AimsTo determine the global extent of hypoglycaemia experienced by patients with diabetes using insulin, as there is a lack of data on the prevalence of hypoglycaemia in developed and developing countries.MethodsThis non‐interventional, multicentre, 6‐month retrospective and 4‐week prospective study using self‐assessment questionnaire and patient diaries included 27 585 patients, aged ≥18 years, with type 1 diabetes (T1D; n = 8022) or type 2 diabetes (T2D; n = 19 563) treated with insulin for >12 months, at 2004 sites in 24 countries worldwide. The primary endpoint was the proportion of patients experiencing at least one hypoglycaemic event during the observational period.ResultsDuring the prospective period, 83.0% of patients with T1D and 46.5% of patients with T2D reported hypoglycaemia. Rates of any, nocturnal and severe hypoglycaemia were 73.3 [95% confidence interval (CI) 72.6–74.0], 11.3 (95% CI 11.0–11.6) and 4.9 (95% CI 4.7–5.1) events/patient‐year for T1D and 19.3 (95% CI 19.1–19.6), 3.7 (95% CI 3.6–3.8) and 2.5 events/patient‐year (95% CI 2.4–2.5) for T2D, respectively. The highest rates of any hypoglycaemia were observed in Latin America for T1D and Russia for T2D. Glycated haemoglobin level was not a significant predictor of hypoglycaemia.ConclusionsWe report hypoglycaemia rates in a global population, including those in countries without previous data. Overall hypoglycaemia rates were high, with large variations between geographical regions. Further investigation into these differences may help to optimize therapy and reduce the risk of hypoglycaemia.

This study aimed to observe the incidence rates of hamstring strain injuries (HSIs) across different competition levels and ages during the Penn Relays Carnival. Over a 3-year period, all injuries treated by the medical staff were recorded. The type of injury, anatomic location, event in which the injury occurred, competition level, and demographic data were documented. Absolute and relative HSI (per 1000 participants) were determined, and odds ratios (ORs) were calculated between sexes, competition levels, and events. Throughout the study period 48,473 athletes registered to participate in the Penn Relays Carnival, with 118 HSIs treated by the medical team. High school girls displayed lesser risk of HSI than high school boys (OR = 0.55, P = 0.021), and masters athletes were more likely than high school- (OR = 4.26, P < 0.001) and college-level (OR = 3.55, P = 0.001) athletes to suffer HSI. The 4 × 400-m relay displayed a greater likelihood of HSI compared with the 4 × 100-m relay (OR = 1.77, P = 0.008). High school boys and masters-level athletes are most likely to suffer HSI, and there is higher risk in 400-m events compared with 100-m events.

Hypoglycaemia has a major impact on patients and their behaviour. These global data for the first time reveal regional variations in response to hypoglycaemia and highlight the importance of patient education and management strategies.

Gastrointestinal (GI) complaints are common among athletes with rates in the range of 30% to 70%. Both the intensity of sport and the type of sporting activity have been shown to be contributing factors in the development of GI symptoms. Three important factors have been postulated as contributing to the pathophysiology of GI complaints in athletes: mechanical forces, altered GI blood flow, and neuroendocrine changes. As a result of those factors, gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI bleeding, or exercise-related transient abdominal pain (ETAP) may develop. GERD may be treated with changes in eating habits, lifestyle modifications, and training modifications. Nausea and vomiting may respond to simple training modifications, including no solid food 3 hours prior to an athletic event. Mechanical trauma, decreased splanchnic blood flow during exercise, and non-steroidal anti-inflammatory drugs (NSAID) contribute to gastritis, GI bleeding, and ulcer formation in athletes. Acid suppression with proton-pump inhibitors may be useful in athletes with persistence of any of the above symptoms. ETAP is a common, poorly-understood, self-limited acute abdominal pain which is difficult to treat. ETAP incidence increases in athletes beginning a new exercise program or increasing the intensity of their current exercise program. ETAP may respond to changes in breathing patterns or may resolve simply with continued training. Evaluation of the athlete with upper GI symptoms requires a thorough history, a detailed training log, a focused physical examination aimed at ruling out potentially serious causes of symptoms, and follow-up laboratory testing based on concerning physical examination findings.

Serum IDeg concentrations reached steady state within 2-3 days of once-daily subcutaneous administration in all subjects with T1DM or T2DM, including elderly and African American and Hispanic/Latino subjects. At steady state, serum IDeg concentrations were unchanged from day to day.

Acupuncture is an ancient traditional Chinese medical therapy that is used widely around the world. When practiced by a certified provider, it is safe and often perceived as calming and relaxing for patients. Animal and human studies have found a physiological basis for acupuncture needling in that it affects the complex central and peripheral neuro-hormonal network. Although it is unclear whether acupuncture is beneficial over sham/placebo acupuncture, acupuncture care yields clinically relevant short-and long-term benefits for low back pain, knee osteoarthritis, chronic neck pain, and headache. The integration of acupuncture into a primary care setting also appears to be cost-effective. Furthermore, the practice of acupuncture in primary care involves rigorous training, financial discipline, and art of communication. When it is done correctly, acupuncture proves to be beneficial for both patients and providers. KeywordsAcupuncture/history/standards; Acupuncture Therapy/adverse effects; China; Evidence-Based Medicine; Meta-Analysis; Primary Care General IntroductionAcupuncture is a traditional Chinese medical therapy that uses hair-thin metal needles to puncture the skin at specific points on the body to relieve pain and promote wellbeing. In this paper we provide a historical and philosophical overview of acupuncture and describe its current use in the United States. We will then synthesize the basic scientific theory of acupuncture and present recent clinical evidence of how acupuncture may be used for a broad category of diseases with a specific focus on conditions common to a primary care clinic, including low back pain, osteoarthritis, neck pain and headache. Furthermore, we will discuss the practical issues concerning the integration of acupuncture into primary care to create coordinated, patient-centered care.

AimsA prospective meta‐analysis of phase 3 trials showed lower rates of nocturnal hypoglycaemia with insulin degludec vs. insulin glargine. We investigated the consistency of the results across different definitions of hypoglycaemia.MethodsThis post‐hoc, patient‐level meta‐analysis included six randomized, controlled, 26‐ or 52‐week phase 3a trials in insulin‐naïve participants with Type 2 diabetes mellitus (Type 2 diabetesinsulin naïve), participants with Type 2 diabetes mellitus using basal−bolus therapy (Type 2 diabetesBB) and those with Type 1 diabetes mellitus. We used three definitions of hypoglycaemia and different timescales for the nocturnal period. Rates were analysed for the entire core trial period, the ‘maintenance period’ only, and the extension trial set population. Analyses utilized a negative binomial regression model.ResultsIn Type 2 diabetesinsulin naïve participants, risk of nocturnal hypoglycaemia was significantly lower with insulin degludec vs. insulin glargine for all hypoglycaemia definitions and trial periods. Risk was also lower for the timescale 21.59–05.59, but not 00.01–07.59. For Type 2 diabetesBB, nocturnal hypoglycaemia rates were lower with insulin degludec vs. insulin glargine across all definitions, timescales and trial periods, with one exception. For individuals with Type 1 diabetes mellitus, nocturnal hypoglycaemia risk was significantly lower with insulin degludec during the maintenance period for the original definition (plasma glucose < 3.1 mmol/l, timescale 00.01–05.59) and in the extension trial set population for all hypoglycaemia definitions except for the nocturnal timescale 00.01–07.59.ConclusionsCompared with insulin glargine, insulin degludec is associated with lower rates of nocturnal hypoglycaemia in people with Type 2 diabetes mellitus, and similar or lower rates in Type 1 diabetes mellitus, across different definitions.

Meningitis and the clinical syndrome of acute meningococcemia are well-described sequelae from infections caused by Neisseria meningitidis. Within the realm of this syndrome, secondary sites of infection are not uncommon. There is a concomitant septic arthritis in 11% of cases of meningococcemia. 1 We describe below the rare clinical scenario of a 29-year-old woman with primary meningococcal arthritis without the clinical syndrome associated with meningococcemia. Case ReportA 29-year-old woman presented to the outpatient office with a chief complaint of an acutely painful and swollen left knee. On awaking that morning, she noted a decreased ability to flex and extend her left knee and extreme pain during ambulation. She had no medical or surgical history and was not on any medications. When doctors inquired about sexual contacts, she stated she had not been sexually active in the past 3 months. Three weeks before, she had a negative screening test for Neisseria gonorrhea and Chlamydia trachomatis during an annual gynecologic examination. She was afebrile and other vital signs were normal. She appeared to be well, but an erythematous, warm, swollen left knee that was diffusely tender to palpation was found. Active and passive range of motion was severely limited secondary to pain. An erythematous, macular rash was noted on the bilateral lower extremities. She was promptly transferred to the hospital with the diagnosis of septic arthritis.Orthopedic surgery consultation was obtained on arrival to the emergency department. Aspiration of the left knee yielded grossly purulent synovial fluid. It was sent for evaluation by Gram stain, culture, cell count, and crystal analysis. Serum laboratory testing for C-reactive protein, complete blood cell count, and 2 sets of blood cultures was performed (see Table 1). The patient was started on Vancomycin 1 g intravenously every 12 hours for Gram-positive bacteria, given the initial gram stain result. She was taken to the operating room for urgent arthroscopic incision, drainage, and lavage of the left knee. During transportation to the operating room, the patient developed pain in the left shoulder. Examination at that time revealed decreased range of motion secondary to pain. Arthrocentesis of the left shoulder, while the patient was under anesthesia, yielded grossly purulent fluid. Open incision and drainage of the left shoulder was performed, followed by arthroscopic incision and drainage of the left knee.On postoperative day 1, blood cultures and synovial fluid cultures collected from operative intervention revealed Gram-negative diplococci. Ceftriaxone 1 g intravenously every 24 hours was initiated for presumed gonococcal arthritis. Soon thereafter, the organisms were identified as Neisseria meningitides; vancomycin was discontinued. Two sets of blood cultures revealed N. meningitidis. The patient had fever of 102.9°F on postoperative day 2, but she remained stable and never showed signs or symptoms of meningitis or the clinical syndrome of meningococcemia during her hosp...