IMPORTANCE Numerous glucose-lowering drugs are used to treat type 2 diabetes. OBJECTIVE To estimate the relative efficacy and safety associated with glucose-lowering drugs including insulin. DATA SOURCES Cochrane Library Central Register of Controlled Trials, MEDLINE, and EMBASE databases through March 21, 2016. STUDY SELECTION Randomized clinical trials of 24 weeks' or longer duration. DATA EXTRACTION AND SYNTHESIS Random-effects network meta-analysis. MAIN OUTCOMES AND MEASURES The primary outcome was cardiovascular mortality. Secondary outcomes included all-cause mortality, serious adverse events, myocardial infarction, stroke, hemoglobin A 1c (HbA 1C) level, treatment failure (rescue treatment or lack of efficacy), hypoglycemia, and body weight. RESULTS A total of 301 clinical trials (1 417 367 patient-months) were included; 177 trials (56 598 patients) of drugs given as monotherapy; 109 trials (53 030 patients) of drugs added to metformin (dual therapy); and 29 trials (10 598 patients) of drugs added to metformin and sulfonylurea (triple therapy). There were no significant differences in associations between any drug class as monotherapy, dual therapy, or triple therapy with odds of cardiovascular or all-cause mortality. Compared with metformin, sulfonylurea (standardized mean difference [SMD], 0.18 [95% CI, 0.01 to 0.34]), thiazolidinedione (SMD, 0.16 [95% CI, 0.00 to 0.31]), DPP-4 inhibitor (SMD, 0.33 [95% CI, 0.13 to 0.52]), and α-glucosidase inhibitor (SMD, 0.35 [95% CI, 0.12 to 0.58]) monotherapy were associated with higher HbA 1C levels. Sulfonylurea (odds ratio [OR], 3.13 [95% CI, 2.39 to 4.12]; risk difference [RD], 10% [95% CI, 7% to 13%]) and basal insulin (OR, 17.9 [95% CI, 1.97 to 162]; RD, 10% [95% CI, 0.08% to 20%]) were associated with greatest odds of hypoglycemia. When added to metformin, drugs were associated with similar HbA 1C levels, while SGLT-2 inhibitors offered the lowest odds of hypoglycemia (OR, 0.12 [95% CI, 0.08 to 0.18]; RD, −22% [−27% to −18%]). When added to metformin and sulfonylurea, GLP-1 receptor agonists were associated with the lowest odds of hypoglycemia (OR, 0.60 [95% CI, 0.39 to 0.94]; RD, −10% [95% CI, −18% to −2%]). CONCLUSIONS AND RELEVANCE Among adults with type 2 diabetes, there were no significant differences in the associations between any of 9 available classes of glucose-lowering drugs (alone or in combination) and the risk of cardiovascular or all-cause mortality. Metformin was associated with lower or no significant difference in HbA 1C levels compared with any other drug classes. All drugs were estimated to be effective when added to metformin. These findings are consistent with American Diabetes Association recommendations for using metformin monotherapy as initial treatment for patients with type 2 diabetes and selection of additional therapies based on patient-specific considerations.

Dietary interventions have uncertain effects on mortality, cardiovascular events and ESKD among people with CKD as these outcomes were rarely measured or reported. Dietary interventions may increase health-related quality of life, eGFR, and serum albumin, and lower blood pressure and serum cholesterol levels.Based on stakeholder prioritisation of dietary research in the setting of CKD and preliminary evidence of beneficial effects on risks factors for clinical outcomes, large-scale pragmatic RCTs to test the effects of dietary interventions on patient outcomes are required.

Background: Accurate definition of the gastroduodenal and ileocaecal junctions (GDJ, ICJ) is essential for the measurement of regional transit times. Aims:To compare the assessment of these landmarks using the novel gas-sensing capsule and validated wireless motility capsule (WMC), and to evaluate intra-subject variance in transit times Methods: Healthy subjects ingested the gas-sensing capsule and WMC tandemly in random order. Inter-observer agreement was evaluated by intra-class correlation coefficient (ICC). Agreement between the paired devices' transit times was assessed using Bland-Altman analysis; coefficient of variation was performed to express intraindividual variance in transit times. Similar analyses were completed with tandemly ingested gas-sensing capsules. Results:The inter-observer agreement for landmarks for both capsules was excellent (mean ICC ≥0.97) in 50 studies. The GDJ was identifiable in 92% of the gas-sensing capsule studies versus 82% of the WMC studies (p = 0.27); the ICJ in 96% versus 84%, respectively (p = 0.11). In the primary cohort (n = 26), median regional transit times differed by less than 6 min between paired capsules. Bland-Altman revealed a bias of −0.12 (95% limits of agreement, −0.94 to 0.70) hours for GDJ and − 0.446 (−2.86 to 2.0) hours for ICJ. Similar results were found in a demographically distinct validation cohort (n = 24). For tandemly ingested gas-sensing capsules, coefficients of variation of transit times were 11%-35%, which were similar to variance between the paired gas-sensing capsule and WMC, as were the biases. The capsules were well tolerated.Conclusions: Key anatomical landmarks are accurately identified with the gas-sensing capsule in healthy individuals. Intra-individual differences in transit times between capsules are probably due to physiological factors. Studies in populations with gastrointestinal diseases are now required.

Introduction Telehealth is widely proposed to improve access and equity in provision of rehabilitation, including wheelchair assessment, yet the design requirements of telehealth wheelchair assessment that will be accepted and utilised at scale are unclear. Service design that addresses the existing inequities in outcomes for indigenous populations, such as Māori will be critical. The aim of this study was to examine the design requirements of a telehealth wheelchair assessment service from the perspectives of key stakeholders such as wheelchair users and their families, including indigenous (Māori) and health professionals including occupational therapist, and physiotherapist assessors and technicians. Methods Within a wider mixed methods design, inductive thematic analysis was applied to focus group and interview data from 23 assessors (19 occupational therapists and four physiotherapist assessors, one of whom was Māori) and 19 wheelchair users (three of whom were Māori). Results Eight themes were discerned with the final three themes emphasising the experiences of particular concern to Māori: (1) At the mercy of the system; (2) The hurdle of technology; (3) More efficient for all; (4) Lost information and connection; (5) Rights and the right way forward; (6) Cultural safety; (7) Whanaungatanga (relationship building); and (8) Summative disadvantage for Tāngata whaikaha (Māori with disabilities). Themes reflected a recognition of risks and uncertainty associated with tele‐delivered assessment. Conversely, advantages in access, equity, and professional competency were reimagined. Perspectives of Māori included both risks and advantages as perceived by Māori. Conclusion Substantial dissatisfaction with current wheelchair assessment services among wheelchair users provides context to the impetus for a successful design of a telehealth assessment service. Training in conducting telehealth wheelchair assessment is essential incorporating culturally safe communication practices and support of wheelchair user autonomy while identifying solutions that achieve wheelchair user goals.

Wheelchairs can significantly improve quality of life for those who need them, yet access to physiotherapists or occupational therapists specialising in wheelchair and seating assessment can be difficult, especially for Mäori. This paper reports on a national online survey that was undertaken as phase 1 of a mixed methods study of key stakeholders of the perceived social and technical requirements of a telehealth wheelchair assessment service for people with complex mobility needs. Key stakeholders included wheelchair users and their families, specialist and non-specialist assessors, technicians, and service managers. Responses (n = 114) indicated perceived shortcomings with current in-person assessment. Telehealth assessment was anticipated to improve service quality, particularly the timeliness of services (52/92, 57%) and prioritisation of the urgency of assessment (71/92, 77%). Preferences were for use of existing software rather than bespoke systems. Training in conducting assessment via telehealth was considered essential by most assessors (29/41, 71%). Internet connectivity was in place for most wheelchair users (43/47, 92%) but was inadequate for 29% (14/49) of assessors (pre-COVID-19). Mäori wheelchair users largely had infrastructure in place for telehealth assessment (10/11, 91%) and held positive expectations of it. Telehealth wheelchair and seating assessment is anticipated to improve the quality of care for wheelchair users with complex needs. Upgraded technical capability of public health services and robust training in conducting assessment via telehealth will be critical to successful uptake of this service. Specific needs for Mäori wheelchair users warrant further investigation.