Insulin for type 2 diabetes: choosing a second-line insulin regimen

Guidance has been published on the choice of initial insulin regimen for patients with type 2 diabetes [NPH (isophane) insulin or a long-acting insulin analogue] but not on how to choose a second regimen when glycaemic control becomes unsatisfactory.

AIMS

To develop pragmatic clinical guidance for choosing a second-line insulin regimen tailored to the individual needs of patients with type 2 diabetes after failure of first-line insulin therapy.

METHODS

Formulation of a consensus by expert panel based on published evidence and best clinical practice, taking into account patient preferences, lifestyle and functional capacity.

RESULTS

Six patient-dependent factors relevant to the choice of second-line insulin regimen and three alternative insulin regimens (twice-daily premixed, basal-plus and basal-bolus) were identified. The panel recommended one or more insulin regimens compatible with each factor, emphasising the fundamental importance of a healthy lifestyle that includes exercise and weight reduction. These recommendations were incorporated into an algorithm to provide pragmatic guidance for clinicians.

CONCLUSION

The three alternative insulin regimens offer different benefits and drawbacks and it is important to make the right choice to optimise outcomes for patients.

Hybrid Lumbar Fusion: A clinical and radiological review at 2 years

We report on our first 20 patients treated with hybrid lower lumbar stabilization, in which one or more segments were treated with caged interbody fusion by PLIF technique and one or more adjacent segments were stabilized using GRAF instrumentation.

The indications for interbody fusion included spondylolysis; previous failed disc surgery, and primary discopathy with positive discography and/or active modic signal on MRI.

The indication for flexible stabilization of adjacent segments was for disc degeneration on MRI scanning with or without evidence of posterior annular tear.

This was a prospective study with clinical evaluation using VAS pain scales and Oswestry disability score. All patients were reviewed by an independent consultant radiologist to assess integrity of the implant after two years and underwent CT scanning to assess progression of the caged fusion. There were no instances of failed fusion in this group and no cases of implant failure.

Long-term follow up of sequential mobilisation and autologous transplantation with CD34-selected cells in multiple myeloma: a multimodality approach

BACKGROUND

Even after high dose chemotherapy (HDT) and autologous haemopoietic stem cell transplantation, the majority of patients with multiple myeloma eventually relapse.

AIM

The aim of the present study was to study the -feasibility and outcome of delivering a regimen including in vivo and in vitro purging and double HDT in patients with multiple myeloma.

METHODS

Thirty-four patients with advanced multiple myeloma were enrolled in a program of vincristine, doxorubicin and dexamethasone chemotherapy, high dose cyclophosphamide/granulocyte macrophage colony stimulating factor (GM-CSF) stem cell mobilisation, CD34 selection of harvested stem cells (in vitro purging), double HDT (cyclophosphamide/epirubicin in the first, busulphan/melphalan in the second) rescued by CD34(+)-selected cells, the second rescue using cells harvested following the first HDT (in vivo purging) and interferon maintenance.

RESULTS

Forty-four per cent of patients completed the program. Fifty-three per cent of withdrawals were as a result of insufficient stem cells. This correlated to previous chemotherapy. Therapy-related mortality was 6%. CD34(+) selection achieved more than a 2-log reduction of CD38(++) cells; in vivo purging achieved 80%. Although similar numbers of CD34(+) cells were reinfused at both HDT, platelet recovery was slower after the second HDT. Additional complete remissions were achieved after each phase of therapy, 3% at the end of vincristine, doxorubicin and dexamethasone and 33% after completing planned HDT. Factors associated with longer overall survival included age less than 60 years (P = 0.044), serum beta-2-microglobulin below 3 micro gamma/L at entry (P = 0.042) and less than 2 months between the two HDT (P = 0.024). The only factor associated with a longer event-free survival was less than 2 months between HDT on study (P = 0.038).

CONCLUSIONS

(i) dose intensification with two HDT delivered within 2 months might be associated with a better patient outcome, (ii) early mobilisation should be incorporated in multiple myeloma HDT programs and (iii) higher CD34(+) doses may be required for tandem transplants.

Selected CD34 blood cell allografts for older patients: low transplant-related mortality, graft failure and acute GvHD

BACKGROUND

Early transplant mortality is related to acute GvHD, which this study in older patients (40 to 60 years) decreased by reducing the graft T-cell number while maintaining a high CD34 cell number--by positive CD34 cell selection. Potential increased risk of relapse is addressed by giving donor leucocyte infusion (DLI) post-transplant.

METHODS

CD34 cells selected by Isolex devices from leukophereses obtained from Filgrastim-treated matched sibling donors were transplanted and DLI given later if there was no GvHD.

RESULTS

Selection of CD34 cells achieved a median of 5.2 million cells/kg, with minimum target for transplantation achieved in 17 of 21 donors. Median CD3 cell number was 0.24 million/kg. Engraftment was rapid and graft failure rare. Transplant-related mortality was low (6% at 3 months). Acute GvHD of >or=Grade 2 occurred in only two patients (12.5%). DLI were given to only six patients who had resolved Grade 1 or no GvHD. Eight of the 17 patients relapsed, including three of the six who had DLI. Extensive chronic GvHD developed in six of 12 evaluable patients, two of these had received DLI. Seven of the 17 patients (41%) are alive at median follow-up of 56 months.

CONCLUSION

CD34 selection allows transplantation of high numbers of CD34 cells with low CD3 cell count, reducing early mortality in patients 40-60 years old because of rapid hemopoietic reconstitution and low acute GvHD incidence. Administration of DLI was often precluded by low-grade acute GvHD.

Nutrition and diabetes control: advice for non-dietitians

Diabetes mellitus affects 2-4% of the UK population and its prevalence is predicted to double by 2010. It has been widely acknowledged that dietary therapy can reduce the risk of complications in people with diabetes. However, as there are insufficient diabetes specialist dietitians to deliver dietary advice to all people with diabetes, the burden of care will fall on the primary care team. Dietary advice given to people with diabetes by healthcare professionals needs to be consistent. As recommendations change with new evidence, professionals have a duty to update their knowledge. This article reviews current nutritional recommendations from the UK, Europe and the USA and offers suggestions for translating dietary theory into practice. It emphasizes the importance of an individual approach, taking into account usual eating patterns, lifestyle, age, culture and medication.

Novel post-replicative DNA modification in Streptomyces: analysis of the preferred modification site of plasmid pIJ101

Both Streptomyces lividans and Streptomyces avermitilis have the ability to site specifically modify their DNA, rendering it susceptible to in vitro Tris-dependent double-strand cleavage. We have cloned a 160 bp fragment containing the preferred modification site of plasmid pIJ101 and, employing an in vitro primer extension assay, determined that the modifications occur at guanine residues on either strand separated by 3 bp. These guanines are located within a 6 bp palindromic 'core' sequence. A cloned copy of a 35 bp region of the plasmid containing this core sequence was not recognized by the modifying activity in vivo. To further investigate the nature of the site specificity a set of deletion mutants of the 160 bp sequence were analysed. This revealed that a substantial portion of this sequence is essential for authentic modification. The essential region contains three 13 bp direct repeats, the central one containing the core sequence, while the left-hand and right-hand copies overlap two potential stem-loop structures. Deletion of either left- or right-hand repeat structures abolishes modification within the core sequence, although the left-hand deletion resulted in modification at a secondary site within the right-hand direct repeat. These data support a post-replicative mechanism of modification, underlined by the observation that the modifications are not detected in single-stranded plasmid replication intermediates.

Myeloma stem cells in autografting in multiple myeloma

Autologous transplantation has been used increasingly over the last 10 years for the treatment of multiple myeloma. As is the case in other cancers treated by high-dose therapy and stem cell rescue, the contribution of occult tumor cells in the graft to relapse posttransplant remains to be resolved. In this report, we review the biology and differentiation of plasma cells in the context of their significance as an origin of relapse in multiple myeloma.

An incremental response to high-dose therapy in multiple myeloma

Results of conventional chemotherapy for multiple myeloma are disappointing. High-dose chemoradiotherapy with auto-transplantation is increasingly reported and some results are encouraging. We report the results of peripheral blood stem cell transplantation (PBSCT) for multiple myeloma at a single institution over a 6-year period. Forty patients, including 18 de novo patients, received debulking chemotherapy consisting of vincristine, adriamycin, and dexamethasone or methyl-prednisolone followed by stem cell mobilization with high-dose cyclophosphamide. Twenty-nine patients received PBSCT following high-dose chemoradiotherapy. Following PBSCT 92% of evaluable patients obtained at least a partial remission and 29% reached complete remission. Objective treatment responses, defined as at least a 50% reduction in serum paraprotein or marrow plasma cells, were observed following each treatment step of debulking chemotherapy, mobilization and PBSCT in 50, 42 and 71% of patients, respectively. The median overall survival from diagnosis in patients transplanted was 50 months and the median overall and progression-free survivals following transplant were 26 and 18 months, respectively. Median follow-up was 28 months. Overall treatment-related mortality was 20% but was significantly lower in de novo vs previously treated patients at 6 and 33% respectively (P = 0.027). De novo patients were more likely to obtain complete remission and had a longer overall survival following transplant but overall survival from diagnosis was similar to previously treated patients. A low serum B2M before mobilization predicted a longer progression-free survival. PBSCT needs to be considered early following diagnosis to maximise treatment response and reduce the high treatment-related mortality seen in heavily pretreated patients. In this treatment program a dose response effect in multiple myeloma was observed possibly suggesting that more intensive therapy than a single transplant may effect greater disease response.

Inducible transposition in Streptomyces lividans of insertion sequence IS6100 from Mycobacterium fortuitum

Transposition of IS6100, originally isolated as part of the compound transposon Tn610 from Mycobacterium fortuitum, was tested in the related actinomycete Streptomyces lividans. Cointegrate formation was observed, as expected for this IS6-related element, and involved apparent random integration of the temperature-sensitive vector carrying IS6100 and concomitant duplication of the insertion sequence. This establishes that a single copy of the insertion sequence can promote transposition and is a precedent for the functioning of a heterologous transposable element in Streptomyces. Transposition could be induced 100-fold by external transcription emanating from a copy of the thiostrepton-inducible promoter ptipA located outwith the insertion sequence and resulting in overexpression of the transposase gene. Thus, in contrast to other prokaryotic transposable elements, IS6100 appears to have no effective means of protecting itself from external activation.

Wound healing on the lower leg after radiotherapy or cryotherapy of Bowen's disease and other malignant skin lesions

To investigate lower leg wound healing after treatment of skin tumours, the results of external beam radiotherapy were assessed for 141 lesions in 91 patients. Poor healing or failure to heal occurred in 33%, and was related to the age of the patients, the diameter of the radiotherapy field, and the dose and energy of radiotherapy used. No effect of fractionation on healing was apparent, but only 14% of patients were exposed to regimens with a nominal standard dose of over 1800 rets. Age > 90 years, field diameter > 4 cm and dose > 3000 cGy were all associated with a risk of impaired healing of over 50%. The most frequent single diagnosis (59 lesions) in the radiotherapy patients was Bowen's disease. The results of wound healing in these patients were compared with the results of cryotherapy to 82 lower leg Bowen's disease lesions in 49 dermatology patients. Only 2% of the cryotherapy lesions failed to heal compared with 20% of the radiotherapy wounds, although 6% of cryotherapy cases had local recurrence compared with none in the radiotherapy group. Serial overlapping cryotherapy fields of up to 2 cm diameter were shown to be a valid treatment option for Bowen's disease, as no patients had therapy-related failure to heal. To avoid the requirement for potentially more difficult post-radiotherapy salvage surgery, intra-epidermal non-invasive skin tumours > 4 cm in diameter on the lower leg are probably initially best treated by a primary surgical procedure or by staged cryotherapy. Invasive carcinoma of > 4 cm diameter is best treated by surgical excision.(ABSTRACT TRUNCATED AT 250 WORDS)

Tris-dependent oxidative DNA strand scission during electrophoresis

The DNA of two Streptomyces species contains site-specific labile modifications. During gel electrophoresis the DNA can undergo Tris-dependent strand scission at the positions of these modifications. Our investigations into the nucleolytic activity which reacts with the modifications implicate a peracid derivative of Tris formed at the anode; the kinetics of production and decay of this activity were followed using both a DNA cleavage assay and a reduced methyl viologen assay to measure oxidant. Anode activation could be chemically mimicked by addition of peracetic acid to Tris buffers. We tested the DNA cleavage activity of several other compounds after anode or chemical activation; we used an analogue of Tris lacking a primary amine group and also several reagents known to promote DNA strand cleavage by amine-catalysis at abasic sites. Anode generation of oxidant could be detected for compounds containing either hydroxyl or carboxyl groups. However, DNA cleavage activity correlated with oxidant formation only for those compounds also containing primary amine groups. These results support a mechanism of DNA strand scission at modification sites via concerted peracid-mediated oxidative and amine-catalysed reactions. The novel finding of Tris-dependent formation of a long-lived reactive oxidant at the anode suggests that this compound is unsuited as an electrophoresis buffer for certain biological macromolecules.

Characterization of a Streptomyces-lividans-type site-specific DNA modification system in the avermectin-producer Streptomyces avermitilis permits investigation of two novel giant linear plasmids, pSA1 and pSA2

The degradation of Streptomyces avermitilis DNA samples analysed by conventional pulsed-field gel electrophoresis was shown to be due to Tris-dependent, double-strand cleavage. Using alternative electrophoretic conditions, separation of intact DNA molecules was achieved, permitting the identification of two novel giant linear plasmids: the 100 kb pSA1 and 250 kb pSA2. Use of pSA2 DNA as a probe showed that pSA1 does not cross-hybridize, indicating that the plasmids are not closely related. The site-specificity of the DNA modifications, which render the DNA susceptible to Tris-dependent cleavage, was found to be essentially identical to that of similar modifications found in the DNA of S. lividans.

Carotid artery stenosis following adjuvant radiotherapy for a parotid pleomorphic adenoma

Carotid artery stenosis following radiotherapy for head and neck cancer is probably underdiagnosed. We report a symptomatic case and suggest that greater awareness of the condition should result in suitable investigation and appropriate medical or surgical treatment.

Spinal cord compression: prognosis and implications for treatment fractionation

A review of 158 cases of metastatic extradural spinal cord compression referred to three radiotherapy departments shows that the median survival time is less than 3 months, that recovery of motor and sphincter function is uncommon, and that low fraction (2-5) regimens have a similar clinical outcome to more protracted regimens.

Tris-dependent site-specific cleavage of Streptomyces lividans DNA

During conventional gel electrophoresis, Streptomyces lividans DNA undergoes site-specific double-strand cleavage at the positions of closely opposed unstable modifications introduced into the DNA in vivo. We investigated this electrophoretic instability and demonstrated that it was dependent on Tris. Tris buffer was activated at the anode to generate a nucleolytic species; prior to activation, Tris was not able to cleave the DNA. The nucleolytic species was shown to react with thiourea, which could thus protect the DNA from strand cleavage. Non-degradative electrophoresis of the DNA could also be achieved in an alternative buffer such as Hepes.

Genetic instability and DNA amplification in Streptomyces lividans 66

Streptomyces lividans 66 exhibits genetic instability, involving sequential loss of resistance to chloramphenicol (Cams) and subsequent mutation of argG. Associated with this instability is the amplification of a 5.7-kilobase (kb) amplified DNA sequence (ADS). We have characterized a second, independent pathway of genetic instability, involving sequential loss of resistance to tetracycline (Tets) followed by mutation in nitrogen assimilation (Ntr). We detected DNA amplification in many of these mutant strains, as well as other reiterations coresident with the 5.7-kb ADS in Cams Arg mutants. However, in contrast to the 5.7-kb ADS, none of the novel elements were observed to amplify at high frequency. The mutation of argG is due to a deletion, one endpoint of which is defined by the 5.7-kb ADS. This amplification derives from a structure, the tandemly duplicated amplifiable unit of DNA (AUD), present in the wild-type genome. We found that progenitor strains containing just a single-copy AUD failed to reproducibly generate amplification of this element in Cams argG mutants, and DNA deletion endpoints proximal to the element were found to be unspecific. These results suggest that a duplicated AUD structure is required for high-frequency amplification and that this reiteration can subsequently buffer the extent of deletion formation in the relevant chromosomal region.

Relationship of an unstable argG gene to a 5.7-kilobase amplifiable DNA sequence in Streptomyces lividans 66

The relationship between an unstable argG gene and a 5.7-kilobase (kb) amplifiable DNA sequence in Streptomyces lividans 66 was investigated. Spontaneous, high-frequency Arg mutants deleted for this gene typically contain 200 to 300 copies of the tandemly reiterated sequence. A library of S. lividans 66 (strain 1326) wild-type genomic DNA was prepared in the vector lambda Charon 35. Chromosome walking over 44 kb established that argG is located 25 kb distant from a duplicated amplifiable DNA structure. A sequence was characterized, located farther distal from the amplifiable structure, containing strong homology with an internal sequence of the amplifiable DNA, which may have a role in the deletion of argG. Genetic mapping showed that argG and the 5.7-kb amplifiable sequence are linked to another unstable gene, determining chloramphenicol resistance (Camr) and that together these genes may be located in a silent chromosomal arc.

Transposon-encoded site-specific recombination: nature of the Tn3 DNA sequences which constitute the recombination site res

The tnpR gene of transposon Tn3 encodes a site-specific recombination enzyme that acts at res, a DNA region adjacent to tnpR, to convert co-integrate intermediates of interreplicon transposition to the normal transposition end-products. We have used two complementary approaches to study the nature of the Tn3 recombination region, res. Firstly, the DNA-binding sites for tnpR protein were determined in DNase I protection experiments. These identified a 120-bp region between the tnpA and tnpR genes that can be subdivided into three separate protein-binding sites. Genetic dissection experiments indicate that few, if any, other sequences in addition to this 120-bp region are required for res function. Moreover, we have shown that the two directly repeated res regions within a molecule are unequal partners in the recombination reaction: a truncated res region, which is unable to recombine with a second identical res region, can recombine efficiently with an intact res region. This demonstration, along with the observation that tnpR/res recombination acts efficiently on directly repeated res regions within a molecule but inefficiently both on inverted res regions in the same molecule and in the fusion reaction between res regions in different molecules, leads us to propose that one-dimensional diffusion (tracking) of tnpR protein along DNA is used to locate an initial res region, and then to bring a second directly repeated res region into a position that allows recombination between the res regions.