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Clinical Question: Among patients with type 2 diabetes mellitus who do not achieve optimal glycemic control with insulin monotherapy, is the addition of oral hypoglycemic agents associated with benefits (measured by lowering of hemoglobin A1c) or adverse effects?, Bottom Line: Adding a sulfonylurea to insulin was associated with more hypoglycemic events compared with insulin alone, but this association was not observed for metformin. Adding a sulfonylurea or metformin to insulin was associated with a decrease in hemoglobin A1c of approximately 1.0%.

Objective: About 20% of patients with type 2 diabetes achieve all their treatment targets. Shared decision making (SDM) using a support aid based on the 5-years results of the ADDITION study on multifactorial treatment, could increase this proportion., Research Design and Methods: Cluster-randomized trial in 35 former ADDITION primary care practices. Practices were randomized to SDM or care as usual (1:1). Both ADDITION and non-ADDITION type 2 diabetes patients, 60-80 years, known with diabetes for 8-12 years, were included. In the intervention group, patients were presented evidence about the relationship between treatment intensity and cardiovascular events. They chose intensive or less intensive treatment and prioritized their targets. After 1 year priorities could be rearranged., Follow-Up: 24 months. Intention-to-treat analysis., Main Outcome Measure: proportion of patients that achieved all three treatment targets., Results: At baseline 26.4% in the SDM group (n=72) had already achieved all three treatment goals (CG: 23.5%, n=81). In the SDM group 44 patients chose intensive treatment, 25 continued their former less intensive treatment and three people switched from the more to the less intensive protocol. After 24 months 31.8% of the patients in the SDM group achieved all three treatment targets (CG: 25.3%), RR 1.26 (95% CI 0.81-1.95). Mean systolic blood pressure decreased in the SDM group (-5.4 mm Hg, P<.01), mean HbA1c and total cholesterol did not change., Conclusions: Despite an already high baseline level of diabetes care, we found strong indications that SDM on both intensity of treatment and prioritizing treatment goals further improved outcomes., (© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Aims: To compare the proportion of cardiometabolic well-controlled type 2 diabetes mellitus (T2DM) patients according to a clearly defined, simple personalised approach, versus the 'one-size-fits-all' approach., Methods: Observational study using routine data of primary care type 2 diabetes patients in the Netherlands. The proportions of patients that reach the targets for HbA1c, systolic blood pressure and low-density lipoprotein cholesterol in the two different approaches were compared., Results: Of the 890 patients (54.7% men, mean age 62.7 years), 31.8% were well-controlled according to the individualised approach and 24.8% according to the 'one-size-fits-all' approach. For specific subgroups personalising the treatment led to a 5.2%, 27.3% and 45.6% increase of patients achieving low-density lipoprotein cholesterol, HbA1c and systolic blood pressure goals respectively., Conclusions: A clearly defined and relatively simple personalised approach leads to a higher proportion of T2DM patients considered as cardiometabolic well-controlled. This approach may especially be beneficial for patients aged ≥70 years on more than metformin monotherapy (HbA1c) and for patients aged ≥80 years (SBP). Precisely these patients are suggested not to benefit from stricter HbA1c or SBP targets, whereas they may experience more adverse effects (e.g. hypoglycaemia, postural hypotension) when a stricter target value is pursued., (Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Background: Many self-management programs have been developed so far. Their effectiveness varies. The program 'Beyond Good Intentions' (BGI) is based on proactive coping and has proven to be (cost-) effective in achieving reductions in BMI and blood pressure in screen-detected type 2 diabetes patients up until nine months follow-up. However, its long-term effectiveness in people already known with diabetes is lacking. In addition, its (cost-) effectiveness might increase if people who are likely not to be benefit from the program are excluded in a valid way. Therefore it was aimed to investigate the long-term effects of the educational program BGI on cardiovascular risk, quality of life and diabetes self-management behaviour in a pre-selected group of patients known with type 2 diabetes up to 5 years., Methods: Randomised controlled trial with 2.5 year follow-up. Adults (≤75 years) with a type 2 diabetes duration between 3 months and 5 years will be included. With the use of a self-management screening tool (SeMaS) their potential barriers of self-management due to depression and/or anxiety will be determined. Based on the results of the SeMaS selection patients will be randomised (1:1) to the BGI-group (n = 53) or the control-group (n = 53). In addition to receiving usual care, patients in the BGI-group will follow the 12-week theory-based self-management program and a booster session a few months thereafter. The control-group will receive care as usual. The primary outcome is change in Body Mass Index after 2.5 years follow-up. Secondary outcomes are HbA1c, lipid profile and systolic blood pressure, (diabetes) quality of life, level of physical activity, dietary intake and medication adherence and proactive coping. Cost-effectiveness will be based on total use of health care resources during the entire study period. Difference between groups in change over time will be analysed according to intention-to-treat analysis., Conclusions: By differentiating between patients who will and those who are likely not to benefit from the educational program, a more (cost-) effective self-management program might be designed, also on the long-run. Trial registration NTR 5330.

Aims: To explore differences in clinical characteristics of patients with and without type 2 diabetes (T2DM) hospitalized with a first myocardial infarction (MI)., Methods: In this cross-sectional study we examined differences between patients with and without T2DM hospitalized with a first MI (n=563). Multiple linear regression modeling was used to examine the association between T2DM and age of occurrence of MI. We adjusted for gender, systolic blood pressure (BP), lipids and creatinine level to examine whether these variables explained the association between T2DM and age of occurrence of MI., Results: Among 563 patients with a first MI, T2DM patients (n=77) were older than non-diabetic patients (67.8±10.9 vs. 64.4±13.4years, p<0.05), had lower LDL (2.5±0.8 vs. 3.4±1.1mmol/l, p<0.001) and total cholesterol levels (4.4±0.9 vs. 5.4±1.2mmol/l, p<0.001), but higher systolic BP (150.3±29.9 vs. 141.7±27.5mmHg, p<0.05). The association between T2DM and age of occurrence of MI was largely explained by cholesterol levels., Conclusions: T2DM patients were older when hospitalized with a first MI. This difference was largely explained by differences in cholesterol levels. The lower cholesterol levels in T2DM patients compared to non-diabetic patients, and maybe also the older age of occurrence of MI, might reflect the results successful primary prevention and systematic monitoring in T2DM., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to determine the developmental trajectories of expressive (speech) and receptive (spoken and written language) communication by type of motor disorder and intellectual disability in individuals with cerebral palsy (CP)., Method: The development of 418 participants (261 males, 157 females; mean age 9y 6mo [SD 6y 2mo], range 1-24y; Gross Motor Function Classification System (GMFCS) level I [n=206], II [n=57], III [n=59], IV [n=54], V [n=42]) was followed for 2 to 4 years in a longitudinal study. Communication performance was measured using the Vineland Adaptive Behavior Scales. The type of motor disorder was differentiated by type of CP as unilateral spastic (USCP, n=161), bilateral spastic (BSCP, n=202), and non-spastic (NSCP, n=55), while intellectual disability was determined by IQ or school type (regular or special). A multilevel analysis was then used to model the developmental trajectories., Results: The most favourable development of expressive communication was seen in USCP (vs BSCP β [SE]-2.74 [1.06], NSCP β [SE]-2.67 [1.44]). The difference between the development trajectory levels of children with and without intellectual disability was smaller for children with USCP than for those with BSCP and NSCP. For receptive communication, the most favourable development was found for all children with USCP and for BSCP or NSCP without intellectual disability (vs intellectual disability β [SE]-4.00 [1.16]). Development of written language was most favourable for children without intellectual disability (vs intellectual disability β [SE]-23.11 [2.85])., Interpretation: The development of expressive communication was found to be most closely related to type of motor disorder, whereas the development of receptive communication was found to be most closely related to intellectual disability., (© 2014 Mac Keith Press.)

Aims: Despite diabetes patients' efforts to control their disease, many of them are confronted with an acute coronary event. This may evoke depressive feelings and self-management may be complicated. According to the American Diabetes Association, the transition from hospital to home after an acute coronary event (ACE) is a high-risk time for diabetes patients; it should be improved. Before developing an intervention for diabetes patients with an ACE in the period after discharge from hospital, we want to gain a detailed understanding of patients' views, perceptions and feelings in this respect., Methods: Qualitative design. Two semi-structured focus groups were conducted with 14 T2DM patients (71% male, aged 61-77 years) with a recent ACE. One focus group with partners (67% male, aged 64-75 years) was held. All interviews were transcribed verbatim and analyzed by two independent researchers., Results: Patients believed that coping with an ACE differs between patients with and without T2DM. They had problems with physical exercise, sexuality and pharmacotherapy. Patients and partners were neither satisfied with the amount of information, especially on the combination of T2DM and ACE, nor with the support offered by healthcare professionals after discharge. Participants would appreciate tailored self-management support after discharge from hospital., Conclusions: Patients with T2DM and their partners lack tailored support after a first ACE. Our findings underpin the ADA recommendations to improve the transition from hospital to home. The results of our study will help to determine the exact content of a self-management support program delivered at home to help this specific group of patients to cope with both conditions., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the effect of multidisciplinary treatment on obesity and health-related quality of life (HRQOL)., Methods: Obese children were randomized to a multidisciplinary lifestyle treatment, including medical, nutritional, physical, and psychological counseling during 3 months, (n = 40, BMI-SDS; 4.2 ± 0.7, age; 13.3 ± 2.0) or standard care, including an initial advice on nutrition and physical activity by the pediatrician (n = 39, BMI-SDS; 4.3 ± 0.7, age; 13.1 ± 1.9). At baseline, after 3 months of treatment and at 12 months follow-up, data were collected for BMI-SDS and a European validated questionnaire for assessing HRQOL (DISABKIDS)., Results: A significantly reduced BMI-SDS was found for the intervention group after 3 months treatment (4.0 ± 0.9 vs. 4.2 ± 0.7, P = 0.02) and at 12 months follow-up (3.8 ± 1.1 vs. 4.2 ± 0.7, P = 0.03). HRQOL in the intervention group was significantly improved at 12 months follow-up and unchanged in the obese control group. Agreement between child and parent report was moderate (67-85%), with parents reporting a lower HRQOL for their obese children than children themselves in both groups., Conclusion: Multidisciplinary treatment is effective in reducing BMI-SDS and improving HRQOL after 12 months follow-up.