Volkert Siersma

Symptoms, signs and complications in newly diagnosed type 2 diabetic patients, and their relationship to glycaemia, blood pressure and weight

Aims/hypothesisTo document the prevalence of typical diabetic symptoms, signs and complications in the diagnosis of type 2 diabetes mellitus, examine their pre-diagnostic duration, and analyse associations with glycaemic level, blood pressure (BP), and weight.MethodsAn epidemiological population-based study of 1137 Danish patients with type 2 diabetes newly diagnosed by general practitioners (GPs). GPs and patients together filled in a questionnaire about typical symptoms, signs and complications preceding the diagnosis.ResultsAbnormal thirst, frequent urination, weight loss, genital itching, stomatitis, visual disturbances, fatigue, confusion and (in men) balanitis were associated with glycaemic level irrespective of age, sex, BMI, BP, complications and antihypertensive treatment. Eighty-nine percent of the patients presented with one or more of these hyperglycaemic symptoms and signs, and the pre-diagnostic duration was typically less than 3 months. Only a few symptoms, signs and complications were associated with weight and BP.Conclusions/interpretationIn patients newly diagnosed with type 2 diabetes in family practice, typical diabetic symptoms, signs and complications are common. Typical diabetic symptoms and signs are associated with hyperglycaemia. The pre-diagnostic duration of hyperglycaemic symptoms and signs were typically short, thus questioning the feasibility of early detection relying on increased anticipatory care by GPs. In contrast, elevated levels of cardiovascular risk factors and longer pre-diagnostic duration of cardiovascular complications suggest these might have a central role in an early diagnosis of type 2 diabetes.

Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients

Background:  Postoperative cognitive dysfunction (POCD) is a common complication after cardiac and major non‐cardiac surgery with general anaesthesia in the elderly. We hypothesized that the incidence of POCD would be less with regional anaesthesia rather than general.

Sample Size in Qualitative Interview Studies Guided by Information Power

Sample sizes must be ascertained in qualitative studies like in quantitative studies but not by the same means. The prevailing concept for sample size in qualitative studies is “saturation.” Saturation is closely tied to a specific methodology, and the term is inconsistently applied. We propose the concept “information power” to guide adequate sample size for qualitative studies. Information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed. We suggest that the size of a sample with sufficient information power depends on (a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue, and (e) analysis strategy. We present a model where these elements of information and their relevant dimensions are related to information power. Application of this model in the planning and during data collection of a qualitative study is discussed.

Cognitive dysfunction after minor surgery in the elderly

Background:  Major surgery is frequently associated with postoperative cognitive dysfunction (POCD) in elderly patients. Type of surgery and hospitalization may be important prognostic factors. The aims of the study were to find the incidence and risk factors for POCD in elderly patients undergoing minor surgery.

Long-Term Psychosocial Consequences of False-Positive Screening Mammography

PURPOSE Cancer screening programs have the potential of intended beneficial effects, but they also inevitably have unintended harmful effects. In the case of screening mammography, the most frequent harm is a false-positive result. Prior efforts to measure their psychosocial consequences have been limited by short-term follow-up, the use of generic survey instruments, and the lack of a relevant benchmark—women with breast cancer. METHODS In this cohort study with a 3-year follow-up, we recruited 454 women with abnormal findings in screening mammography over a 1-year period. For each woman with an abnormal finding on a screening mammogram (false and true positives), we recruited another 2 women with normal screening results who were screened the same day at the same clinic. These participants were asked to complete the Consequences of Screening in Breast Cancer—a validated questionnaire encompassing 12 psychosocial outcomes—at baseline, 1, 6, 18, and 36 months. RESULTS Six months after final diagnosis, women with false-positive findings reported changes in existential values and inner calmness as great as those reported by women with a diagnosis of breast cancer (Δ = 1.15; P = .015; and Δ = 0.13; P = .423, respectively). Three years after being declared free of cancer, women with false-positive results consistently reported greater negative psychosocial consequences compared with women who had normal findings in all 12 psychosocial outcomes (Δ >0 for 12 of 12 outcomes; P <.01 for 4 of 12 outcomes). CONCLUSION False-positive findings on screening mammography causes long-term psychosocial harm: 3 years after a false-positive finding, women experience psychosocial consequences that range between those experienced by women with a normal mammogram and those with a diagnosis of breast cancer.

Apolipoprotein E Genotype and Cognitive Dysfunction after Noncardiac Surgery

Background:Apolipoprotein E is important in recovery after neuronal damage. The &egr;4 allele of the apolipoprotein E gene has been shown as a risk factor for Alzheimer disease, poor outcome after cerebral injury, and accelerated cognitive decline with normal aging. The authors hypothesized that patients with the &egr;4 allele would have an increased risk of postoperative cognitive dysfunction (POCD) after noncardiac surgery. Methods:In a multicenter study, a total of 976 patients aged 40 yr and older undergoing noncardiac surgery were tested preoperatively and 1 week and 3 months after surgery with a neuropsychological test battery comprising seven subtests. POCD was defined as a decline in test performance of more than 2 SD from the expected. Apolipoprotein E genotypes were determined by blood sample analysis at a central laboratory. Multivariate logistic regression analysis with POCD as the dependent variable assessed presence of the &egr;4 allele (yes/no) and other possible risk factors. Results:The &egr;4 allele was found in 272 patients. One week after surgery, the incidence of POCD was 11.7% in patients with the &egr;4 allele and 9.9% in patients without the &egr;4 allele (P = 0.41). Three months later, POCD was found in 10.3% of patients with the &egr;4 allele and in 8.4% of patients without the &egr;4 allele (P = 0.40). Multivariate logistic regression analysis did not identify the &egr;4 allele as a risk factor at 1 week (P = 0.33) or 3 months (P = 0.57). Conclusions:The authors were unable to show a significant association between apolipoprotein E genotype and POCD, but statistical power was limited because of a lower incidence of POCD than expected.

Is peri‐operative cortisol secretion related to post‐operative cognitive dysfunction?

Background:  The pattern of cortisol secretion is influenced by surgery. As cortisol can adversely affect neuronal function, this may be an important factor in the development of post‐operative cognitive dysfunction (POCD). We hypothesized that the incidence of POCD would be related to changes in cortisol level.

Efficacy of psychosocial intervention in patients with mild Alzheimer’s disease: the multicentre, rater blinded, randomised Danish Alzheimer Intervention Study (DAISY)

Objective To assess the efficacy at 12 months of an early psychosocial counselling and support programme for outpatients with mild Alzheimer’s disease and their primary care givers. Design Multicentre, randomised, controlled, rater blinded trial. Setting Primary care and memory clinics in five Danish districts. Participants 330 outpatients with mild Alzheimer’s disease and their 330 primary care givers. Interventions Participating dyads (patient and primary care giver) were randomised to control support during follow-up or to control support plus DAISY intervention (multifaceted and semi-tailored counselling, education, and support). Main outcome measures Primary outcomes at 12 months for patients were change from baseline in mini mental state examination (MMSE) score, Cornell depression scale score, and proxy rated European quality of life visual analogue scale (EQ-VAS) score. For care givers, outcomes were change from baseline in geriatric depression scale (GDS 30 items) score and EQ-VAS score. Results Because of multiple testing, statistical significance was set at an adjusted P limit of <0.0005. At 12 months there were no significant differences between the two allocation groups in changes from baseline in the primary and secondary outcomes. However, although non-significant with the adjusted P limit, a small difference was observed for one of the primary patient outcomes (Cornell depression scale score) in patients in favour of the DAISY intervention group before and after adjusting for attrition (P=0.0146 and P=0.0103 respectively). Conclusions The multifaceted, semi-tailored intervention with counselling, education, and support for patients with mild Alzheimer’s disease and their care givers did not have any significant effect beyond that with well structured follow-up support at 12 months after adjustment for multiple comparisons. The small positive effect found in the unadjusted primary outcome addressing depressive symptoms in patients may call for further research focusing on patients with Alzheimer’s disease and comorbid depression. Trial registration ISRCTN74848736.

Postoperative cognitive dysfunction: true deterioration versus random variation

Background:  Postoperative cognitive dysfunction (POCD) is a common complication, especially in the elderly. The aim of this study was to describe how variability in neuropsychological testing could lead to the detection of cognitive improvement and poor consistency of POCD between postoperative test sessions.

Urinary Markers of Nucleic Acid Oxidation and Long-Term Mortality of Newly Diagnosed Type 2 Diabetic Patients

OBJECTIVE We analyzed data from a cohort of 1,381 newly diagnosed type 2 diabetic patients to test the hypothesis that urinary markers of nucleic acid oxidation are independent predictors of mortality. RESEARCH DESIGN AND METHODS We examined the relationship between urinary excretion of markers of DNA oxidation (8-oxo-7,8-dihydro-2′-deoxyguanosine [8-oxodG]) and RNA oxidation (8-oxo-7,8-dihydroguanosine [8-oxoGuo]) and long-term mortality using Cox proportional hazards regression. RESULTS After multivariate adjustment, the hazard ratios for all-cause and diabetes-related mortality of patients with 8-oxoGuo levels in the highest quartile compared with those in the lowest quartile were 1.44 (1.12–1.85) and 1.54 (1.13–2.10), respectively. Conversely, no significant associations between 8-oxodG and mortality were found in the adjusted analyses. CONCLUSIONS Urinary excretion of the RNA oxidation marker 8-oxoGuo measured shortly after diagnosis of type 2 diabetes predicts long-term mortality independently of conventional risk factors. This finding suggests that 8-oxoGuo could serve as a new clinical biomarker in diabetes.