Expenditure on diabetes treatments and achievement of glycaemic control: retrospective analysis

AIMS

To establish if a relationship exists between the prescribing costs of diabetes treatments and the achievement of Quality and Outcome Framework DM6 standards of glycaemic control.

METHODS

A retrospective cross-sectional study of all 92 primary care organizations in the north of England comparing net ingredient cost of diabetes treatments, corrected for diabetic population, with the percentage of patients achieving HbA(1c) < 7.4% (Quality and Outcome Framework DM6 indicator).

RESULTS

The overall net ingredient cost for diabetes treatments varies from pound 225 to pound 382 per person per year. On regression analysis, expenditure on all diabetes treatments, on glitazones or on blood glucose test strips have no significant impact upon the percentage of people achieving an HbA(1c) < 7.4%. There is an inverse relationship between spending on analogue insulins and target achievement (r = -0.08, P = 0.001).

CONCLUSIONS

At primary care organization level, there is no association between weighted expenditure on diabetes treatments and achievement of glycaemic control targets. Although there are limitations to what can be inferred from analyses of this type, these data support a judicious and carefully directed approach to the use of newer, more expensive treatments until clear evidence of added benefit is forthcoming.

Gastrointestinal complications of epidermolysis bullosa in children

BACKGROUND

Epidermolysis bullosa (EB) is a group of inherited disorders characterized by skin and mucous membrane fragility. Gastrointestinal (GI) complications have been described in many types of EB and are responsible for significant morbidity.

OBJECTIVES

To delineate the nature and frequency of GI complications in a large cohort of paediatric patients with EB and to postulate why some complications occur more commonly in some specific subtypes.

METHODS

The case notes of 223 children with EB seen at a national referral centre were examined retrospectively for the presence of GI symptoms, investigations and interventions.

RESULTS

GI complications were present in 130/223 (58%) of all patients. In EB simplex, constipation and gastro-oesophageal reflux (GOR) were frequently observed. In junctional EB, failure to thrive and protein-losing enteropathy (PLE) were the prominent GI manifestations. Constipation was common in patients with dystrophic EB (DEB) requiring laxatives and in some cases fibre supplementation. GOR affected three-quarters of those with recessive DEB, two-thirds also having significant oesophageal strictures. Over half of patients with recessive DEB required gastrostomy insertion. Diarrhoea affected a small but significant proportion of children with recessive DEB with macroscopic and/or microscopic changes of colitis in the majority.

CONCLUSION

GI problems in EB are very common with subtype specificity for some of these complications. The occurrence of diarrhoea, PLE and colitis in the context of EB has not been highlighted previously, and may arise secondarily to antigenic exposure in the gut lumen as a result of mucosal fragility.

Prognostic significance of thymidylate synthase, dihydropyrimidine dehydrogenase and thymidine phosphorylase protein expression in colorectal cancer patients treated with or without 5-fluorouracil-based chemotherapy

BACKGROUND

Low tumour expression levels of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD) and thymidine phosphorylase (TP) have been linked with improved outcome for colorectal cancer (CRC) patients treated with 5-fluorouracil (5-FU). It is unclear whether this occurs because such tumours have better prognosis or they are more sensitive to 5-FU treatment.

PATIENTS AND METHODS

Associations between TS, DPD and TP levels, determined by tissue microarrays and immunohistochemistry, and survival was evaluated in 945 CRC patients according to treatment status.

RESULTS

Low TS and DPD expression associated with worse prognosis in stage II [hazard ratio (HR) = 1.69, 95% confidence interval (CI) (1.09-2.63) and HR = 1.92 (95% CI 1.23-2.94), respectively] and stage III CRC patients treated by surgery alone [HR = 1.39 (95% CI 0.92-2.13) and HR = 1.49 (95% CI 1.02-2.17), respectively]. Low TS, DPD and TP associated with trends for better outcome in stage III patients treated with 5-FU [HR = 0.81 (95% CI 0.49-1.33), HR = 0.70 (95% CI 0.42-1.15) and HR = 0.66 (95% CI 0.39-1.12), respectively].

CONCLUSION

Low TS and DPD expression are prognostic for worse outcome in CRC patients treated by surgery alone, whereas low TS, DPD and TP expression are prognostic for better outcome in patients treated with 5-FU chemotherapy. These results provide indirect evidence that low TS, DPD and TP protein expression are predictive of good response to 5-FU chemotherapy.

Toward distinguishing woodsmoke and diesel exhaust in ambient particulate matter

Particulate matter (PM) from biomass burning and diesel exhaust has distinct X-ray spectroscopic, carbon specific signatures, which can be employed for source apportionment. Characterization of the functional groups of a wide selection of PM samples (woodsmoke, diesel soot, urban air PM) was carried out using the soft X-ray spectroscopy capabilities at the synchrotron radiation sources in Berkeley (ALS) and Brookhaven (NSLS). The spectra reveal that diesel exhaust particulate (DEP) matter is made up from a semigraphitic solid core and soluble organic matter, predominantly with carboxylic functional groups. Woodsmoke PM has no or a less prevalent, graphitic signature, instead it contains carbon-hydroxyl groups. Using these features to apportion the carbonaceous PM in ambient samples we estimate that the relative contribution of DEP to ambient PM in an urban area such as Lexington, KY and St. Louis, MO is 7% and 13.5%, respectively. These values are comparable to dispersion modeling data from nonurban and urban areas in California, and with elemental carbon measurements in urban locations such as Boston, MA, Rochester, NY, and Washington, DC.

Gender differences in diastolic function among youth

BACKGROUND

Youth were studied to determine the influence of gender on diastolic function, which has been shown to express abnormalities early in the course of congestive heart failure.

METHODS

The study participants were 121 normotensive individuals (53 girls, 68 boys) ages 14 to 18 years. Demographics, hemodynamics, and Doppler-derived indices of diastolic function were collected. Dependent measures of diastolic function were the ratio of early (E) to late (A) peak filling velocities and the isovolumetric relaxation time (IVRT).

RESULTS

The girls had a higher relative wall thickness (RWT) (36.58% +/- 4.59% vs 34.60% +/- 4.01%; p < 0.02), higher A (48.40 +/- 8.47 cm/s vs 42.36 +/- 10.43 cm/s; p < 0.001), a lower E/A ratio (1.96 +/- 0.40 vs 2.38 +/- 0.68; p < 0.01), and a shorter IVRT (51.80 +/- 11.14 ms vs 59.00 +/- 14.36 ms; p < 0.01) than the boys. The differences in deceleration time were not significant (181.30 +/- 81.33 ms vs 170.30 +/- 31.06 ms). Hierarchical stepwise regression analysis predicting E/A ratio found gender (male > female) to be the best predictor (R (2 )= 0.09) followed by heart rate (R (2) increase = 0.07; total R (2 )= 0.15; p < 0.01) and by RWT (R (2) increase = 0.05; total R (2 )= 0.21; p < 0.015). For IVRT prediction, gender (male > female) was the best predictor (R (2 )= 0.11), followed by total peripheral resistance (R (2) increase = 0.06; total R (2 )= 0.17; p < 0.017).

CONCLUSION

The study data indicate that gender differences in diastolic function exist already in youth. Girls show a higher RWT, a lower E/A ratio, and a shorter IVRT. The implications of these differences for cardiovascular morbidity and mortality of the two genders require attention.

Validation of a computerised logMAR visual acuity measurement system (COMPlog): comparison with ETDRS and the electronic ETDRS testing algorithm in adults and amblyopic children

BACKGROUND/AIM

The COMPlog clinical visual acuity measuring system is being developed for both routine and research use. This study aimed to validate its performance in amblyopic children and both normal and diseased adults against the gold standard ETDRS chart and the E-ETDRS computerised acuity measurement algorithm.

METHOD

Timed test and retest fully interpolated five letters per line logMAR visual acuity measurements were taken for 70 adults and 59 amblyopic children using the ETDRS chart and the COMPlog visual acuity measurement system. 39 of the adults also underwent computerised acuity testing using the E-ETDRS testing algorithm. The tested adults included normals as well as subjects with a range of ocular diseases. The methods of Bland and Altman were employed with test-retest variability (TRV) expressed as 95% confidence limits for agreement.

RESULTS

No significant bias was observed between the gold standard ETDRS acuity measurements and those taken with either COMPlog or E-ETDRS. TRVs of +/-0.12 logMAR and +/-0.10 logMAR were respectively found for COMPlog measurements in the amblyopic children and adult groups compared with +/-0.12 logMAR for the ETDRS chart in both groups. The TRV of the E-ETDRS system was slightly greater at +/-0.16 logMAR. Median testing times for COMPlog and ETDRS were 95 and 85 s and 66 and 56 s respectively in the paediatric and adult groups and 120 s for the E-ETDRS measurements on adults.

DISCUSSION

COMPlog measurements agree well with and are similarly reliable to the gold standard ETDRS chart with comparable test times. E-ETDRS algorithm measurements took approximately twice as long.

Heparin-bonded catheters for prolonging the patency of central venous catheters in children

BACKGROUND

Central venous catheters (CVCs) are a mainstay in the management of critically ill children. However, these catheters are associated with mechanical and infectious complications which reduce their life span. Heparin bonding of catheters has shown promise in animal studies and in adults.

OBJECTIVES

The primary objective was to determine the effect of heparin-bonded CVCs on the duration of catheter patency in children. Secondary objectives were to determine the effect of heparin-bonded catheters on catheter related thrombosis, occlusion, sepsis and side effects.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Register (inception to August 2007) which contains trials identified through searches of MEDLINE (1966 to August 2007), EMBASE (1980 to August 2007), CINAHL (1982 to August 2007), and hand searches along with the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2007, Issue 3.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials of heparin-bonded catheters versus non-heparin bonded catheters or antibiotic-impregnated catheters that reported on any of the prespecified outcomes, without language restriction.

DATA COLLECTION AND ANALYSIS

Methodological quality of the trials was assessed using the information provided in the studies and by contacting authors. Data were extracted and the effect size was estimated and reported as relative risk (RR), risk difference (RD) or number needed to treat (NNT), as appropriate.

MAIN RESULTS

Two eligible studies reflecting 287 patients were included; both had good methodological quality. There was no difference in the duration of catheter patency between heparin bonded and non-heparin bonded catheters (median duration 7 days vs 6 days) reported in one study. There was no difference in the risk of catheter related thrombosis (RR 0.71, 95% CI 0.44 to 1.15; RD -0.05, 95% CI 0.13 to 0.02; I(2) = 79%). Data from one study revealed a statistically significant reduction in the risk of catheter occlusion (RR 0.06, 95% CI 0.00 to 1.07; RD -0.08, 95% CI -0.13 to -0.02; NNT 13, 95% CI 8 to 50), catheter-related infections (RR 0.06, 95% CI 0.01 to 0.41; RD -0.17, 95% CI -0.25 to -0.10; NNT 6, 95% CI 4 to 10) and catheter colonization (RR 0.21, 95% CI 0.06 to 0.71; RD -0.11, 95% CI -0.19 to -0.04; NNT 9, 95% CI 5 to 25) in the heparin-bonded catheter group.

AUTHORS' CONCLUSIONS

Two eligible studies on the use of heparin-bonded catheters versus placebo in children were identified. The use of heparin-bonded catheters is a promising therapy but warrants further studies.

Effects of genetic variation in the novel organic cation transporter, OCTN1, on the renal clearance of gabapentin

Gabapentin is an anticonvulsant that is widely prescribed for epilepsy and other neuropathic disorders. The pharmacokinetics, particularly the absorption and renal elimination, of gabapentin appear to involve membrane transporters. In this study, we tested the hypothesis that organic cation transporter 1 (OCTN1), a multispecific transporter expressed at the apical membrane in intestine and kidney, plays a role in gabapentin pharmacokinetics and that the common variant of OCTN1, OCTN1-L503F, contributes to variation in the pharmacokinetics of the drug. We observed that OCTN1 facilitates the Na+-independent transport of gabapentin, and that the OCTN1-L503F variant is deficient in gabapentin transport activity in stably transfected HEK-293 cells (fourfold enhanced uptake of gabapentin by OCTN1-503L vs twofold enhanced uptake by OCTN1-L503F, compared to mock-transfected cells). In clinical studies, we found that in subjects homozygous for the L503F variant, gabapentin renal clearance (CL(R)) approximates the glomerular filtration rate (mean+/-SE: 110+/-12 ml/min, n=9), whereas in subjects homozygous for the reference allele, gabapentin undergoes net secretion in the kidney (141+/-7.8 ml/min, n=11, P<0.05). Creatinine clearance and OCTN1 genotype accounted for 56% of the variation in CL(R) and were the only significant predictors of CL(R) (P<0.05). Importantly, OCTN1 genotype was the only significant predictor of net secretion of gabapentin (P<0.008). Oral bioavailability of gabapentin was not affected by OCTN1 genotype. We conclude that OCTN1 contributes to active tubular secretion of gabapentin, and that this effect may be diminished or absent in individuals carrying the OCTN1-L503F polymorphism. These results provide clinical evidence of the role of genetic variation in renal drug transporters in active drug secretion in vivo.

Non-malignant disease mortality in meat workers: a model for studying the role of zoonotic transmissible agents in non-malignant chronic diseases in humans

BACKGROUND

Current research efforts have mainly concentrated on evaluating the role of substances present in animal food in the aetiology of chronic diseases in humans, with relatively little attention given to evaluating the role of transmissible agents that are also present. Meat workers are exposed to a variety of transmissible agents present in food animals and their products. This study investigates mortality from non-malignant diseases in workers with these exposures.

METHODS

A cohort mortality study was conducted between 1949 and 1989, of 8520 meat workers in a union in Baltimore, Maryland, who worked in manufacturing plants where animals were killed or processed, and who had high exposures to transmissible agents. Mortality in meat workers was compared with that in a control group of 6081 workers in the same union, and also with the US general population. Risk was estimated by proportional mortality and standardised mortality ratios (SMRs) and relative SMR.

RESULTS

A clear excess of mortality from septicaemia, subarachnoid haemorrhage, chronic nephritis, acute and subacute endocarditis, functional diseases of the heart, and decreased risk of mortality from pre-cerebral, cerebral artery stenosis were observed in meat workers when compared to the control group or to the US general population.

CONCLUSIONS

The authors hypothesise that zoonotic transmissible agents present in food animals and their products may be responsible for the occurrence of some cases of circulatory, neurological and other diseases in meat workers, and possibly in the general population exposed to these agents.

Efficacy of dasatinib in chronic phase chronic myelogenous leukemia patients after imatinib failure according to baseline BCR- ABL mutations

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Background: Dasatinib is an oral, multi-targeted BCR-ABL and SRC kinase inhibitor with preclinical activity against 20/21 imatinib (Im) resistant BCR-ABL mutations. Clinical efficacy was demonstrated in phase I, II, and III studies in patients (pts) with chronic myelogenous leukemia (CML) in all phases of the disease and BCR-ABL positive acute lymphoblastic leukemia (ALL). We sought to establish a relationship between type of BCR-ABL mutations associated with Im resistance and efficacy of dasatinib in chronic phase (CP) CML pts. Methods: Between 10/03 and 03/06, dasatinib was commenced in 1,093 CP-CML pts recruited for three consecutive trials and administered for a median of 8.7 months (range <1–25.9). BCR-ABL mRNA was screened for mutations of amino acids 207–517 by D-HPLC and/or regular sequencing and data are available from 961 cases (88%). ABL polymorphisms K247R and E499E were excluded from analysis. Results: Prior to dasatinib, 75 different BCR-ABL mutations involving 56 amino acids were detected in 18/240 Im intolerant (7.5%) and 324/721 (45%) Im resistant pts. 267 pts showed one, 53 pts two, 16 pts three, and six pts four mutations. In Im resistant pts, response was not different between 370 pts with and 351 pts without baseline mutations: Complete hematologic response (CHR) was achieved in 89% vs 92%; major cytogenetic response (MCR) in 48% vs 52% being complete (CCR) in 38 vs 36%, respectively. Response dynamics were associated with preclinical activity of dasatinib: classifying mutations for IC50 values <2, 2–20 and >1,000nM (T315I), CHR was achieved in 93, 85 and 28%; MCR in 48, 42 and 0%; and CCR in 37, 35 and 0% of cases, respectively. During follow up, new mutations were detected in 30 cases, predominantly T315I (n=10), Y253H/F (n=4), and F317L (n=3). Conclusions: We conclude that dasatinib is capable of inducing hematologic and cytogenetic remissions in a significant proportion of Im resistant pts associated with BCR-ABL mutations, except T315I, but also in pts with BCR-ABL independent causes of resistance. Quality of response depends on the individual type of the mutation which is consistent with preclinical observations.

No significant financial relationships to disclose.

Bilateral intraparotid and extraparotid Warthin's tumours

Warthin's tumour is a benign adenoma in the parotid gland, but extraparotid and synchronous bilateral Warthin's tumours may occur. In this report, we describe a patient with simultaneous bilateral involvement of the parotid glands and neck by multiple Warthin's tumours, an occurrence not previously described.

The risk of cross-infection when marking surgical patients prior to surgery - review of two types of marking pens

INTRODUCTION

Two types of marker pens were compared to find whether they produced different risks of infection transmission over different time intervals.

PATIENTS AND METHODS

Twenty-four patients were marked according to the type of surgery: each had a set of new dry white-board marker (DWM) and a permanent marker (PM) pen. Once used, their tips were used to inoculate blood agar plates at different time intervals.

RESULTS

At 0 min, 96% of the DWM pens and 29% of the PM pens were positive of growth. At 3 and 10 min, all of the DWM pens remained positive. The rate dropped to 16.67% in 3 min down to none at 10 min for the PM pens.

CONCLUSIONS

DWM pens carry a significant risk of transmitting infection between patients. It is recommended that they are not used in marking. PM pens should not be used between patients in less than a 10-min interval.

Diabetes, kidney disease and anaemia: time to tackle a troublesome triad?

Both chronic kidney disease (CKD) and type II diabetes mellitus (DM) are increasing in frequency among Western populations and both are potent risk factors for the development of anaemia. The presence of CKD and diabetes together represent the most important aetiopathogenic combination for the development of anaemia. New evidence has highlighted some of the underlying mechanisms which make diabetic patients more susceptible to dyserythropoiesis, particularly once they have developed concomitant CKD. In addition, recent publications from large-scale epidemiological studies have highlighted the impact of anaemia on diabetic patients. The purpose of this review was to focus on the pathophysiology and impact of anaemia in DM.

Nevirapine versus efavirenz based antiretroviral treatment in naive Indian patients: comparison of effectiveness in clinical cohort

OBJECTIVE

Our objective was to compare immunologic effectiveness of nevirapine and efavirenz based antiretroviral therapy in antiretroviral naïve HIV-1 infected Indian patients.

DESIGN AND METHODS

Study was an observational, non-randomized, longitudinal cohort. Antiretroviral naive HIV-1 infected patients receiving efavirenz + 2NRTI (n=254) and nevirapine + 2 NRTI (n=857) from April 2000 were followed up at two tertiary care HIV clinics at Ahmedabad and Pune. Patients were followed up clinically monthly and CD4 was carried out every 3 monthly. All patients were examined for various side effects as well as development of various OIs. Data were analyzed using standard statistical methods.

RESULTS

Baseline characteristics for both the groups (NVP and EFV) were comparable. In the random effects model, there was an increase of 40.97 (p < 0.05) units of CD4 cell counts with an unit increase in time in the NVP arm as against a 44.75 (p < 0.05) units of increase in CD4 cell counts in the EFV group with a unit increase in time, which is significant for both groups. However, at any given point of time there was no difference in the rate of increase of CD4 count between the two treatment arms (p = 0.58). Hypersensitivity reaction (6.6% in NVP vs. 2.32% in EFV, p = 0.0146) and hepatitis (3.2% in NVP vs. 0% in EFV, p = 0.0085) were more common with nevirapine, while neurologic disturbances (0.93% in NVP vs. 20.15% in EFV, p = 0.0001) were more common with efavirenz. Incidence of distal sensory neuropathy and lipid abnormalities was similar in both the groups.

CONCLUSION

Use of NVP and EFV based HAART in antiretroviral naive Indian patients led to significant and durable rise in CD4 cell count. Although observational and non-randomized, our study showed equivalent immunological response amongst NVP and EFV based HAART which is in line with the results of the 2NN study.