A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes

AIMS/HYPOTHESIS

This 52-week multinational, randomised, open-label, parallel-group, non-inferiority trial compared clinical outcomes following supplementation of oral glucose-lowering drugs with basal insulin analogues detemir and glargine in type 2 diabetic patients.

METHODS

Insulin-naive adults (n=582, HbA(1c) 7.5-10.0%, BMI <or= 40.0 kg/m(2)) were randomised 1:1 to receive insulin detemir or glargine once daily (evening) actively titrated to target fasting plasma glucose (FPG) <or= 6.0 mmol/l. An additional morning insulin detemir dose was permitted if pre-dinner plasma glucose (PG) was >7.0 mmol/l after achieving FPG <7.0 mmol/l. Due to labelling restrictions, no second glargine dose was allowed.

RESULTS

Baseline HbA(1c) decreased from 8.6 to 7.2 and 7.1% (NS) with detemir and glargine, respectively. FPG improved from 10.8 to 7.1 and 7.0 mmol/l (NS), respectively. With detemir, 45% of participants completed the study on once daily dosing and 55% on twice daily dosing, with no difference in HbA(1c). Overall, 52% of participants achieved HbA(1c) <or= 7.0%: 33% (detemir) and 35% (glargine) without hypoglycaemia. Within-participant variability for self-monitored FPG and pre-dinner PG did not differ by insulin treatment, nor did the relative risk of overall or nocturnal hypoglycaemia. Modest reductions in weight gain were seen with detemir vs glargine in completers (3.0 vs 3.9 kg, p=0.01) and in the intention-to-treat population (2.7 vs 3.5 kg, p=0.03), primarily related to completers on once-daily detemir. Mean daily detemir dose was higher (0.78 U/kg [0.52 with once daily dosing, 1.00 U/kg with twice daily dosing]) than glargine (0.44 IU/kg). Injection site reactions were more frequent with detemir (4.5 vs 1.4%).

CONCLUSIONS/INTERPRETATION

Supplementation of oral agents with detemir or glargine achieves clinically important improvements in glycaemic control with low risk of hypoglycaemia. Non-inferiority was demonstrated for detemir using higher insulin doses (mainly patients on twice daily dosing); weight gain was somewhat reduced with once daily insulin detemir.

Selection of patients for liver transplantation and allocation of donated livers in the UK

BACKGROUND

The increasing shortfall between the number of patients who would benefit from liver transplantation and the availability of donor livers means that rationing has to occur. The processes of selection of patients for transplantation and for allocation of donor livers should be done according to ethical and, where possible, evidence-based criteria so that there is clarity and that the competing requirements of equity, justice, utility and benefit can be balanced.

METHODS

To achieve these goals for patients in the United Kingdom in need of transplantation, we have developed guidelines for the selection of patients to the national waiting list based on the risk of death without a transplant and the ability of the procedure to improve the recipient's quality of life. Guidelines have been developed for both those with acute liver failure and chronic liver disease. Allocation will depend on matching of the donor liver to the recipient.

RESULTS

The proposed system, to be introduced into the UK compares with some other systems, where different models for selection and allocation have been introduced.

Factors and perceptions that influence women's decisions to have a single embryo transferred

The aim of this study was to identify factors that inhibit or promote the adoption of single embryo transfer (SET). A cohort of 163 women patients receiving IVF/intracytoplasmic sperm injection treatment, comprising 87 women choosing SET and 63 women choosing double embryo transfer (DET), were interviewed using a structured questionnaire. The data were compared using logistic regression analysis. Confidence in the chance of pregnancy with SET, younger age and first treatment were predictive of a decision for SET. Preference for a healthy and singleton pregnancy was predictive but perceptions of the incidence or risk of multiple gestation were not. Factors such as a sense of time urgency and past experience of treatment were significant and predictive of diminished choice of SET. The clinic doctor was an important influencing factor. The results of this study confirm that improved pregnancy rates in SET coupled with an official clinic policy to promote SET in younger, first cycle patients influenced many women to choose SET. However, repeated treatment, advancing age and urgency to become pregnant are factors that moderate a woman's choice for SET.

Quality of diabetes care in the UK: comparison of published quality-of-care reports with results of the Quality and Outcomes Framework for Diabetes

AIMS

To conduct a systematic review of published observational studies of quality of diabetes care in primary care in the UK and to compare the results with the quality of care data from the Quality and Outcomes Framework (QOF) of the new General Practice Contract in the UK.

METHODS

medline and embase were searched for articles published from 1999 to June 2006. We also searched for reference lists of studies that fitted our inclusion criteria. All members of the Primary Care Diabetes Europe were contacted and asked to send lists of any relevant published articles. Abstracts were reviewed and data were collected independently by two authors.

RESULTS

Abstracts of 742 papers were identified, of which six papers fulfilled the final selection criteria. The total number of people included in the six published studies was 83 098 (a range of 504 to 54 180 people) compared with the UK QOF data of 1.8 million people with diabetes. The quality indicators for assessment of care varied between different published studies, making comparisons more difficult. Overall, there was a trend towards improvement in both process and outcome of care in the published studies. The quality of care achieved as a result of QOF was greater than that found in published studies.

CONCLUSIONS

There have been improvements in both process and outcome measures recorded in publications of quality of diabetes care in the UK between 2000 and 2004. Modest financial incentives in primary care are a successful method of improving care for people with diabetes.

Crohn's disease: systematic review of assessment of disease severity and its relevance to surgery

BACKGROUND

The aims of treatments for Crohn's disease are symptom control by medical or surgical means and improvement in health-related quality of life (HRQOL). A wide number of classification systems, instruments of disease activity measurement (DAM) and HRQOL are available, but few are used in routine surgical practice.

OBJECTIVE

To review the validity of DAM and HRQOL instruments and their applicability to surgically treated patients.

METHOD

A systematic literature search was undertaken to identify these instruments. Qualifying articles were used to determine the construct, content and criterion validity of the instruments identified with respect to surgically treated patients.

RESULTS

Thirteen disease activity indices and 11 HRQOL assessment tools were identified. Construct validity was demonstrated throughout but concerns of content and criterion validity were noted.

CONCLUSION

None of the current disease activity or HRQOL tools can be used without potential bias in a trial of surgical vs medical therapy as the items included favour the outcomes experienced following medical therapy. A more balanced assessment tool in the setting of a multidisciplinary trial is needed.

Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis

BACKGROUND

Ileal-pouch anal anastomosis has an established role in the treatment of ulcerative colitis. Controversy exists regarding the routine use of a diverting ileostomy. The aim of this study was to review the clinical and functional outcome of patients undergoing restorative proctocolectomy in the absence of a diverting ileostomy (one-stage).

MATERIALS AND METHODS

Between 1990 and 1999, 87 patients with ulcerative colitis underwent a one-stage restorative proctocolectomy. The median age at the time of operation was 34 years (range 12-64 years) and median follow-up was 36 months (range 24-144 months). The clinical notes were reviewed retrospectively.

RESULTS

The median in-patient stay was 15 days (range 9-36). There were no post-operative deaths. The complication rate within 30 days of surgery approximated to 40%. The median daytime pouch evacuation rate was 5. Only 13% of patients had to empty their pouch at night on a regular basis. Pelvic sepsis secondary to anastomotic leakage was the most commonly encountered problem, occurring in 15 patients. Small bowel obstruction was encountered in ten patients. One pouch required excision for a recurrent pouch-vaginal fistula.

CONCLUSION

Despite refinements in the surgical technique, restorative proctocolectomy is associated with significant morbidity. For a selected group of patients undergoing an ileo-anal anastomosis, a defunctioning ileostomy may be avoided.

Successful outcome after a technically challenging liver transplant during pregnancy

Little is known about the implications of liver transplantation (OLT) during pregnancy. We report the case of a 26-year-old woman with cryptogenic familial biliary cirrhosis that decompensated rapidly. OLT was performed using the donor iliac vein for a retrogastric portal vein conduit to the superior mesenteric vein and the donor iliac artery for an infrarenal aortic conduit. During the latter anastomosis, a viable fetus was noticed. Both donor and recipient were cytomegalovirus positive. Postoperative ultrasound revealed a 13.5-week-old viable fetus. The patient received tacrolimus, azathioprine, and prednisolone. The pregnancy progressed normally with the vaginal delivery of a healthy male infant after 36 weeks gestation. Nineteen months later, both the mother and child were well. This case demonstrated that even technically difficult OLT during pregnancy can have a successful outcome, raising the question of whether transplant patients of childbearing age should be routinely tested for pregnancy.

Control of axonal growth and regeneration of sensory neurons by the p110delta PI 3-kinase

The expression and function of the 8 distinct catalytic isoforms of PI 3-kinase (PI3K) in the nervous system are unknown. Whereas most PI3Ks have a broad tissue distribution, the tyrosine kinase-linked p110δ isoform has previously been shown to be enriched in leukocytes. Here we report that p110δ is also highly expressed in the nervous system. Inactivation of p110δ in mice did not affect gross neuronal development but led to an increased vulnerability of dorsal root ganglia neurons to exhibit growth cone collapse and decreases in axonal extension. Loss of p110δ activity also dampened axonal regeneration following peripheral nerve injury in adult mice and impaired functional recovery of locomotion. p110δ inactivation resulted in reduced neuronal signaling through the Akt protein kinase, and increased activity of the small GTPase RhoA. Pharmacological inhibition of ROCK, a downstream effector of RhoA, restored axonal extension defects in neurons with inactive p110δ, suggesting a key role of RhoA in p110δ signaling in neurons. Our data identify p110δ as an important signaling component for efficient axonal elongation in the developing and regenerating nervous system.

Initiation of insulin glargine in suboptimally controlled patients with type 2 diabetes: sub-analysis of the AT.LANTUS trial comparing treatment outcomes in subjects from primary and secondary care in the UK

AIM

The AT.LANTUS study compared insulin glargine initiation and titration using one of two algorithms in suboptimally controlled subjects with type 2 diabetes mellitus (T2DM) based on a primary outcome of severe hypoglycaemia. Secondary outcomes included other categories of hypoglycaemia, glycaemic control, weight changes and insulin dose. Here, we report the results of a subanalysis of the trial, which investigated whether insulin glargine can be initiated and titrated as effectively in primary [general practitioner (GP)] as secondary (hospital) care in patients with T2DM in the UK.

METHODS

The main study was a multicentre (n = 611), multinational (n = 59), open-label, 24-week randomized trial in 4,588 suboptimally controlled subjects with T2DM. Insulin glargine was titrated to target fasting blood glucose (FBG) levels of <or=5.5 mmol/l according to algorithm 1 (clinic-driven titration) or algorithm 2 (patient-managed titration). In this substudy, 819 subjects (GP, n = 215; hospital, n = 604) from 57 primary and 130 secondary care centres were included in the subanalysis; subjects were switched to once-daily insulin glargine from baseline treatments that consisted primarily of oral antidiabetic agents (OADs) (38%) only or premixed insulin +/- OAD (23%).

RESULTS

Both the GP and the hospital groups of subjects experienced a low incidence of severe hypoglycaemia (<1%), with significant decreases in HbA1c levels (-0.51 and -0.95% respectively; p < 0.001), large reductions in FBG levels (-2.72 and 3.0 mmol/l respectively; p < 0.001) and modest weight gain of 1 and 1.2 kg respectively (p < 0.05). With the exception of absolute reductions in HbA1c and reductions in basal and prandial insulin made on switching to insulin glargine, there were few significant differences in subjects managed in primary compared with secondary care.

CONCLUSIONS

This study shows that despite differences in diabetes duration and baseline glycaemic control, an insulin glargine-based therapy can be safely and effectively initiated in a diverse range of suboptimally controlled subjects with T2DM in both primary and secondary care settings in the UK. Rates of hypoglycaemia were low and consistent with the results of the main study. Absolute reductions in HbA1c were greatest in the secondary care setting, but similar levels of glycaemic control were achieved in both groups due to differences in baseline HbA1c. In the patients managed in primary care, there was an overall reduction in prandial and basal insulin used when switching to a basal insulin regimen and a lack of titration of prandial insulin. Therefore, the role of prandial insulin, its initiation and titration, appears to be an area that requires more focus in primary care.

Nutrition knowledge and body mass index

The purpose of this study was to investigate the relationship between nutrition knowledge and body mass index (BMI). The General Nutrition Questionnaire was distributed to 500 individuals on the database of a large general practice. Results demonstrated that there was no significant correlation between levels of nutrition knowledge and BMI; however, a high level of nutrition knowledge was found among the sample. This suggests that a knowledge deficit may not be the most significant factor preventing overweight individuals from adopting a healthier diet and questions the utility of purely educational approaches to dietary behaviour change. Evidence-based health behaviour change techniques are discussed.

Does insulin detemir have a role in reducing risk of insulin-associated weight gain?

Weight gain is often perceived as inevitable with insulin therapy, particularly as we strive for tight glycaemic control and are using increasingly proactive insulin titration regimes. The United Kingdom Prospective Diabetes Study documented that weight gain occurs most rapidly soon after insulin therapy is first initiated. The timing of this side effect is particularly undesirable, as weight gain may interfere with patients' adjustment to insulin therapy and may undermine appropriate diabetes self-management behaviours. Until recently, many patients had little alternative other than to accept unwanted weight gain if they were to achieve sufficient glycaemic control to reduce risk of chronic complications of diabetes. Insulin detemir is a novel basal insulin analogue that has consistently been shown in randomized, controlled trials to have a weight-sparing effect (i.e. weight loss or reduced weight gain compared with other insulins) in both type 1 and type 2 diabetes. Indeed, unlike neutral protamine Hagedorn (NPH) insulin, the weight-sparing effect of insulin detemir appears to be most prominent in people who are the most obese. The mechanisms behind the weight-sparing effect of insulin detemir are still being clarified. Reduced risk of hypoglycaemia with insulin detemir, coupled with a more consistent and reliable delivery of the desired dose than is available with traditional basal insulin, such as NPH, has been proposed to minimize defensive snacking by patients, and help to limit weight gain. However, even if this was proven, it would be unlikely to fully explain the weight-sparing effect of insulin detemir. Two additional theories have been put forward. One suggests that due to its novel method of prolonging action via acylation and albumin binding, insulin detemir may differentially influence hepatocytes more than peripheral tissues, thus effectively suppressing hepatic glucose output without promoting lipogenesis in the periphery. The second theory suggests that insulin detemir may be more effective than human insulin in communicating satiety signals within the central nervous system. Further clarification of these hypotheses is required.

Pharmacological, behavioural and mechanistic analysis of HIV-1 gp120 induced painful neuropathy

A painful neuropathy is frequently observed in people living with human immunodeficiency virus type 1 (HIV-1). The HIV coat protein, glycoprotein 120 (gp120), implicated in the pathogenesis of neurological disorders associated with HIV, is capable of initiating neurotoxic cascades via an interaction with the CXCR4 and/or CCR5 chemokine receptors, which may underlie the pathogenesis of HIV-associated peripheral neuropathic pain. In order to elucidate the mechanisms underlying HIV-induced painful peripheral neuropathy, we have characterised pathological events in the peripheral and central nervous system following application of HIV-1 gp120 to the rat sciatic nerve. Perineural HIV-1 gp120 treatment induced a persistent mechanical hypersensitivity (44% decrease from baseline), but no alterations in sensitivity to thermal or cold stimuli, and thigmotactic (anxiety-like) behaviour in the open field. The mechanical hypersensitivity was sensitive to systemic treatment with gabapentin, morphine and the cannabinoid WIN 55,212-2, but not with amitriptyline. Immunohistochemical studies reveal: decreased intraepidermal nerve fibre density, macrophage infiltration into the peripheral nerve at the site of perineural HIV-1 gp120; changes in sensory neuron phenotype including expression of activating transcription factor 3 (ATF3) in 27% of cells, caspase-3 in 25% of cells, neuropeptide Y (NPY) in 12% of cells and galanin in 13% of cells and a spinal gliosis. These novel findings suggest that this model is not only useful for the elucidation of mechanisms underlying HIV-1-related peripheral neuropathy but may prove useful for preclinical assessment of drugs for the treatment of HIV-1 related peripheral neuropathic pain.

The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: a review

This evidence-based review focuses on the impact of potentially modifiable, non-communicable lifestyle factors on reproductive performance in the general population and the infertile population undergoing assisted reproductive technology (ART) treatment. The impact of several lifestyle factors including; age, weight, smoking, diet, exercise, psychological stress, caffeine consumption, alcohol consumption and exposure to environmental pollutants are included in the review. The databases of Medline, PubMed and Cinahl were searched to identify relevant publications. There is strong evidence that age, weight and smoking impact on general health and adversely on reproductive performance. However there is a need for further research focusing specifically on the relationship between diet and various levels of exercise on reproductive performance. There are several other factors such as psychological stress, caffeine consumption, alcohol consumption and exposure to environmental pollutants that have been implicated but the evidence is equivocal. It is concluded that lifestyle modification can assist couples to conceive spontaneously or optimize their chances of conception with ART treatment.

Osteochondrosis and copper: Histology of articular cartilage from foals out of copper supplemented and non-supplemented dams

Copper (Cu) supplementation of dams in late gestation may be protective against articular cartilage abnormalities in foals. Articular cartilage was harvested from 22 Thoroughbred foals at 160 days of age, at sites predisposed to osteochondrosis (OC), and examined for evidence of early cartilage abnormalities and established dyschondroplastic (DCP) lesions to determine if there were any significant differences due to mare Cu supplementation by injection during late gestation, or foal liver Cu concentration. Cu supplemented mares received calcium Cu edetate injections in late gestation (250 mg at around 220, 248, 276 and 304 days gestation, then every two weeks until foaling). Foals were euthanased at 160 days of age and articular cartilage was harvested from four defined sites. Samples were examined for histological appearance of chondrocytes after staining with haematoxylin and eosin, and were also stained with toluidine blue to indicate proteoglycan content. Alkaline phosphatase (ALP) activity was detected by histochemistry, and histocytochemical techniques were used to determine the expression of cathepsin B. Cu supplementation of the dam, or liver Cu concentration of the foal at birth or 160 days of age had no statistically significant effect on the frequency of cartilage irregularities observed grossly, or abnormalities detected histologically at four defined sites. ALP expression was similar in all samples. Cathepsin B expression varied between sites, and was seen in chondrocyte clusters. The intensity of toludine blue staining varied between sites. Minor histological cartilage abnormalities were observed in cartilage from clinically normal animals. These abnormalities might be 'early' dyschondroplastic lesions, which could resolve or progress. The role of Cu in the development, resolution or progression of dyschondroplastic lesions is poorly understood.

An absence of cutaneous neurofibromas associated with a 3-bp inframe deletion in exon 17 of the NF1 gene (c.2970-2972 delAAT): evidence of a clinically significant NF1 genotype-phenotype correlation

Neurofibromatosis type 1 (NF1) is characterized by cafe-au-lait spots, skinfold freckling, and cutaneous neurofibromas. No obvious relationships between small mutations (<20 bp) of the NF1 gene and a specific phenotype have previously been demonstrated, which suggests that interaction with either unlinked modifying genes and/or the normal NF1 allele may be involved in the development of the particular clinical features associated with NF1. We identified 21 unrelated probands with NF1 (14 familial and 7 sporadic cases) who were all found to have the same c.2970-2972 delAAT (p.990delM) mutation but no cutaneous neurofibromas or clinically obvious plexiform neurofibromas. Molecular analysis identified the same 3-bp inframe deletion (c.2970-2972 delAAT) in exon 17 of the NF1 gene in all affected subjects. The Delta AAT mutation is predicted to result in the loss of one of two adjacent methionines (codon 991 or 992) ( Delta Met991), in conjunction with silent ACA-->ACG change of codon 990. These two methionine residues are located in a highly conserved region of neurofibromin and are expected, therefore, to have a functional role in the protein. Our data represent results from the first study to correlate a specific small mutation of the NF1 gene to the expression of a particular clinical phenotype. The biological mechanism that relates this specific mutation to the suppression of cutaneous neurofibroma development is unknown.