The U.K. service level audit of insulin pump therapy in adults

AIMS

The National Institute for Health and Clinical Excellence (NICE) published guidelines for the use of continuous subcutaneous insulin infusion in 2008 (technology appraisal 151). The first U.K.-wide insulin pump audit took place in 2012 with the aim of determining adherence to the guidance issued in NICE technology appraisal 151. The results of the adult service level audit are reported here.

METHODS

All centres providing continuous subcutaneous insulin infusion services to adults with diabetes in the U.K. were invited to participate. Audit metrics were aligned to technology appraisal 151. Data entry took place online using a DiabetesE formatted data collection tool.

RESULTS

One hundred and eighty-three centres were identified as delivering adult continuous subcutaneous insulin infusion services in the U.K., of which 178 (97.3%) participated in the audit. At the time of the audit, 13 428 adults were using insulin pump therapy, giving an estimated prevalence of use of 6%. Ninety-three per cent of centres did not report any barriers in obtaining funding for patients who fulfilled NICE criteria. The mean number of consultant programmed activities dedicated to continuous subcutaneous insulin infusion services was 0.96 (range 0-8), mean whole-time equivalent diabetes specialist nurses was 0.62 (range 0-3) and mean whole-time equivalent dietitian services was 0.3 (range 0-2), of which 39, 61 and 60%, respectively, were not formally funded.

CONCLUSIONS

The prevalence of continuous subcutaneous insulin infusion use in the U.K. falls well below the expectation of NICE (15-20%) and that of other European countries (> 15%) and the U.S.A. (40%). This may be attributable, in part, to lack of healthcare professional time needed for identification and training of new pump therapy users.

Effects of methylnaltrexone in patients with narcotic bowel syndrome: a pilot observational study

BACKGROUND

Narcotic bowel syndrome (NBS) describes disabling chronic severe abdominal pain that worsens despite continuing or escalating doses of opiates. Therapy is very limited.

AIM

To examine effects of blocking peripheral µ-opioid receptors on the symptomatology of patients with NBS and its safety.

METHODS

An open-label observational study was performed in four women with NBS. After a 2-week run-in period, patients were treated for 12 weeks with 8-12 mg methylnaltrexone bromide subcutaneously every other day, increasing to daily if there was poor response. Patient and physician assessment was documented, and patients completed an eight-symptom visual analogue scale weekly and the Functional Assessment of Chronic Illnesses Therapy-Fatigue questionnaire for fatigue. Patients were observed for 4 weeks following withdrawal of the drug.

RESULTS

One patient was unable to tolerate the study medication because of worsening pain after injection, and withdrew. Two showed clear benefit with reduction of symptoms overall, pain, bloating, distension, nausea and tiredness, with improved satisfaction and consistency of bowel actions and fatigue scores. Both reduced analgesic usage. The third had improved ileostomy output and had no episodes of severe bloating, but pain scores remained high. All three worsened after drug withdrawal and requested retreatment. Three experienced abdominal pains of moderate severity for 30-60 min consistently within 5 min of each injection. No other adverse events were experienced.

CONCLUSIONS

Methylnaltrexone has a positive impact on symptoms in women with NBS, although treatment does induce transient pain following its administration. Larger studies are required to examine its efficacy and longer term safety in this patient group.

Survey of general practitioners' attitudes to prescribing statins in different patient groups: a web-based survey

Low rates of statin prescribing have been noted in several major studies of patients with schizophrenia and the aim of this study was to investigate clinicians' attitudes to prescribing statins to different patient groups. The general practitioners (GPs) in Dumfries and Galloway were randomized into two groups. They received an email invitation to a web-based survey. The survey asked for treatment recommendation for three patient vignettes, each with a 10-year cardiovascular risk of 20%. In one group descriptions of the patient included type 1 diabetes, epilepsy and unemployed and in the other group these were replaced by type 2 diabetes, schizophrenia and retired. The questionnaires had no other differences. After three email invites, 53 questionnaires were completed (40% of a potential 133 participants). Statin therapy was recommended by 88% and 85% of respondents for patients with type 1 and type 2 diabetes, respectively; by 37% of respondents for patients with schizophrenia and 31% for patients with epilepsy; by 33% of respondents for retired patients and 23% of respondents for patients who are unemployed. This study demonstrates under-prescribing of statins. This was not worse for patients with schizophrenia as compared with patients with epilepsy. This suggests that the low rates of treatment of metabolic risk factors in patients with schizophrenia are not the result of clinician bias when compared with patients with epilepsy. Clinician bias, however, may reduce the chances of an unemployed patient receiving statin treatment.

A solid phase extraction-liquid chromatographic-tandem mass spectrometry method for determination of concentrations of GDC-0941, a small molecule class I phosphatidylinositide 3-kinase inhibitor, to support clinical development

A solid phase extraction (SPE) liquid chromatographic-tandem mass spectrometry (LC-MS/MS) method for the determination of GDC-0941 concentrations in human plasma has been developed and validated to support clinical development. An Oasis MCX 10mg 96-well SPE plate was used to extract plasma samples (50 μL) and the resulting extracts were analyzed using reverse-phase chromatography and mass spectrometer coupled with a turbo-ionspray interface. The method was validated over the calibration curve range 0.500-500 ng/mL with linear regression and 1/x(2) weighting. Within-run relative standard deviation (%RSD) ranged from 1.5 to 11.5%, while the between-run %RSD varied from 0.0 to 4.4%. The accuracy ranged from 96.0% to 110.0% of nominal for within-run and 98.0% to 108.0% of nominal for between-run at all concentrations including the LLOQ quality control at 0.500 ng/mL. Extraction recovery of GDC-0941 was between 79.0% and 86.2%. Stability of GDC-0941 was established in human plasma for 602 days at -70 °C and 598 days at -20°C, respectively, and established in reconstituted sample extracts for 167 h when stored at room temperature. Internal standard normalized matrix factor was 1.1, demonstrating that the use of the stable-labeled internal standard GDC-0941-d(8) effectively compensated observed matrix effect and resulting in no adverse impact on the quality of the data produced. This assay was used for the determination of GDC-0941 human plasma concentrations over a sufficient time period to determine pharmacokinetic parameters at relevant clinical doses.

The role of continuous subcutaneous insulin infusion therapy in patients with diabetic gastroparesis

AIMS/OBJECTIVE

To describe the effectiveness of continuous subcutaneous insulin infusion (CSII) in patients with symptomatic diabetic gastroparesis and unstable glycaemic control.

METHODS

Data from 26 patients with symptomatic diabetic gastroparesis and unstable glycaemic control using multiple-dose insulin (MDI) regimens, and subsequently managed with CSII, were analysed.

RESULTS

Following initiation of CSII, the median length of inpatient bed days associated with hospital admissions related to gastroparesis and glycaemic instability was reduced from 8.5 (range 0-144) days patient( -1) year( -1) prior to CSII to 0 (range 0-15) days patient( -1) year( -1). The median HbA(1c) reduction with CSII was 1.8% (22 mmol/mol; p < 0.05). The median capillary blood glucose (CBG) with CSII was significantly lower than with MDI: 7.7 mmol/l (range 3.8-15.4 mmol/l) vs 9.8 mmol/l (range 2.3-27 mmol/l), respectively, p < 0.001. Glycaemic variability with CSII was significantly reduced compared with MDI: CBG CV 0.37 vs CV 0.53, respectively, p < 0.001.

CONCLUSIONS/INTERPRETATION

CSII therapy in patients with diabetic gastroparesis results in significant improvement in glycaemic control and reductions in glycaemic variability and number of hospital inpatient bed days.

Ozone-surface reactions in five homes: surface reaction probabilities, aldehyde yields, and trends

Field experiments were conducted in five homes during three seasons (summer 2005, summer 2006 and winter 2007) to quantify ozone-initiated secondary aldehyde yields, surface reaction probabilities, and trends any temporal over a 1.5-year interval. Surfaces examined include living room carpets, bedroom carpets, kitchen floors, kitchen counters, and living room walls. Reaction probabilities for all surfaces for all seasons ranged from 9.4 x 10(-8) to 1.0 x 10(-4). There were no significant temporal trends in reaction probabilities for any surfaces from summer 2005 to summer 2006, nor over the entire 1.5-year period, indicating that it may take significantly longer than this period for surfaces to exhibit any 'ozone aging' or lowering of ozone-surface reactivity. However, all surfaces in three houses exhibited a significant decrease in reaction probabilities from summer 2006 to winter 2007. The total yield of aldehydes for the summer of 2005 were nearly identical to that for summer of 2006, but were significantly higher than for winter 2007. We also observed that older carpets were consistently less reactive than in newer carpets, but that countertops remained consistently reactive, probably because of occupant activities such as cooking and cleaning.

PRACTICAL IMPLICATIONS

Ozone reactions taking place at indoor surfaces significantly influence personal exposure to ozone and volatile reaction products. These field studies show that indoor surfaces only slowly lose their ability to react with ozone over several year time frames, and that this is probably because of a combination of large reservoirs of reactive coatings and periodic additions of reactive coatings in the form of cooking, cleaning, and skin-oil residues. When considering exposure to ozone and its reaction products and in the absence of dramatic changes in occupancy, activities or furnishings, indoor surface reactivity is expected to change very slowly.

The influence of chemical interactions at the human surface on breathing zone levels of reactants and products

Using computational fluid dynamics simulations of an occupant in a ventilated room, we find that breathing zone ozone levels can be substantially lower and ozone reaction products associated with human surfaces (ORPHS) levels considerably higher than room levels. For air exchange rates <3/h, the ratio of the breathing zone to the ozone concentration 1 m from the body (bulk air), r(ozone), ranges from 0.59 to 0.75 for floor or ceiling air supply. ORPHS are enriched in the breathing zone, with concentrations for these conditions ranging from 1.2 to 2.5 greater than bulk air concentrations. At high air exchange rates (>8/h), the breathing zone concentrations approach bulk air concentrations (r(ozone) > 0.9) with a floor supply, whereas large concentration gradients occur between breathing zone and bulk air with a ceiling supply. At these high air exchange rates, ORPHS levels are 1.6-2.0 and 2.9-6.0 times the bulk air concentrations for floor and ceiling supply, respectively. The extent of depletion of ozone or enrichment of ORPHS is large enough that reliance on micro-environmental measurements alone, to assess the intake of ozone or ORPHS, is undesirable.

PRACTICAL IMPLICATIONS

Chemical reactions between ozone and human and clothing surfaces are predicted to significantly reduce ozone concentrations, and increase ozone reaction products associated with human surfaces (ORPHS) concentrations, in the breathing zone, relative to those concentrations in the larger microenvironment of a room. Existing measurements may overestimate ozone exposure and intake in typical indoor environments.

The impact of paediatric tracheostomy on both patient and parent

OBJECTIVE

We set out to assess the impact of paediatric tracheostomy, performed in a central London hospital, on patients and their families.

METHODS

We conducted structured interviews with caregivers of tracheostomised children using the Pediatric Tracheotomy Health Status Instrument during all in-patient admissions for airway endoscopy over a 6-month period.

RESULTS

Completed questionnaires were received from 26 caregivers, 7 (27%) of whose children had been successfully decannulated. Carers reported adverse effects on all aspects of their quality of life, including sleep, relationships, social life and ability to work. The families included in the study had gross household incomes below the mean for SE London. There is a shortfall in the provision of home nursing when compared with the needs of the caregivers.

CONCLUSIONS

Tracheostomy has wide ranging effects on the quality of life of both the patient and their caregivers. We identified the need for better pre-operative preparation where possible, and greater support for such families in the community.

Incomplete resection of focal cortical dysplasia is the main predictor of poor postsurgical outcome

BACKGROUND

Focal cortical dysplasia (FCD) is recognized as the major cause of focal intractable epilepsy in childhood. Various factors influencing postsurgical seizure outcome in pediatric patients with FCD have been reported.

OBJECTIVE

To analyze different variables in relation to seizure outcome in order to identify prognostic factors for selection of pediatric patients with FCD for epilepsy surgery.

METHODS

A cohort of 149 patients with histologically confirmed mild malformations of cortical development or FCD with at least 2 years of postoperative follow-up was retrospectively studied; 113 subjects had at least 5 years of postoperative follow-up. Twenty-eight clinical, EEG, MRI, neuropsychological, surgical, and histopathologic parameters were evaluated.

RESULTS

The only significant predictor of surgical success was completeness of surgical resection, defined as complete removal of the structural MRI lesion (if present) and the cortical region exhibiting prominent ictal and interictal abnormalities on intracranial EEG. Unfavorable surgical outcomes are mostly caused by overlap of dysplastic and eloquent cortical regions. There were nonsignificant trends toward better outcomes in patients with normal intelligence, after hemispherectomy and with FCD type II. Other factors such as age at seizure onset, duration of epilepsy, seizure frequency, associated pathologies including hippocampal sclerosis, extent of EEG and MRI abnormalities, as well as extent and localization of resections did not influence outcome. Twenty-five percent of patients changed Engel's class of seizure outcome after the second postoperative year.

CONCLUSIONS

The ability to define and fully excise the entire region of dysplastic cortex is the most powerful variable influencing outcome in pediatric patients with focal cortical dysplasia.

Role of internal chain dynamics on the rupture kinetic of adhesive contacts

We study the forced rupture of adhesive contacts between monomers that are not covalently linked in a Rouse chain. When the applied force (f) to the chain end is less than the critical force for rupture (f{c}), the reversible rupture process is coupled to the internal Rouse modes. If f/f{c}>1 the rupture is irreversible. In both limits, the nonexponential distribution of contact lifetimes, which depends sensitively on the location of the contact, follows the double-exponential (Gumbel) distribution. When two contacts are well separated along the chain, the rate limiting step in the sequential rupture kinetics is the disruption of the contact that is in the chain interior. If the two contacts are close to each other, they cooperate to sustain the stress, which results in an "all-or-none" transition.

Effects of dynamic upper-body exercise on lower-limb isometric endurance

Following preliminary indications that in some individuals arm exercise enhanced rather than reduced simultaneous leg endurance, ten young men and women performed three forms of intermittent work to volitional exhaustion, under duty cycles of 45 s work, 15 s rest. The protocols were as follows: (A) knee extensions at 30% maximum voluntary contraction (MVC); (B) 30% MVC knee extensions combined with arm cranking at 130% of their own lactate threshold; (C) combined 30% MVC knee extensions and arm cranking at 20% of their own lactate threshold. Heart rate, oxygen uptake (VO(2)), and blood lactate concentration were among the variables recorded throughout. All physiological indicators of demand were substantially higher in protocol B than in protocols A or C [heart rate: (A) 154 beats . min(-1), (B) 171 beats . min(-1), (C) 150 beats . min(-1); VO(2): (A) 11.9 ml . kg(-1) . min(-1), (B) 21.7 ml . kg(-1) . min(-1), (C) 14.2 ml . kg(-1) . min(-1); blood lactate concentration: (A) 3.3 mmol . l(-1), (B) 5.1 mmol . l(-1), (C) 2.8 mmol . l(-1)], yet there were no significant differences (P > 0.05) in the endurance times between the three conditions [(A) 11.43 min, (B) 11.1 min, (C) 10.57 min] and seven participants endured longest in protocol B. Results from protocol (C) cast doubt on explanations in terms of psychological distraction. We suggest that lactic acid produced by the arms is shuttled to the legs and acts there either as a supplementary fuel source or as an antagonist to the depressing effects of increased potassium concentration.

The shape of a flexible polymer in a cylindrical pore

We calculate the mean end-to-end distance R of a self-avoiding polymer encapsulated in an infinitely long cylinder with radius D. A self-consistent perturbation theory is used to calculate R as a function of D for impenetrable hard walls and soft walls. In both cases, R obeys the predicted scaling behavior in the limit of large and small D. The crossover from the three-dimensional behavior (D --> infinity) to the fully stretched one-dimensional case (D --> 0) is nonmonotonic. The minimum value of R is found at D approximately 0.46R(F), where R(F) is the Flory radius of R at D --> infinity. The results for soft walls map onto the hard wall case with a larger cylinder radius.

Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial

OBJECTIVE

To investigate the effectiveness of intensive innovative methods for implementing dietary prescriptions on weight management and glycaemic control in overweight men with Type II diabetes.

DESIGN

A randomised clinical trial with a 12-week intervention period - three isocaloric dietary intervention groups (intermittent energy restriction, pre-portioned meals and self-selected meals) each with weekly dietitian contact - and a follow-up visit after 18 months.

SUBJECTS

A total of 51 men with Type II diabetes (mean age 54 y, mean body mass index (BMI) 31.7 kg/m(2)).

MEASUREMENTS

Weight, body composition, waist circumference, glycaemic control (HbA(1c)) and blood lipids.

RESULTS

For all subjects, intensive diet therapy over the 12-week intervention period resulted in a mean reduction in energy intake of 2360+/-2780 kJ/day (564+/-665 kcal/day) and significant reductions in weight (6.4+/-4.6 kg), waist circumference (8.1+/-4.6 cm), percent body fat (1.9+/-1.5%), HbA(1c) (1.0+/-1.4%) and triglyceride levels (0.3+/-0.6 mmol/l) compared to baseline levels. Intervention group did not affect clinical outcomes, with the exception of percent body fat. A total of 27 (52.9%) subjects attended the 18-month follow-up visit. At this visit, none of the improvements in clinical parameters was maintained, with all parameters returning to preintervention levels.

CONCLUSIONS

: A dietary prescription of 6000-7000 kJ/day (1400-1700 kcal/day) was effective in achieving a 6% weight loss and improving glycaemic control. The method of implementation made no difference to the outcomes between groups at 12 weeks or 18 months. Thus, we propose that it was the intensive weekly contact with a health professional in combination with moderate energy restriction that facilitated the successful short-term results seen.

Levels and risk assessment for humans and ecosystems of platinum-group elements in the airborne particles and road dust of some European cities

Traffic is the main source of platinum-group element (PGE) contamination in populated urban areas. There is increasing concern about the hazardous effects of these new pollutants for people and for other living organisms in these areas. Airborne and road dusts, as well as tree bark and grass samples were collected at locations in the European cities of Göteborg (Sweden), Madrid (Spain), Rome (Italy), Munich (Germany), Sheffield and London (UK). Today, in spite of the large number of parameters that can influence the airborne PGE content, the results obtained so far indicate significantly higher PGE levels at traffic sites compared with the rural or non-polluted zones that have been investigated (background levels). The average Pt content in airborne particles found in downtown Madrid, Göteborg and Rome is in the range 7.3-13.1 pg m(-3). The ring roads of these cities have values in the range 4.1-17.7 pg m(-3). In Munich, a lower Pt content was found in airborne particles (4.1 pg m(-3)). The same tendency has been noted for downtown Rh, with contents in the range 2.2-2.8 pg m(-3), and in the range 0.8-3.0 and 0.3 pg m(-3) for motorway margins in Munich. The combined results obtained using a wide-range airborne classifier (WRAC) collector and a PM-10 or virtual impactor show that Pt is associated with particles for a wide range of diameters. The smaller the particle size, the lower the Pt concentration. However, in particles <PM-10, some of the highest values correspond to the fraction <0.39 microm. Considering an average Pt content in all particles of approximately 15 pg m(-3), which is representative for all countries and environmental conditions, the tracheobronchial fraction represents approximately 10% and the alveolar fraction approximately 8% of the total particles suspended in air. However, from the environmental risk point of view, an exposure to PGEs in traffic-related ambient air is at least three orders of magnitude below the levels for which adverse health effects might theoretically occur (of approx. 100 ng m(-3)). Therefore, today inhalation exposure to PGEs from automotive catalysts does not seem to pose a direct health risk to the general population. Even though the data available today indicate no obvious health effects, there are still a number of aspects related to PGEs and catalysts that justify further research. First, continual monitoring of changes in PGE levels in air and road dust is warranted, to make sure that there is no dramatic increase from today's levels. Secondly, more detailed information on the chemical composition of the PGE-containing substances or complexes leaving the catalyst surface and the size distribution of the PGE-containing particles released during driving will facilitate a more in-depth human risk assessment.

Environmental risk of particulate and soluble platinum group elements released from gasoline and diesel engine catalytic converters

A comparison of platinum-group element (PGE) emission between gasoline and diesel engine catalytic converters is reported within this work. Whole raw exhaust fumes from four catalysts of three different types were examined during their useful lifetime, from fresh to 80,000 km. Two were gasoline engine catalysts (Pt-Pd-Rh and Pd-Rh), while the other two were diesel engine catalysts (Pt). Samples were collected following the 91441 EUDC driving cycle for light-duty vehicle testing, and the sample collection device used allowed differentiation between the particulate and soluble fractions, the latter being the most relevant from an environmental point of view. Analyses were performed by inductively coupled plasma-mass spectrometry (ICP-MS) (quadrupole and high resolution), and special attention was paid to the control of spectral interference, especially in the case of Pd and Rh. The results obtained show that, for fresh catalysts, the release of particulate PGE through car exhaust fumes does not follow any particular trend, with a wide range (one-two orders of magnitude) for the content of noble metals emitted. The samples collected from 30,000-80,000 km present a more homogeneous PGE release for all catalysts studied. A decrease of approximately one order of magnitude is observed with respect to the release from fresh catalysts, except in the case of the diesel engine catalyst, for which PGE emission continued to be higher than in the case of gasoline engines. The fraction of soluble PGE was found to represent less than 10% of the total amount released from fresh catalysts. For aged catalysts, the figures are significantly higher, especially for Pd and Rh. Particulate PGE can be considered as virtually biologically inert, while soluble PGE forms can represent an environmental risk due to their bioavailability, which leads them to accumulate in the environment.

Characterization of the mouse beta defensin 1, Defb1, mutant mouse model

Beta defensins are small cationic antimicrobial peptides present in the respiratory system which have been proposed to be dysfunctional in the environment of the cystic fibrosis lung. Defb1, a murine homologue to the human beta defensins, has also been found to be expressed in the respiratory system and, in order to examine the function of beta defensins in vivo, gene targeting was used to generate Defb1-deficient (Defb1(tm1Hgu)/Defb1(tm1Hgu) [Defb1(-/-)]) mice. The Defb1 synthetic peptide was shown to have a salt-sensitive antimicrobial activity that was stronger against Staphylococcus aureus than against Escherichia coli or Pseudomonas aeruginosa. Defb1(-/-) mice were found, however, to be effective in the clearance of the cystic fibrosis relevant pathogen S. aureus from the airways after nebulization. Although no overt deleterious phenotype was evident in the Defb1(-/-) mice, the number of mutant mice found to harbor bacteria of the Staphylococcus species in the bladder was significantly higher (P = 0.008) than that of controls, suggesting a role for these peptides in resistance to urinary tract infection.