Background: Combination antiretroviral therapy (cART) has improved the survival of patients with

ObjectiveTo estimate the association between the use of sodium glucose co-transporter-2 (SGLT2) inhibitors and postmarket harms as identified by drug regulatory agencies.DesignWe conducted a systematic review and meta-analysis of randomised controlled trials (RCT). Six large databases were searched from inception to May 2018. Random effects models were used to estimate pooled relative risks (RRs).InterventionSGLT2 inhibitors, compared with placebo or active comparators.Primary outcomesAcute kidney injury (AKI), diabetic ketoacidosis (DKA), urinary tract infections (UTI), bone fractures and lower limb amputations.ResultsWe screened 2418 citations of which 109 were included. Most studies included one of four SGLT2 inhibitors, dapagliflozin, canagliflozin, empagliflozin and ipragliflozin. When compared with placebo, SGLT2 inhibitors were found to be significantly protective against AKI (RR=0.59; 95% CI 0.39 to 0.89; I2=0.0%), while no difference was found for DKA (RR 0.66; 95% CI 0.30 to 1.45, I2=0.0%), UTI (RR 1.02; 95% CI 0.95 to 1.09, I2=0.0%) or bone fracture (RR 0.87; 95% CI 0.69 to 1.09, I2=1.3%). Three studies reported on amputation, with one finding a significant increase risk. No increased risk for either outcome was found when compared with active controls. Subgroup analysis did show an increased risk of UTI with dapagliflozin only (RR 1.21; 95% CI 1.02 to 1.43, I2=0.0%), but no other analysis supported an increased risk of AKI, DKA, UTI or fracture.ConclusionsCurrent evidence from RCTs does not suggest an increased risk of harm with SGLT2 inhibitors as a class over placebo or active comparators with respect to AKI, DKA, UTI or fracture. However, wide CIs for many comparisons suggest limited precision, and therefore clinically important adverse events cannot be ruled out. Dapagliflozin, appears to independently increase the risk of UTI, although the mechanism for this intraclass variation in risk is unclear.PROSPERO registration numberCRD42016038715.

We observed a significant and graded association between mortality risk and insulin exposure level in an inception cohort of patients with type 2 diabetes that persisted despite multivariable adjustment.

among outpatients with pneumonia, oxygen saturations <90% were associated with increased morbidity and mortality. Our results indicate a hospital admission threshold of <92% would be safer and clinically better justified.

Background Using a mobile health (mHealth) intervention, consisting of a smartphone and compatible medical device, has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes while mitigating health care costs. Objective The aim of this study was to explore the potential facilitators and barriers among health care providers (HCPs) regarding the use of mHealth interventions for COPD management. Methods This was a qualitative study. Semistructured individual interviews were conducted with HCPs, including nurses, pharmacists, and physicians who work directly with patients with COPD. A flexible prompts guide was used to facilitate discussions. Interview topics included the following: demographics, mHealth usage, perceptions toward challenges of mHealth adoption, factors facilitating mHealth adoption, and preferences regarding features of the mHealth intervention for COPD management. Interviews were conversational in nature, and items were not asked verbatim or in the order presented. The interviews were transcribed verbatim and compared against the digital recordings to ensure the accuracy of the content. After creating a codebook for analysis, 2 researchers independently coded the remaining interview data using pattern coding. They discussed commonalities and differences in coding until a consensus was reached. Results A total of 30 nurses, physicians, and pharmacists participated. The main facilitators to mHealth adoption are possible health benefits for patients, ease of use, educating patients and their HCPs, credibility, and reducing cost to the health care system. Alternatively, the barriers to adoption are technical issues, privacy and confidentiality issues, lack of awareness, potential limited uptake from the elderly, potential limited connection between patients and HCPs, and finances. Conclusions It is important to understand the perceptions of HCPs regarding the adoption of innovative mHealth interventions for COPD management. This study identifies some potential facilitators and barriers that may inform the successful development and implementation of mHealth interventions for COPD management.

Background-Access to medical care differs between urban and rural residents, but the magnitude of these differences and whether they affect outcomes are unknown. We aimed to determine whether outcomes differ for patients with incident heart failure (HF) by urban-rural status. Methods and Results-This cohort study used administrative data from Alberta, Canada. Patients with incident HF were identified from April 1, 1999, to December 31, 2005, and followed for 1-year. Multivariable logistic regression was used to assess differences in 1-year outcomes after initial HF diagnosis in patients living in rural versus urban settings. We identified 72 043 patients with incident HF (mean age, 72Ϯ14; male sex, 50%) of whom 12 173 (17%) died and 29 074 (39%) were hospitalized within 1 year. Although crude all-cause 1-year mortality rates were higher in urban than in rural residents (17.3% versus 15.6%, PϽ0.001), after adjustment for comorbidities, no significant differences were observed (adjusted odds ratio [aOR], 0.95; 95% CI, 0.90 to 1.00). However, sex-specific analyses indicated that urban men had a significantly lower risk of mortality than rural men (aOR, 0.89; 95% CI, 0.83 to 0.96). In contrast, no difference was observed between urban and rural women (aOR, 1.02; 95% CI, 0.94 to 1.10). Urban patients were more likely to have office-based physician visits in the first year after HF diagnosis (aOR, 1.09; 95% CI, 1.02 to 1.17) and exhibited lower rates of hospitalization (aOR, 0.71; 95% CI, 0.68 to 0.74) and emergency department visits (aOR, 0.62; 95% CI, 0.60 to 0.65) than rural patients. Conclusions-Even within a universal healthcare system, there are differences in outcomes after HF diagnosis based on location of residence. Urban patients with HF are more likely to receive outpatient care and less likely to be hospitalized or present to the emergency department in the first year after diagnosis than rural patients with HF. (Circ Heart Fail. 2011;4:317-323.)

BackgroundPeople with diabetes may be at higher risk for acquiring infections through both glucose-dependent and biologic pathways independent of glycemic control. Our aim was to estimate the association between diabetes and infections occurring in primary care.MethodsUsing the Newfoundland and Labrador Sentinel of the Canadian Primary Care Sentinel Surveillance Network, patients with diabetes ≥18 years between 1 January 2008 and 31 March 2013 were included with at least 1-year of follow-up. We randomly matched each patient with diabetes on the date of study entry with up to 8 controls without diabetes. Primary outcome was the occurrence of ≥1 primary care physician visits for any infectious disease. Secondary outcomes included primary visits for head & neck, respiratory, gastrointestinal, genitourinary, skin and soft tissue, musculoskeletal, and viral infections. Using multivariable conditional logistic regression analysis, we measured the independent association between diabetes and the occurrence of infections.ResultsWe identified 1779 patients with diabetes who were matched to 11,066 patients without diabetes. Patients with diabetes were older, had a higher prevalence of comorbidities, and were more often referred to specialists. After adjusting for potential confounders, patients with diabetes had an increased risk of any infection compared to patients without diabetes (adjusted odds ratio = 1.21, 95% confidence interval 1.07–1.37). Skin and soft tissue infections had the strongest association, followed by genitourinary, gastrointestinal, and respiratory infections. Diabetes was not associated with head and neck, musculoskeletal, or viral infections.ConclusionPatients with diabetes appear to have an increased risk of certain infections compared to patients without diabetes.Electronic supplementary materialThe online version of this article (10.1186/s12879-018-2975-2) contains supplementary material, which is available to authorized users.

Objective To quantify the association between diabetes and the risk of incident infections by conducting a systematic review and meta-analysis. Research design and methods Two reviewers independently screened articles identified from PubMed, EMBASE, Cochrane Library, IPA, and Web of Science databases. Cohort studies (CS) or case-control studies (CCS) evaluating the incidence of infections in adults with diabetes were included. Infections were classified as: skin and soft tissue, respiratory, blood, genitourinary, head and neck, gastrointestinal, bone, viral, and nonspecified infections. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Summary crude and adjusted OR with 95% CIs were calculated using random effects models, stratified by study design. Heterogeneity was measured using the I 2 statistic and explored using subgroup analyses. Results A total of 345 (243 CS and 102 CCS) studies were included. Combining adjusted results from all CS, diabetes was associated with an increased incidence of skin (OR 1.94, 95% CI 1.78 to 2.12), respiratory (OR 1.35, 95% CI 1.28 to 1.43), blood (OR 1.72, 95% CI 1.48 to 2.00), genitourinary (OR 1.61, 95% CI 1.42 to 1.82), head and neck (OR 1.17, 95% CI 1.13 to 1.22), gastrointestinal (OR 1.48, 95% CI 1.40 to 1.57), viral (OR 1.29, 95% CI 1.13 to 1.46), and non-specified (OR 1.84, 95% CI 1.66 to 2.04) infections. A stronger association was observed among CCS: skin (OR 2.64, 95% CI 2.20 to 3.17), respiratory (OR 1.62, 95% CI 1.37 to 1.92), blood (OR 2.40, 95% CI 1.68 to 3.42), genitourinary (OR 2.59, 95% CI 1.60 to 4.17), gastrointestinal (OR 3.61, 95% CI 2.94 to 4.43), and nonspecified (OR 3.53, 95% CI 2.62 to 4.75). Conclusion Diabetes is associated with an increased risk of multiple types of infections. A high degree of heterogeneity was observed; however, subgroup analysis decreased the amount of heterogeneity within most groups. Results were generally consistent across types of infections. INTRODUCTIONThe International Diabetes Federation estimates that there were almost 400 million people living with diabetes throughout the world in 2014. The prevalence of diabetes is expected to increase to more than 590 million people by the year 2035.1 Well-known complications of diabetes include both microvascular (retinopathy, neuropathy, nephropathy) and macrovascular (coronary heart disease, cerebrovascular disease, and peripheral vascular disease) 2 ; however, there are numerous lesser known complications including effects on immunity.3-5 Immune system dysfunction in people with diabetes may be mediated through impaired migration, phagocytosis, intracellular killing, and chemotaxis. [4][5][6][7][8] Indeed, several studies have suggested that people with diabetes are at an increased risk of infection-related mortality 9 10 ; however, not all studies support such an association. 12Furthermore, patients with diabetes tend to be hospitalized for infections more frequently than those without.