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Although nearly 31% of men present without chest pain, a much higher proportion of these patients (42%) are women. 1 Women are more likely to present with a number of atypical findings that may require more careful nursing assessments of patient history to elicit: (1) aching, burning, positional, pleuritic, or localizable discomfort that is neither prolonged nor severe TCG Logan Moonrock Lugged High Top Sneaker ekaeOQj
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; and (4) prodromal symptoms such as unexplained fatigue, shortness of breath, anxiety, sleeping difficulties, or mild chest discomfort that may occur 6 weeks to a year preceding an MI. 6

Although the study focused on examining the relationship of age on gender differences in presentation and mortality in patients hospitalized with MI, I made an observation that I did not see noted anywhere in the findings nor highlighted anywhere in the discussion: In every age group for both men ( Figure 2 ) and women ( Kenneth Cole Reaction Slim Tricks Toe Loop Sandal Womens tV3UVp
), the mortality rate for patients who presented “without chest pain” substantially exceeded that of patients in the same age group and of the same gender who presented “with chest pain.”

View larger version:
Figure 2

Hospital mortality for acute myocardial infarction in men with and without chest pain.

View larger version:
Figure 3

Hospital mortality for acute myocardial infarction in women with and without chest pain.

In addition to the influence of presentation on mortality in younger women (“the absence of chest pain may be a more important predictor of death in younger women with MI compared with other similarly aged groups” 1 (p818) ), these data suggest that on a number of levels, not experiencing chest pain in association with acute MI is a formidable risk factor that heralds a significantly greater chance of death for both men and women and at every age. For men in this study, the difference in mortality for those having versus not having chest pain was greatest in the 65 to 74 years age group, in which men with chest pain had a mortality rate of 6.9% and those without chest pain had mortality of 18.9%, a difference of 12%. For women, the absence of chest pain exacted the highest penalty in the youngest group, in which women with chest pain had mortality of 2.0%, while those without chest pain died at a rate of 15.3%, a difference of 13.3%.

Additional Implications

If the additional observations cited here are supported by other studies, then it becomes important that critical care practitioners assess patients for chest pain and document its presence or absence in the medical record. A few other clinical caveats may also be worthy of consideration for nursing management:

If evidence continues to affirm that acute MI presentations without chest pain are strongly associated with lethal outcomes, then instituting and acting upon this categorical distinction seems like a tiny effort that critical care nurses could do to improve survival for those patients.

Raising awareness among critical care practitioners regarding the clinical implications of this potentially lethal negative finding for all MI patients, including (1) awareness that in patients suspected or having acute MI, the of chest pain represents a red flag associated with significantly higher mortality; (2) awareness that women need to be viewed as a high-risk category of MI patients; and (3) awareness that the younger the woman who denies having chest pain, the greater her risk of death from acute MI.

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Facebook’s relationship with publishers has been strained over Facebook cutting referral traffic to publishers, failing to delivery meaningful revenue from their video content and subjecting them to a controversial issues ads policy that Facebook enacted in response to Russian interference in the 2016 presidential election — not to mention mopping up, along with Google, most of the digital ad market.

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Facebook has gotten more flexible as the testing has gone on, following publisher pushback. Facebook initially required publishers to set their meter at 10 articles a month; in April, it loosened that requirement and let publishers set it at the same level as their own sites.

Facebook also has tested subscription signup buttons outside Instant Articles, on publishers’ Facebook pages, to expand the number of places users might run into subscription offers. It’s tested the ability for publishers to make time-specific offers, like a July 4 sale, and to decide which articles are locked to non-subscribers. It’s also tested ways to predict if someone is likely to subscribe, and putting more subscription offers in front of those people. Right now, the metered model is based on monthly prices, but Facebook said it plans to give publishers the ability to make offers on a weekly and daily basis, too.

A sticking point for some publishers may be that the subscription test requires them to use Facebook’s Instant Articles format. Many publishers have cut back on or stopped using the fast-loading articles feature because they’d rather have visitors read articles on their own sites and Instant Articles keeps readers in Facebook’s ecosystem (and generates ad revenue for Facebook). Many also said they can make more money by selling ads on their own mobile sites. For subscription publishers to rethink Instant Articles, they’d need to see subscription sales there offset any ad revenue downside.

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Article Text

Diabetes and endocrinology
Safety and efficacy of insulin glargine 300 u/mL compared with other basal insulin therapies in patients with type 2 diabetes mellitus: a network meta-analysis

Objective To compare the efficacy and safety of a concentrated formulation of insulin glargine (Gla-300) with other basal insulin therapies in patients with type 2 diabetes mellitus (T2DM).

Design This was a network meta-analysis (NMA) of randomised clinical trials of basal insulin therapy in T2DM identified via a systematic literature review of Cochrane library databases, MEDLINE and MEDLINE In-Process, EMBASE and PsycINFO.

Outcome measures Changes in HbA1c (%) and body weight, and rates of nocturnal and documented symptomatic hypoglycaemia were assessed.

Results 41 studies were included; 25 studies comprised the main analysis population: patients on basal insulin-supported oral therapy (BOT). Change in glycated haemoglobin (HbA1c) was comparable between Gla-300 and detemir (difference: −0.08; 95% credible interval (CrI): −0.40 to 0.24), neutral protamine Hagedorn (NPH; 0.01; −0.28 to 0.32), degludec (−0.12; −0.42 to 0.20) and premixed insulin (0.26; −0.04 to 0.58). Change in body weight was comparable between Gla-300 and detemir (0.69; −0.31 to 1.71), NPH (−0.76; −1.75 to 0.21) and degludec (−0.63; −1.63 to 0.35), but significantly lower compared with premixed insulin (−1.83; −2.85 to −0.75). Gla-300 was associated with a significantly lower nocturnal hypoglycaemia rate versus NPH (risk ratio: 0.18; 95% CrI: 0.05 to 0.55) and premixed insulin (0.36; 0.14 to 0.94); no significant differences were noted in Gla-300 versus detemir (0.52; 0.19 to 1.36) and degludec (0.66; 0.28 to 1.50). Differences in documented symptomatic hypoglycaemia rates of Gla-300 versus detemir (0.63; 0.19to 2.00), NPH (0.66; 0.27 to 1.49) and degludec (0.55; 0.23 to 1.34) were not significant. Extensive sensitivity analyses supported the robustness of these findings.

Conclusions NMA comparisons are useful in the absence of direct randomised controlled data. This NMA suggests that Gla-300 is also associated with a significantly lower risk of nocturnal hypoglycaemia compared with NPH and premixed insulin, with glycaemic control comparable to available basal insulin comparators.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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Strengths and limitations of this study

This is the first comprehensive literature review and network meta-analysis (NMA) summarising the available clinical trial literature on the clinical benefits of the newly approved basal insulin, Gla-300, and potential basal insulin comparators, and enabling comparisons between these therapies.

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