retaught and retaught and will need extensive help in doing so.  Do we blame ourselves?  Do we look at our friends judgementally and think to ourselves "look at the book she is using, it's all wrong?"  No, we assume the child has a problem learning to read and we find a way to teach him.  WE HAVE TO START LOOKING AT BEHAVIOR IN THE SAME WAY.  When a child is exploding, the first step should not be to label the child or blame the parent.  Lets start looking for the skill that is lacking.  When we find that skill, lets teach it.

It's NOT always a control issue.  Sometimes kids act out because they have not been taught to obey and respect authority, but sometimes they act out in spite of good training at home.  The explosions lead to self esteem problems in the child and the child feeling like a "bad kid," which in turn makes explosions bigger and more frequent.  Have you ever looked at a screaming child and demanded he control himself right now or "act your age."  It's a common thing to do.  Have you ever looked at a child with a Learning Disability and said "read on your grade level, now!" or "I have told you and told you how to read, why aren't you reading?"  Of course you haven't.  We work with the reader at his level and patiently try different strategies to improve reading.  We can't demand them to be good readers and we can't demand that a child who does not have the skills to control his emotions "act his age."  These explosive kids need skills and truth be told, we who work with these kids need skills. 

If you are a parent with a child who acts "out of control" stop blaming yourself.  It isn't necessarily because you spanked or didn't spank or were too strict or too lenient.  Your child is lacking the skills she needs to control her emotions.  Also, realize you are going to need to learn new skills to help your child learn the lacking skills.  You are no longer in the Parenting 101 class, you need to move on to the Advanced skill- teaching parenting class. 

The BEST book I have read on this topic is The Explosive Child by Ross Greene.  He addresses the skills these children might be lacking and he has great strategies to address the issue. (see Amazon link below)

If you are a teacher and have an "explosive child" in your class, rethink your perspective of the student.  The child needs to learn skills, so lets focus on teaching the skills and being patient with the children who are slower to learn emotional control.  We as school staff can not make excuses or blame the parents.  We have to reach the child at her level.  We teach a child to read at her level.  We must teach a child to control emotions at her level as well. 

Challenge for Everyone
Let us stop labeling these kids with emotional skill deficits as "bad kids" and stop judging the parents.  Let's be honest with ourselves and recognize we all have shortcomings and could use skills in certain areas.  Maybe our kids need skills in emotional control, maybe we do, maybe we need skills in teaching emotional control, or maybe we need skills in some other area all together.  Let's be patient with our children and our peers and ourselves. Let's stop criticizing ourselves and others and start learning and teaching new skills.   We don't live in a world with bad kids, we live in a world will kids who need skills, so let's teach.





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