Analysis of insulin glulisine at the molecular level by X-ray crystallography and biophysical techniques

This study concerns glulisine, a rapid-acting insulin analogue that plays a fundamental role in diabetes management. We have applied a combination of methods namely X-ray crystallography, and biophysical characterisation to provide a detailed insight into the structure and function of glulisine. X-ray data provided structural information to a resolution of 1.26 Å. Crystals belonged to the H3 space group with hexagonal (centred trigonal) cell dimensions a = b = 82.44 and c = 33.65 Å with two molecules in the asymmetric unit. A unique position of D21Glu, not present in other fast-acting analogues, pointing inwards rather than to the outside surface was observed. This reduces interactions with neighbouring molecules thereby increasing preference of the dimer form. Sedimentation velocity/equilibrium studies revealed a trinary system of dimers and hexamers/dihexamers in dynamic equilibrium. This new information may lead to better understanding of the pharmacokinetic and pharmacodynamic behaviour of glulisine which might aid in improving formulation regarding its fast-acting role and reducing side effects of this drug.

Hypoglycaemic unawareness: A systematic review of qualitative studies of significant others' (SO) supportive interventions for patients with diabetes mellitus

BACKGROUND

Hypoglycemia unawareness (HU) has been attributed to both a downward shift in central nervous system (CNS)-triggered sympatho-adrenal responses to low glycaemic thresholds and a subsequent loss of adrenergic symptoms, which, in addition, to cerebral cortex adaptations permit normal function under hypoglycaemic conditions. Both of these mechanisms are brought about by recurring hypoglycemic events (hypoglycemia-associate autonomic failure, HAAF). This can contribute to repetitive cycles of increasingly severe hypoglycaemia, the consequences of which have considerable impact on relatives and significant others (SO) when providing care to patients with diabetes.

METHODS

A Systematic Review (SR) of 639 qualitative studies was carried out in accordance with the Preferred Reporting Items for Systematic Review (PRISMA) principles. The search strategy was developed using MeSH terms for a range of electronic databases: CINAHL, Pubmed, EMBASE, Medline, AMED and ASSIA were systematically searched in order to identify a variety of literature relevant to the review topic. Four duplicate studies were removed and a further 630 studies were excluded due to being irrelevant. Five qualitative studies were retained and analysed.

RESULTS

The three resultant findings from the literature appraised were i) Experiences and views of Significant Others' (SO) with adult relatives that have HU ii) Support needs of SO and iii) Health professionals interventions to address SO support needs and improve overall HU care. A clear finding was that SO experience difficulties managing HU and this can impact on the relationships that SO and HU patients have. Support needs of SO highlighted were both educational and psychological in nature, with there being a requirement for additional raised awareness within the wider community.

CONCLUSION

It is essential that healthcare professionals offer support, such as teaching and support groups. In addition, providing interventions into improving family knowledge of diabetes and support with regard to psychosocial, behavioural and practical support for the person with diabetes. Moreover, improving resources for families to improve diabetes care. However, as the literature was of a qualitative nature, future recommendations would be quantitative research into these suggested nursing implementations to quantitatively assess their usefulness in practice.

A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU)

BACKGROUND

The World Health Organization (WHO) states that diabetic foot ulcers (DFU) are associated with disability, death among patients with diabetes and substantial costs, if not prevented or managed effectively. The aim here is to examine the effectiveness of patient education in preventing and reducing the incidence or recurrence of adult DFU and amputation.

METHODS

A systematic review and meta-analysis of randomised clinical trials (RCTs) in adults aged 18+ who have diabetes mellitus (type 1 or type 2) or DFU. CINAHL, EMBASE, MEDLINE, PSYCINFO, Cochrane Library and Evidence-Based Nursing, National Library for Health, Medica and Google Scholar were searched. Only English language studies were considered. Databases were searched from their inception to September 2017.

FINDINGS

Six RCTs met the inclusion criteria. Only five RCTs reported on the incidence of DFU whilst only two reported on amputation rates. There was no advantage of combining different educational approaches in preventing/reducing DFU, relative risk (RR) of 0.50 (95%CI 0.21, 1.17) (P = 0.11). Two RCTs based on foot care education alone were compared with usual care; the result showed a non-significant effect (P = 0.57) with high heterogeneity of 77%.Analysis based on intensive versus brief educational approach showed a statistically reduced risk of incidence of DFU in the intervention group when compared to the control group; (RR, 0.37, 95%CI 0.14, 1.01) (P = 0.05) with high heterogeneity of 91%.

INTERPRETATION

The intensive educational intervention was associated with reduced incidence of DFU.

Validation of THIN data for non-melanoma skin cancer

BACKGROUND

The Health Improvement Network (THIN) database began in 2003. It consists of anonymised records from over 300 general practice computer systems and is likely to be valuable for research, planning and strategic issues in health care, but it is important to establish completeness and accuracy of the data.

AIM

To investigate the validity of THIN data for non-melanoma skin cancer (NMSC). We defined NMSC as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

METHODS

Using Read codes we extracted THIN database records of first-recorded diagnoses of NMSC from 1 January 1996 to 31 December 2003. Searches for SCC were unable to distinguish between skin tumours of this type, and SCC at any other site. From our dataset for BCC, 40 patient records were selected at random, and a questionnaire sent to their corresponding practice, asking if they had been referred to hospital/dermatology clinic, and how the diagnosis of BCC had been confirmed.

RESULTS

All the patients in the sample were referred to a hospital or dermatology clinic: 37/40 (93%) had the diagnosis of BCC confirmed, either by a letter from the hospital or a pathology report, a finding that we have reported previously. One patient's diagnosis was confirmed as SCC, and the other two either died or moved away before diagnosis could be confirmed. The 38 patients with diagnoses confirmed were all treated in hospital or dermatology clinic.

CONCLUSIONS

Data for BCC are sufficiently accurate for research. It is also likely that these data will prove valuable for quality management. It is not possible currently to obtain accurate data for SCC of the skin from the THIN database. This seems not to be a problem with the THIN database itself, but attributable to the Read coding scheme being, in practice, unable to allow differentiation between SCCs of different organs.

Trends in incidence of skin basal cell carcinoma. Additional evidence from a UK primary care database study

We determined the trends in incidence of skin basal cell carcinoma (BCC) using a primary care population-based cohort study in the UK. 11,113 adults with a BCC diagnosis were identified from a total of 7.22 million person-years of data between 1996 and 2003 from the Health Improvement Network database. From a random subsample of BCC cases identified from the database, 93% were confirmed by hospital letter and/or pathology report. The incidence of BCC was 153.9 per 100,000 person-years (95% CI 151.1, 156.8) and was slightly higher in men as compared to women (Incidence Rate Ratio 1.10, 95% CI 1.06, 1.14). There was a 3% increase year on year across the study period (IRR 1.03, 95% CI 1.01, 1.04), with the largest increase in incidence seen in the 30-39 year age groups, although this did not reach statistical significance. Our study indicates 53,000 new cases of BCC are estimated every year in the UK and figures are continuing to rise on a yearly basis. Incidence rates are highest for men and in particular in the older age categories. These findings are consistent with those reported for various other populations. We have also found an increase in incidence in ages 30-39, which may suggest a cohort effect of increasing ultraviolet exposure in successive younger generations. This may have a huge public and service impact in future years in countries such as the UK, with predominantly fair-skinned population, with high leisure exposure to ultraviolet light. Our findings underline the need for more elaborate preventive measures.

Coronary heart disease prevention and age inequalities: the first year of the National Service Framework for CHD

BACKGROUND

The National Service Framework for Heart Disease sets national standards and defines service models for coronary heart disease (CHD). Little is known about the impact of this intervention on age inequalities.

AIM

To determine the changes in the uptake of coronary prevention measures before and after the first year of implementation of the National Service Framework for Coronary Heart Disease, and to compare these changes in uptake of coronary prevention in patients aged 75 years and over with younger patients.

DESIGN OF STUDY

Repeated cross-sectional survey using routinely collected data.

SETTING

Seventeen general practices in 17 primary care groups in the Trent Region.

METHOD

All registered patients at baseline and follow-up aged >/=35 years were categorised into three groups: those with either coronary heart disease or a history of stroke; those with diabetes or hypertension who were not in in the first group; and the remaining population. Data from electronic records was collected to show differences in the proportions of patients with coronary risk factors recorded in the previous year. Data was also collected about differences in the proportions of patients with adequate disease control measures.

RESULTS

Improvements were demonstrated in the recording of coronary risk factors and of disease control measures. However, compared with patients aged <75 years, older patients were significantly less likely to have a serum cholesterol level recorded at baseline; to be on lipid lowering drugs; to be on beta blockers post myocardial infarction and to have well controlled blood pressure. These differences persisted at follow-up.

CONCLUSION

There have been substantial improvements in both the recording of coronary risk factors and disease control measures following the implementation of the National Service Framework for Coronary Heart Disease. However, there needs to be an effort to strengthen the focus on the care of older patients.

Antidepressants as risk factor for ischaemic heart disease: case-control study in primary care

OBJECTIVES

To determine whether antidepressants are a risk factor for ischaemic heart disease and to compare the risk for different subgroups of antidepressants and individual antidepressants.

DESIGN

Case-control study.

SETTING

Nine general practices recruited from the Trent Focus Collaborative Research Network.

PARTICIPANTS

933 men and women with ischaemic heart disease matched by age, sex, and practice to 5516 controls.

MAIN OUTCOME MEASURE

Adjusted odds ratio for ischaemic heart disease calculated by logistic regression.

RESULTS

Odds ratios for ischaemic heart disease were significantly raised for patients who had ever received a prescription for tricyclic antidepressants even after diabetes, hypertension, smoking, body mass index, and use of selective serotonin reuptake inhibitors had been adjusted for (1.56; 95% confidence interval 1.18 to 2.05). Patients who had ever taken dosulepin (dothiepin) had a significantly raised odds ratio for ischaemic heart disease after adjustment for confounding factors and use of other antidepressants (1.67, 1.17 to 2.36). There was no significant increase in the odds ratios for amitriptyline, lofepramine, and selective serotonin reuptake inhibitors in multivariate analysis. Increasing maximum doses of dosulepin were associated with increasing odds ratios for ischaemic heart disease. Similarly, there was a significant positive trend associated with increasing numbers of prescriptions of dosulepin (adjusted odds ratio 1.52 for 1 prescription, 1.39 for 2-3, and 1.96 for >/=4, P<0.002).

CONCLUSION

There is good evidence for an association between dosulepin and subsequent ischaemic heart disease and for a dose-response relation.

Sex inequalities in ischaemic heart disease in general practice: cross sectional survey

OBJECTIVE

To study differences in treatment for men and women with ischaemic heart disease by using standards defined in England's national service framework for coronary artery disease.

DESIGN

Cross sectional survey using routinely collected data.

SETTING

18 practices in 18 primary care groups in Trent Region.

SUBJECTS

5891 men and women aged over 35 years with a diagnosis of ischaemic heart disease or prescription for nitrates recorded on computer.

MAIN OUTCOME MEASURE

Difference in the proportion of men and women with ischaemic heart disease and taking lipid lowering treatment.

RESULTS

Women were less likely than men to have a recording of body mass index (79% (2197/2783) v 82% (2552/3102), P=0.002), smoking (86% (2386) v 89% (2779), P<0.0001), and blood pressure (95% (2643) v 96% (2986), P=0.04). Women were also less likely to have a recording of fasting cholesterol concentration (35% (968) v 50% (1550), P<0.0001) but were more likely to be obese (25% (558/2197) v 20% (514/2552), P<0.0001) and have their most recently recorded blood pressure value over the recommended 140/85 mm Hg (60% (1598/2643) v 52% (1553/2986), P<0.0001). Although a higher proportion of women had a raised serum cholesterol concentration (77% (749/968) v 67% (1043/1550), P<0.0001), men were more likely to take aspirin (76% (2358) v 71% (1979), P<0.0001), have a recorded diagnosis of hyperlipidaemia (13% (418) v 10% (274), P<0.0001), and be prescribed lipid lowering drugs (31% (973) v 21% (596), P<0.0001). These differences remained despite adjustments for the practice where the patient is registered, age, smoking status, obesity, diabetes, and hypertension.

CONCLUSION

The results suggest a systematic bias towards men compared with women in terms of secondary prevention of ischaemic heart disease.