Quality indicators for the prevention of type 2 diabetes in Europe--IMAGE

BACKGROUND

The marked increase of type 2 diabetes necessitates active development and implementation of efficient prevention programs. A European level action has been taken by launching the IMAGE project to unify and improve the various prevention management concepts, which currently exist within the EU. This report describes the background and the methods used in the development of the IMAGE project quality indicators for diabetes primary prevention programs. It is targeted to the persons responsible for diabetes prevention at different levels of the health care systems.

METHODS

Development of the quality indicators was conducted by a group of specialists representing different professional groups from several European countries. Indicators and measurement recommendations were produced by the expert group in consensus meetings and further developed by combining evidence and expert opinion.

RESULTS

The quality indicators were developed for different prevention strategies: population level prevention strategy, screening for high risk, and high risk prevention strategy. Totally, 22 quality indicators were generated. They constitute the minimum level of quality assurance recommended for diabetes prevention programs. In addition, 20 scientific evaluation indicators with measurement standards were produced. These micro level indicators describe measurements, which should be used if evaluation, reporting, and scientific analysis are planned.

CONCLUSIONS

We hope that these quality tools together with the IMAGE guidelines will provide a useful tool for improving the quality of diabetes prevention in Europe and make different prevention approaches comparable.

Take action to prevent diabetes--the IMAGE toolkit for the prevention of type 2 diabetes in Europe

When we ask people what they value most, health is usually top of the list. While effective care is available for many chronic diseases, the fact remains that for the patient, the tax payer and the whole of society: prevention is better than cure. Diabetes and its complications are a serious threat to the survival and well-being of an increasing number of people. It is predicted that one in ten Europeans aged 20-79 will have developed diabetes by 2030. Once a disease of old age, diabetes is now common among adults of all ages and is beginning to affect adolescents and even children. Diabetes accounts for up to 18 % of total healthcare expenditure in Europe. The good news is that diabetes is preventable. Compelling evidence shows that the onset of diabetes can be prevented or delayed greatly in individuals at high risk (people with impaired glucose regulation). Clinical research has shown a reduction in risk of developing diabetes of over 50 % following relatively modest changes in lifestyle that include adopting a healthy diet, increasing physical activity, and maintaining a healthy body weight. These results have since been reproduced in real-world prevention programmes. Even a delay of a few years in the progression to diabetes is expected to reduce diabetes-related complications, such as heart, kidney and eye disease and, consequently, to reduce the cost to society. A comprehensive approach to diabetes prevention should combine population based primary prevention with programmes targeted at those who are at high risk. This approach should take account of the local circumstances and diversity within modern society (e.g. social inequalities). The challenge goes beyond the healthcare system. We need to encourage collaboration across many different sectors: education providers, non-governmental organisations, the food industry, the media, urban planners and politicians all have a very important role to play. Small changes in lifestyle will bring big changes in health. Through joint efforts, more people will be reached. The time to act is now.

A European evidence-based guideline for the prevention of type 2 diabetes

BACKGROUND

The prevalence and socioeconomic burden of type 2 diabetes (T2DM) and associated co-morbidities are rising worldwide.

AIMS

This guideline provides evidence-based recommendations for preventing T2DM.

METHODS

A European multidisciplinary consortium systematically reviewed the evidence on the effectiveness of screening and interventions for T2DM prevention using SIGN criteria.

RESULTS

Obesity and sedentary lifestyle are the main modifiable risk factors. Age and ethnicity are non-modifiable risk factors. Case-finding should follow a step-wise procedure using risk questionnaires and oral glucose tolerance testing. Persons with impaired glucose tolerance and/or fasting glucose are at high-risk and should be prioritized for intensive intervention. Interventions supporting lifestyle changes delay the onset of T2DM in high-risk adults (number-needed-to-treat: 6.4 over 1.8-4.6 years). These should be supported by inter-sectoral strategies that create health promoting environments. Sustained body weight reduction by >or= 5 % lowers risk. Currently metformin, acarbose and orlistat can be considered as second-line prevention options. The population approach should use organized measures to raise awareness and change lifestyle with specific approaches for adolescents, minorities and disadvantaged people. Interventions promoting lifestyle changes are more effective if they target both diet and physical activity, mobilize social support, involve the planned use of established behaviour change techniques, and provide frequent contacts. Cost-effectiveness analysis should take a societal perspective.

CONCLUSIONS

Prevention using lifestyle modifications in high-risk individuals is cost-effective and should be embedded in evaluated models of care. Effective prevention plans are predicated upon sustained government initiatives comprising advocacy, community support, fiscal and legislative changes, private sector engagement and continuous media communication.

[The resource orientated integration of chronic mentally ill into regular employment via "One-Euro-Jobs"--initial experiences of a model project]

Until recently the vocational rehabilitation of chronic mentally ill often resulted in employment in the framework of sheltered workshops. There are an increased number of workshops and day clinics but in this context the patient does not come in contact with the everyday working environment. However, several multicenter studies demonstrated that "Individual Placement Support" (IPS) is more effective than vocational services. The aim of our project is to show that this concept is applicable even to patients with chronic and severe psychiatric diseases. We created "One-Euro-Jobs" for patients with chronic mental illnesses within regular employments in the confinements of our clinic. The choice of workplace was carried out according to the individual experience and knowledge and included the library, central buying and post office. Until now 15 mentally ill patients with an average disease duration of 11 years were included in the project. 1 patient discontinued within the first 3 weeks. The others were occupied on average for 9 months. Our project shows that integration of chronically mental ill patients in regular employment environments is possible. Concerns that the pressure and stress would be too extreme were proved to be unfounded.

[Mucormycosis in paranasal sinuses]

Three patients with mucormycosis of the paranasal sinuses were treated in the University ENT departments in Bochum and Essen in recent years. All patients were immunocompromised for different reasons and had reduced resistance against microorganism infection. They presented with symptoms of orbital complications of sinusitis. The further progress of these life-threatening fungal infections with a mortality rate between 35 and 70% depends on early and definitive diagnosis and radical surgical therapy to reduce the amount of infectious agent. The difficulties of early diagnosis by imaging, histology, microbiology, or molecular biology and postoperative therapeutic options especially with amphotericin B, liposomal amphotericin B, and posaconazole are illustrated and discussed.

Venous air embolism induces both platelet dysfunction and thrombocytopenia

BACKGROUND

In vitro, air bubbles can induce platelet activation and platelet to air bubble binding. We therefore tested in vivo the hypothesis that venous air embolism (VAE) induces (1) platelet dysfunction and (2) thrombocytopenia.

METHODS

Adult swine (60.8+/-3.9 kg; n=8) were anaesthetized, mechanically ventilated, and placed in a semi-upright position. Air boli (0.5-80 ml) were injected randomly via an ear vein, and arterial blood was sampled after cumulative air dosages of 0, 80, 160, and 240 ml. Coagulation was assessed by impedance aggregometry, rotational thrombelastometry, whole blood count, plasmatic coagulation variables, and fibrinogen, d-dimer, protein C, and antithrombin plasma concentrations, respectively.

RESULTS

VAE induced a 47% decrease in platelet count (303 vs. 160 nl(-1); P<0.001) over the dose range assessed, with haematocrit being unaltered. Furthermore, VAE-impaired platelet aggregation induced by adenosine diphosphate, arachidonic acid, collagen, and the thromboxan analogue U46619 over the dose range assessed independent of thrombocytopenia. (P<0.05 vs. baseline). In contrast, rotational thrombelastometry alone was quite insensitive in detecting VAE-induced coagulation changes, showing only at near lethal air dosages a prolonged clot formation time following activation with tissue factor, contact activator, and during spontaneous coagulation (P<0.05 vs. baseline).

CONCLUSIONS

VAE induces both a dose-dependent decrease in platelet count and a marked decrease in platelet aggregation, independent of thrombocytopenia (P<0.05 vs. baseline).

[Biomaterials for craniofacial reconstruction]

Biomaterials for reconstruction of bony defects of the skull comprise of osteosynthetic materials applied after osteotomies or traumatic fractures and materials to fill bony defects which result from malformations, traumata or tumor resections. Other applications concern functional augmentations for dental implants or asthetic augmentations in the region of the face. For ostheosynthesis, mini- and microplates from titanium alloys provide major advantages concerning biocompatibility, stability and individual fitting to the implant bed. The necessity of removal of asymptomatic plates and screws after fracture healing is still a controversial issue. Risks and costs of secondary surgery for removal face a low rate of complications (due to corrosion products) when the materials remains in situ. Resorbable osteosynthesis systems have similar mechanical stability and are especially useful in the growing skull. The huge variety of biomaterials for reconstruction of bony defects makes it difficult to decide which material is adequate for which indication and for which site. The optimal biomaterial that meets every requirement (e. g. biocompatibility, stability, intraoperative fitting, product safety, low costs etc.) does not exist. The different material types are (autogenous) bone and many alloplastics such as metals (mainly titanium), ceramics, plastics and composites. Future developments aim to improve physical and biological properties, especially concerning surface interactions. To date, tissue engineered bone is far from routine clinical application.

Cell-free DNA in amniotic fluid remains to be attached to HMGA2-implications for noninvasive prenatal diagnosis

OBJECTIVE

The expression of the high mobility group protein gene HMGA2 is primarily confined to embryonic and fetal cells. The aim of this study was to determine the relative expression level of HMGA2 in cells of amniotic fluid samples. Furthermore, it should be investigated by chromatin immunoprecipitation whether or not HMGA2 is attached to cell-free DNA in amniotic fluid.

METHOD

Expression levels of HMGA2 in 58 amniotic fluid samples from the second trimester were measured using quantitative real-time polymerase chain reaction (PCR). Furthermore, the presence of HMGA2, attached to cell-free DNA was tested by chromatin immunoprecipitation.

RESULTS

Expression of HMGA2 was detected in all samples, but in cells of the amniotic fluid it was 161-fold higher than in cells of the urine from healthy donors. The real-time PCR with GAPDH showed a signal in all samples treated with the improved protocol of immunoprecipitation.

CONCLUSION

Our data clearly show that cells of the amniotic fluid strongly overexpress HMGA2 according to their fetal origin. The fact that apparently HMGA2 remains to be attached to cell-free DNA suggests interesting new approaches in noninvasive prenatal diagnosis.

Improved risk stratification in unstable angina: identification of patients at low risk for in-hospital cardiac events by admission echocardiography

BACKGROUND

Current protocols for risk stratification of patients with acute chest pain syndromes rely on clinical parameters and are oriented toward identification of patients at high risk for adverse cardiac events; however, this paradigm for risk stratification does not adequately address the observation that adverse cardiac events are relatively uncommon in this population. In an era of cost containment, consideration also should be given to identification of patients at low risk for adverse cardiac events, who may be safely discharged without expensive inpatient hospitalization.

HYPOTHESIS

The purpose of this study was to develop echocardiographic predictors that identify unstable angina patients at low risk for adverse cardiac events and that discriminate between low- and high-risk patients.

METHODS

The predictive accuracy of retrospectively determined echocardiographic predictors were compared in a population-based sample of 66 consecutive unstable angina patients undergoing echocardiography within 24 h of admission.

RESULTS

Echocardiographic predictors of adverse events included wall motion score index > or = 0.2, ejection fraction < or = 40%, and mitral regurgitation severity > 2. One or more echocardiographic predictors of adverse events were present in 32 patients (48%). A composite echocardiographic predictor of adverse events was specific, had a high positive predictive value for the identification of high-risk patients, and discriminated between unstable angina patients at high and low risk for adverse cardiac events.

CONCLUSION

Echocardiographic predictors of adverse events are specific and discriminate between unstable angina patients at high and low risk for adverse cardiac events.

Kinetic analysis and modeling of the liquid-liquid conversion of emulsified di-rhamnolipids by Naringinase from Penicillium decumbens

The enzymatic conversion of an aggregate-forming substrate was kinetically analyzed and a model was applied for the prediction of reaction-time courses. An L-rhamnose molecule from a di-rhamnolipid is cleaved by Naringinase from Penicillium decumbens leading to a mono-rhamnolipid. Optimal reaction rates were found when both, substrate and product build large co-aggregates in a slightly acidic aqueous phase. On the other hand, reaction rates were independent of initial di-rhamnolipid concentration and this was interpreted by assuming that the reaction occurs in the aqueous phase according to Michaelis-Menten kinetics in combination with competitive L-rhamnose inhibition. Rhamnolipids were therefore assumed to be highly concentrated in aggregates, a second liquid phase, whereas diffusive rhamnolipid transport from and to the aqueous phase occurs due to the enzymatic reaction. Furthermore, ideal surfactant mixing between di- and mono-rhamnolipid was assumed for interpretation of the negative effect of the last on the reaction rate. A model was created that describes the system accordingly. The comparison of the experimental data, were in excellent agreement with the predicted values. The findings of this study may beneficially be adapted for any bioconversion involving aggregate-forming substrate and/or product being catalyzed by hydrophilic enzymes.

The effect of mutual information on independent component analysis in EEG/MEG analysis: a simulation study

OBJECTIVE

This study investigated the influence of mutual information (MI) on temporal and dipole reconstruction based on independent components (ICs) derived from independent component analysis (ICA).

METHOD

Artificial electroencephalogram (EEG) datasets were created by means of a neural mass model simulating cortical activity of two neural sources within a four-shell spherical head model. Mutual information between neural sources was systematicallyvaried.

RESULTS

Increasing spatial error for reconstructed locations of ICs with increasing MI was observed. By contrast, the reconstruction error for the time course of source activity was largely independent of MI but varied systematically with Gaussianity of the sources.

CONCLUSION

Independent component analysis is a viable tool for analyzing the temporal activity of EEG/MEG (magnetoencephalography) sources even if the underlying neural sources are mutually dependent. However, if ICA is used as a preprocessing algorithm for source localization, mutual information between sources introduces a bias in the reconstructed locations of the sources.

SIGNIFICANCE

Studies using ICA-algorithms based on MI have to be aware of possible errors in the spatial reconstruction of sources if these are coupled with other neural sources.