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.

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 noninvasive method for distinguishing among canid species: amplification and enzyme restriction of DNA from dung

Endangered San Joaquin kit foxes Vulpes macrotis mutica can be sympatrically distributed with as many as four other canids: red fox, gray fox, coyote and domestic dog. Canid scats are often found during routine fieldwork, but cannot be reliably identified to species. To detect and study the endangered kit fox, we developed mitochondrial DNA markers that can be amplified from small amounts of DNA extracted from scats. We amplified a 412-bp fragment of the mitochondrial cytochrome-b gene from scat samples and digested it with three restriction enzymes. The resulting restriction profiles discriminated among all five canid species and correctly identified 10 'unknown' fox scats to species in blind tests. We have applied our technique to identify canids species for an environmental management study and a conservation study. We envision that our protocol, and similar ones developed for other endangered species will be greatly used for conservation management in the future.

Gastrointestinal somatostatin: extraction and radioimmunoassay in different species

A radioimmunoassay capable of detecting 300 fg somatostatin has been developed and levels of the polypeptide in gastrointestinal tissues from man, dog, and rat have been measured. Rapid freezing of collected samples and careful control of extraction is necessary. Concentrations in different regions of dog antrum (425 +/- 50 to 773 +/- 254 ng/g tissue) are similar to those in antrum from duodenal ulcer patients and control subjects: 614 +/- 125 and 465 +/- 104 ng/g tissue respectively. Levels in histologically normal human pancreas (253 +/- 43 ng/g tissue) are comparable with those in dog pancreas (333 +/- 66 ng/g tissue), whereas in two cases of neonatal hypoglycaemia the concentration exceeded 3000 ng/g tissue. On gel chromatography the majority of immunoreactive somatostatin elutes as the synthetic tetradecapeptide and a small fraction as a larger species.

Left ventricular function at rest and during exercise after aortic valve replacement in patients with aortic regurgitation

To determine the effect of aortic valve replacement on reversing abnormalities of left ventricular function in patients with aortic regurgitation, radionuclide cineangiography was used to study 16 sympatomatic patients with aortic regurgitation before and 6 months after aortic valve replacement. Before operation, left ventricular ejection fraction was 46 +/- 3 percent at rest (normal mean +/- standard error of the mean 57 +/- 1 percent; P less than 0.001), and decreased to 37 +/- 4 percent during exercise (normal 71 +/- 2 percent; P less than 0.001). after operation, ejection fraction rose to 58 +/- 4 percent at rest, indistinguishable from the normal value, and during exercise was 53 +/- 4 percent, increased (P less than 0.001) from before operation but significantly (P less than 0.001) subnormal. Thus, aortic valve replacement can improve but usually does not normalize left ventricular function during exercise in symptomatic patients with aortic regurgitation.

Calcium-antagonist receptors in the atrial tissue of patients with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is characterized by a nondilated, hypertrophied left ventricle in the absence of any overt cause. A possible role of adrenergic innervation or of cellular calcium regulation is suggested by the presence of hyperdynamic left ventricular function and by the clinical and symptomatic improvement seen in patients treated with beta-receptor antagonists or calcium antagonists. Therefore, we measured the density of calcium-antagonist receptors and beta-adrenoceptors in the atrial myocardium of 16 patients with hypertrophic cardiomyopathy and 19 patients with various other cardiac disorders. For comparison, we also measured the number of voltage-sensitive sodium channels. Calcium-antagonist binding sites, measured as the amount of dihydropyridine bound to atrial tissue, were increased by 33 percent in patients with hypertrophic cardiomyopathy (mean [+/- SD], 397 +/- 104 fmol per milligram of protein in patients with hypertrophic cardiomyopathy, as compared with 299 +/- 108 in patients with other cardiac disorders; P less than 0.01). The densities of saxitoxin-binding sites on voltage-sensitive sodium channels and beta-adrenoceptors were the same in the two groups, although the density of beta-adrenoceptors was higher in atrial samples from patients receiving beta-receptor antagonists (165 +/- 86 fmol per milligram of protein [patients receiving beta-blockers] vs. 85 +/- 60 [patients not receiving beta-blockers]; P less than 0.04). The increase in the number of calcium-antagonist receptors in hypertrophic cardiomyopathy suggests that abnormal calcium fluxes through voltage-sensitive calcium channels may play a pathophysiologic part in the disease.

Isolation of a neuropeptide from locust corpus cardiacum which influences ileal transport

1. Schistocerca gregaria ion-transport peptide (Scg-ITP) was isolated from aqueous extracts of the corpus cardiacum by a four-step procedure, utilizing reverse-phase high-performance liquid chromatography for separation and stimulation of a Cl(-)-dependent short-circuit current (Isc) across locust ilea as the bioassay. 2. Scg-ITP has an unblocked N terminus and an apparent relative molecular mass of 7700. Thirty-one residues (of an estimated 65) were identified by sequence analysis. 3. Scg-ITP is structurally related to a crustacean family of neuropeptides which includes the crustacean hyperglycaemic hormones from the shore crab Carcinus maenas and the crayfish Orconectes limosus and moult-inhibiting hormone and vitellogenesis-inhibiting hormone from the lobster Homarus americanus. 4. Scg-ITP has no sequence homology with neuroparsins (Nps). Nps are the only other neuropeptides isolated to date that might regulate reabsorption in an insect hindgut (rectum).

Fluoride determination in plasma by ion selective electrodes: a simplified method for the clinical laboratory

A potentiometric method for the determination of fluoride (F-) in serum and plasma is proposed; it is based on a combination of the single-known-addition method and the electrode slope-by-dilution method. This procedure provides reliable results in extremely low measuring ranges down to 2.5 mug/l, where the electrode slope deviates markedly from Nernstian behaviour. In this method no electrode calibration is required and only one standard is necessary. 1 ml of plasma is sufficient for one analysis. Apart from a 5% enrichment of all samples with a concentrated total ionic strength adjustment buffer, no further preparation of the sample is required. The simplicity of the various pipetting and analytical steps, and also of the evaluation of the readings, may render this method highly suitable for the clinical laboratory. Investigations into the accuracy and precision of the method produced satisfactory results. The recovery in plasma amounted to 99.7%, even in the low measuring ranges. The discrimination capacity of the method amounts to 0.1 mug/l. With the apparatus and experimental procedures described, 18 plasma analyses per day can be performed even at low F- concentrations with which longer electrode stabilization periods are required. Storage of the plasma samples frozen at --20 degrees C for up to 8 weeks exerts no effect on the F- concentration. Problems of sample contamination and other disturbances are discussed. Determinations of normal values in 20 test subjects resulted in a mean value of 10.4 plus or minus 4.01 mug/l (Mean plus or minus S.D.). The modal value amounted to 9.5 mug/l, and the range was between 5.9 and 18.8 mug/l. The F- content of the drinking water supplied to this group of persons amounted to 180 mug/l. The importance of the method has been illustrated using a clinico-nephrological study as an example.

Variations in the carcinogenicity of tremolite dust samples of differing morphology

Six samples of tremolite of different morphological type were prepared as dusts of respirable size and used in intraperitoneal injection studies in rats. Three "asbestiform" tremolites produced mesotheliomas in almost all animals, although with significantly different tumor-induction periods. A brittle type of fibrous tremolite which, when manipulated to prepare "respirable dust," produced a sample with relatively few asbestiform fibers remaining nonetheless produced tumors in 70% of rats. Two samples of nonfibrous tremolite produced respirable dust samples containing numerous elongated fragments with aspect ratios greater than 3:1, which therefore fitted the definition of respirable fibers. Both these samples produced relatively few tumors, although one had more long "fibers" than did the brittle tremolite that produced 70% of tumors. This study has therefore demonstrated that different morphologic forms of tremolite produce dusts with very different carcinogenic potential. Carcinogenicity does not depend simply on the number of elongated particles injected, and we need to develop methods of distinguishing carcinogenic tremolite fibers from relatively innocuous tremolite dusts, with similar numbers of elongated particles of similar aspect ratios.

Glutathione: new candidate neuropeptide in the central nervous system

The physiological significance of glutathione in the mammalian central nervous system is still uncertain, although some evidence indicates that it may be an important regulatory peptide. In the present study, the distribution and characteristics of glutathione binding sites in the brain have been studied. Biotinyl-glutathione was synthesized as a probe to detect glutathione binding sites in the CNS. Specific glutathione binding sites in the brain were largely localized to the white matter, suggesting the presence of glutathione receptors on neuroglial cells. The colloidal gold technique and immunofluorescence double staining allowed the visualization of the receptor at the cellular level and thus demonstrated that there are glutathione receptors on cultured astrocytes. Glutathione applied to cultured astrocytes elicited increased levels of intracellular inositol-1,4,5-trisphosphate, suggesting that glutathione receptors were coupled to phospholipase C. The localization of glutathione receptors on astrocytes and the activation of a second messenger system by glutathione suggest that glutathione may be a neuropeptide in the central nervous system.

Growth hormone cell antibodies and partial growth hormone deficiency in a girl with Turner's syndrome

Growth hormone (GH) cell auto-antibodies have been demonstrated in the serum of a girl with an iso-chromosome variant of Turner's syndrome. On two occasions she showed an abnormal response of GH release during insulin induced hypoglycaemia. Her response to GH treatment was poor, but this was commenced at a very late bone-age. It is possible that autoimmunity is a new aetiological factor for GH deficiency in some cases.

A prospective study of risk factors for foot ulceration: the West of Ireland Diabetes Foot Study

BACKGROUND

This is the first study to examine risk factors for diabetic foot ulceration in Irish general practice.

AIM

To determine the prevalence of established risk factors for foot ulceration in a community-based cohort, and to explore the potential for estimated glomerular filtration rate (eGFR) to act as a novel risk factor.

DESIGN

A prospective observational study.

METHODS

Patients with diabetes attending 12 (of 17) invited general practices were invited for foot screening. Validated clinical tests were carried out at baseline to assess for vascular and sensory impairment and foot deformity. Ulcer incidence was ascertained by patient self-report and medical record. Patients were re-assessed 18 months later.

RESULTS

Of 828 invitees, 563 (68%) attended screening. On examination 23-25% had sensory dysfunction and 18-39% had evidence of vascular impairment. Using the Scottish Intercollegiate Guidelines Network risk stratification system we found the proportion at moderate and high risk of future ulceration to be 25% and 11%, respectively. At follow-up 16/383 patients (4.2%) developed a new foot ulcer (annual incidence rate of 2.6%). We observed an increasing probability of abnormal vascular and sensory test results (pedal pulse palpation, doppler waveform assessment, 10 g monofilament, vibration perception and neuropathy disability score) with declining eGFR levels. We were unable to show an independent association between new ulceration and reduced eGFR [Odds ratio 1.01; P = 0.64].

CONCLUSION

Our data show the extent of foot complications in a representative sample of diabetes patients in Ireland. Use of eGFR did not improve identification of patients at risk of foot ulceration.

Situating theory in practice: student views of theory-practice in Project 2000 nursing programmes

In this paper the views of student nurses taking Project 2000 at a Scottish College of Nursing are reported. A random sample of 19 students were interviewed. The interviews focused on the relationship between the college course and the students' experiences on placement. The majority had difficulty in relating the college course to their practice, except when it came to very specific parts of the programme, for example basic medical procedures. Only a minority could integrate the broader aspects of the course to their practice, largely because there was such a long period of time between studying a topic in college and the related placement. It is tempting to see the results as supporting the situated cognition hypothesis that theory loses meaning out of context, and it is evident, even from this limited study, that the success of Project 2000, with its emphasis on the 'knowledgeable doer', could depend, to a great extent, on the careful phasing of college coursework and placement to enable students to integrate theory and practice more effectively.

Large differences in substitutional pattern and evolutionary rate of 12S ribosomal RNA genes

We demonstrate using Drosophila, periodical cicadas, and hominid primates, that the molecular clock based on animal mitochondrial small-subunit (12S) rRNA genes ticks at significantly different relative rates depending on which taxa and which region of the gene are examined. Drosophila, which are commonly used as model taxa, are evolving in a highly peculiar manner with the majority of sites in the 3' half of the 12S gene apparently invariant. The analogous 3' half of the mitochondrial large-subunit rRNA gene (16S) appears to be similarly constrained. It is surprising that these regions that are already highly constrained in all animals should be even more constrained in Drosophila, especially when the Drosophila mitochondrial genome as a whole does not display a similar rate slowdown. This extreme 12S rate slowdown is not apparent in periodical cicadas or hominid primates and appears to be related to strong structural and functional constraints rather than a depressed mutation rate. Finally, the slow average rate of evolution in the third domain of Drosophila does not imply that the few variable sites lack multiple hits.

Effect of the dopamine receptor blocking agent pimozide on the growth hormone response to arginine and exercise and on the spontaneous growth hormone fluctuations

Pimozide, a specific blocker of dopamine receptors, was administered orally to 10 diabetics for 2 days before an arginine-hydrochloride infusion. In 8 healthy volunteers and 20 diabetics exercise tests on a bicycle ergometer were performed with a load of 100 Watts and 50 Watts respectively without or after a single dose of pimozide 30 min before the test. In 4 male diabetics day profiles of growth hormone (GH) were estimated without and during treatment with pimozide for 4 days. The arginine and exercise induced GH release was found to be significantly lowered by pimozide, whereas the marked spontaneous fluctuations in the diabetics were even enhanced by pimozide. These data support the concept of the involvement of dopaminergic stimulation in the response of GH to arginine and exercise. The spontaneous fluctuations of GH, however, seem to be regulated by other neuroendocrine mechanisms.

Metabolic and clinical studies on patients with acromegaly treated with bromocriptine over 22 months

In twenty-two patients with active acromegaly who were untreated or unsuccessfully operated or irradiated (mean growth hormone (GH) values greater than 4 ng/ml) the following investigations were performed: routine laboratory tests, tomography of pituitary fossa, oral glucose tolerance tests, TRH and other pituitary function tests and GH profiles over 5-10 h before and during bromocriptine treatment with daily doses between 7.5 and 50 mg. In seventeen patients GH was suppressed to less than 50% by bromocriptine, in thirteen of them it was normalized on at least one occasion. A TRH induced GH release was observed in all but two responders to bromocriptine before therapy. This effect of TRH was not blunted during treatment with bromocriptine and also in the two patients with negative tests before therapy a significant GH increase was observed. In no non-responder to bromocriptine was a significant increase of GH after TRH observed. One patient showed a secondary resistance to bromocriptine during a period of treatment with griseofulvin. In the remaining sixteen patients the GH suppression has been consistent for between 3 and 22 months. A single dose of pimozide abolished the bromocriptine effect on GH totally in one patient; in others a slight or no significant effect was observed. Tissue swelling and sweating decreased in all bromocriptine responders and glucose tolerance improved in five patients. In four diabetic patients a partial or full remission of diabetes occurred. Apart from postural hypotension after the first administration in two patients no other severe side effects have been observed. Sella size and the other pituitary functions did not change during the time of the study. It seems that a high percentage of acromegalics may be successfully treated with bromocriptine.

Vagal release of IR-VIP and IR-gastrin from the isolated perfused rat stomach

The effects of electrical stimulation of the vagus at varying pulse widths on the release of immunoreactive VIP (IR-VIP) and IR-gastrin have been investigated, using the isolated perfused rat stomach preparation. Electrical stimulation of vagal trunks at a pulse width of 0.1 msec duration yielded no change in basal IR-VIP levels whereas a pulse width of 5.0 msec produced a prompt sustained increase. Stimulation at either pulse width evoked gastrin release. Atropine blocked the vagal release of IR-gastrin but not IR-VIP whereas hexamethonium blocked both responses. Exogenously administered porcine VIP, at concentrations mimicking endogenously released levels, was used in an attempt to reproduce the effects observed by vagal stimulation. Exogenous VIP had no effect on gastrin or somatostatin-like immunoreactivity (SLI) release. These in vitro studies support a role for VIP as a neurotransmitter released from the stomach by low-threshold non-cholinergic vagal fibres, but involving autonomic ganglia.

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.

Is multidisciplinary learning effective among those caring for people with diabetes?

The role of multi-professional learning for those providing clinical services to people with diabetes has yet to be defined. Several assumptions are generally made about education in the context of multi-professional settings. It is argued that different professions learning together could potentially improve professional relationships, collaborative working practices and ultimately standards of care. Greater respect and honesty may emerge from a team approach to learning with a commensurate reduction in professional antagonism. Personal and professional confidence is reportedly enhanced through close contact with other professionals during team-based learning exercises. We have examined current evidence to support multidisciplinary learning in the context of medical education generally as well as in diabetes education. Previous investigation of available literature by Cochrane reviewers, aimed at identifying studies of interprofessional education interventions, yielded a total of 1042 articles, none of which met the stated inclusion criteria. Searches involving more recent publications failed to reveal more robust evidence. Despite a large body of literature on the evaluation of interprofessional education, studies generally lacked the methodological rigour needed to understand the impact of interprofessional education on professional practice and/or health care outcomes. Nevertheless, planners continue to advocate, and endorse, joint training between different groups of workers (including nurses, doctors and those in professions allied to medicine) with the objective of producing an integrated workforce of multidisciplinary teams. Whilst the concept of multi-professional learning has strong appeal, it is necessary for those responsible for educating health care professionals to demonstrate its superiority over separate learning experiences.

Anti-MAG antibody and antibody complexes: detection by radioimmunoassay

A radioimmunoassay (RIA) for measuring isotype-specific antibodies to the myelin-associated glycoprotein (MAG) was developed using radiolabeled CNS MAG in a double-antibody precipitation system. Anti-MAG activity was detected by RIA only in patients with neuropathy and anti-MAG M proteins. Anti-MAG IgM or IgG antibodies were not detected in serum of patients with Guillain-Barré syndrome, chronic relapsing polyneuritis, or multiple sclerosis (MS). Some patients with anti-MAG IgM M proteins also had complexes of IgG or IgA bound to the M protein. In one patient, anti-CNS MAG activity was detected by RIA, but not by ELISA or immunoblot. Anti-MAG antibody activity in patients with neuropathy seems to be isotypically restricted, and there is no evidence for antibody reactivity to MAG in other demyelinating diseases.