Factors associated with glycemic control in type 1 diabetes patients in China: A cross-sectional study

Aims/Introduction

Glycemic control in type 1 diabetes can be challenging, and is influenced by many factors. This study aimed to investigate glycemic control and its associated factors in Chinese people with type 1 diabetes.

Materials and Methods

This cross‐sectional study included 779 participants with type 1 diabetes selected from hospital records review, outpatient clinics and inpatient wards. Data were collected through face‐to‐face interviews, medical records and venous blood samples. Multiple logistic regression analysis was carried out to determine factors associated with glycemic control.

Results

Among 779 participants, 49.2% were male. The median age was 24 years (interquartile range 14–36 years). The median age at diagnosis of diabetes was 17 years (interquartile range 10–28 years) and the median duration of diabetes was 4 years (interquartile range 1–8 years). The mean ± standard deviation hemoglobin A1c was 9.1 ± 2.5%. Nearly 80% of participants had inadequate glycemic control (hemoglobin A1c ≥7.0%). Multivariable analysis showed that age at diagnosis of diabetes ≤20 years, living in a rural location, low household income, low intake of fruit and vegetables, low level of physical activity, low adherence to insulin, and low utilization of insulin pump were independent risk factors for poor glycemic control (hemoglobin A1c ≥9.0%).

Conclusions

Inadequate glycaemic control is common among people with type 1 diabetes in China. Efforts should be made to control the modifiable risk factors, which include low intake of fruit and vegetables, low level of physical activity, and low adherence to insulin for the improvement of glycemic control. Appropriate use of insulin pump among type 1 diabetes should be encouraged.

Molecular biology and targeted therapy in metastatic renal cell carcinoma

The treatment of metastatic renal cell carcinoma is challenging as it has proven to be relatively resistant to conventional oncological treatments. An improved understanding of the molecular biology of renal cell carcinoma has led to the development of a number of targeted therapies in metastatic renal cell carcinoma. This includes vascular endothelial growth factor inhibitors, tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors and most recently immune checkpoint inhibitors. This article will review the mechanisms of development and progression of renal cell carcinoma as well as the mechanisms of current approved treatments in metastatic disease.

Level of evidence: Not applicable for this multicentre audit.

Stem cell therapy for stress urinary incontinence

Stress urinary incontinence is the involuntary loss of urine on effort or physical exertion. It is a highly prevalent condition affecting both men and women. Treatment is performed in a step-wise approach involving conservative measures, such as weight loss and pelvic floor exercises, medical treatment with duloxetine and a variety of surgical treatment options. However, recent restrictions in the use of synthetic mesh and tape have limited the surgical treatment options, leading to the need for new and novel treatment for stress urinary incontinence. Stem cell therapy is a developing medical field and offers the potential to restore normal physiological function of the urethral sphincter. The effectiveness of stem cell therapy in stress urinary incontinence has been demonstrated in pre-clinical studies, leading to its evaluation in several clinical studies. This review assesses the current evidence for the safety and efficacy of stem cell treatment for patients with stress urinary incontinence who have failed conservative and/or medical management and have not undergone previous surgical treatment for stress urinary incontinence.

Evidence Level: Not applicable

Objective outcome measures: Collecting meaningful data on alopecia areata

BACKGROUND

Although alopecia areata is a common disorder, it has no US Food and Drug Administration-approved treatment and evidence-based therapeutic data are lacking.

OBJECTIVE

To develop guidelines for the diagnosis, evaluation, assessment, response criteria, and end points for alopecia areata.

METHODS

Literature review and expert opinion of a group of dermatologists specializing in hair disorders.

RESULTS

Standardized methods of assessing and tracking hair loss and growth, including new scoring techniques, response criteria, and end points in alopecia areata are presented.

LIMITATIONS

The additional time to perform the assessments is the primary limitation to use of the methodology in clinical practice.

CONCLUSION

Use of these measures will facilitate collection of standardized outcome data on therapeutic agents used in alopecia areata both in clinical practice and in clinical trials.

Frontal Fibrosing Alopecia: An Emerging Epidemic

Since the initial description of frontal fibrosing alopecia (FFA) in 1994, increasingly more cases of FFA have been reported in literature. Although clear epidemiologic data on the incidence and prevalence of FFA is not available, it is intriguing to consider whether FFA should be labeled as an emerging epidemic. A medline trend analysis as well as literature review using keywords "alopecia," "hair loss," and "cicatrical" were performed. Medline trend analysis of published FFA papers from 1905 to 2016 showed that the number of publications referenced in Medline increased from 1 (0.229%) in 1994 to 44 (3.5%) in 2016. The number of patients per published cohort also increased dramatically since the first report of FFA. Over the time period of January 2006-2016, our multi hair-referral centers collaboration study also showed a significant increase in new diagnoses of FFA. At this juncture, the cause for the rapid rise in cases is one of speculation. It is plausible that a cumulative environmental or toxic factor may trigger hair loss in FFA. Once perhaps a "rare type" of cicatricial alopecia, FFA is now being seen in a frequency in excess of what is expected, thus suggestive of an emerging epidemic.

Age distribution and metabolic disorders in people with Type 1 diabetes in Beijing and Shantou, China: a cross-sectional study

AIMS

To examine whether the age profile of people with Type 1 diabetes differs from that of the general population and in what manner, and to study the clinical characteristics related to metabolic disorders among people with Type 1 diabetes in China.

METHODS

We sequentially enrolled 849 people with Type 1 diabetes from hospital records review, inpatient wards and outpatient clinics. Data were collected via face-to-face interviews, medical records and venous blood samples. Beijing census data for 2011 were used to provide the general population statistics. Descriptive analysis of the results and tests for differences were performed.

RESULTS

The median (interquartile range) age at diagnosis of diabetes was 16 (9-28) years and the duration of diabetes was 4 (1-8) years. The mean ± sd HbA_1c concentration was 76±28 mmol/mol (9.1±2.5%). Compared with the general population, the population with Type 1 diabetes comprised more young individuals and fewer elderly individuals. The overall prevalence of metabolic syndrome among those with Type 1 diabetes was 10.1% (95% CI 7.9-12.2). People with metabolic syndrome were older and were diagnosed with diabetes at an older age. Hypertension and dyslipidaemia were more common in obese individuals with Type 1 diabetes than in their non-obese counterparts.

CONCLUSIONS

Compared with the general population, people with Type 1 diabetes comprised more young and fewer elderly individuals. The prevalence of metabolic syndrome in the Type 1 diabetes population was 10.1%. Hypertension and dyslipidaemia were more prevalent in obese than non-obese individuals.

Type 1 diabetes mellitus care and education in China: The 3C study of coverage, cost, and care in Beijing and Shantou

AIMS

The paucity of data on Type 1 diabetes in China hinders progress in care and policy-making. This study compares Type 1 diabetes care and clinical outcomes in Beijing and Shantou with current clinical guidelines.

METHODS

The 3C Study was a cross-sectional study of the clinical practices and outcomes of people with Type 1 diabetes. The study sequentially enrolled 849 participants from hospital records, inpatient wards, and outpatient clinics. Data were collected via face-to-face interviews with patients and health professionals, the Summary of Diabetes Self-Care Activities, medical records, and venous blood samples. Care was audited using ISPAD/IDF indicators. Data underwent descriptive analysis and tests for association.

RESULTS

The median age was 22years (IQR=13-34years), and 48.4% of the sample had diabetes less than six years. The median HbA1c was 8.5% (69mmol/mol) (IQR 7.2-10.5%), with significant regional variance (p=0.002). Insulin treatment was predominantly two injections/day (45% of patients). The highest incidence of diabetic ketoacidosis was 14.4 events/100 patient years among adolescents. Of the 57.3% of patients with LDL-C>2.6mmol/L, only 11.2% received treatment. Of the 10.6% considered hypertensive, 47.1% received treatment. Rates of documented screening for retinopathy, nephropathy, and peripheral neuropathy were 35.2%, 42.3%, and 25.0%, respectively. The median number of days of self-monitoring/week was 3.0 (IQR=1.0-7.0). There were significant differences in care practices across regions.

CONCLUSIONS

The study documented an overall deficit in care with significant regional differences noted compared to practice guidelines. Modifications to treatment modalities and the structure of care may improve outcomes.

Effects of Finasteride on Apoptosis and Regulation of the Human Hair Cycle

Background:

A number of studies have provided evidence that apoptosis is a central element in the regulation of hair follicle regression. In androgenetic alopecia (AGA), the exact location and control of key players in the apoptotic pathways remains obscure.

Objective:

In the present study, we used a panel of antibodies and investigated the spatial and cellular pattern of expression of caspases and inhibitors of apoptosis (IAPs), such as XIAP and FLIP, in men with normal scalp and in men with AGA before and after 6 months of treatment with 1 mg oral finasteride treatment.

Methods and Results:

Constitutive expression of caspases-1, −3, −8, and −9 and XIAP was detected predominantly within the isthmic and infundibular hair follicle area, basilar layer of the epidermis, and eccrine and sebaceous glands. AGA-affected tissues showed an increase in caspase (−1, −3, −6, −9) immunoreactivity with a concomitant decrease in XIAP staining. After 6 months of finasteride treatment, both caspases and XIAP were similar to levels exhibited by normal subjects. Immunoblot analysis was performed to determine antibody specificity and cellular expression of caspases. Purified populations of keratinocytes, melanocytes, dermal papilla, and dermal fibroblasts derived from human hair follicles were cultured in vitro and treated with 0.5 μm staurosporin. Time-course experiments revealed that processing of caspase-3 is a principal event during apoptosis of these hair cell types.

Conclusion:

These data suggest that alterations in levels of caspases and IAPs regulate hair follicle homeostasis. Moreover, finasteride appears to influence caspase and XIAP expression in hair follicle cells thus signaling anagen, active growth in the hair cycle.

Eagle Syndrome: Case Report

Eagle syndrome (ES) is now defined as both an elongation of the styloid process (SP) and ossification of the stylohyoid ligament (SHL). Because subjective symptomatology is varied or can be absent, imaging is the best approach to diagnosis.

Bivalirudin Anticoagulation for a Pediatric Patient with Heparin-Induced Thrombocytopenia and Thrombosis Requiring Cardiopulmonary Bypass for Ventricular Assist Device Placement

The direct thrombin inhibitor bivalirudin is an option for anticoagulation in patients with heparin induced thrombocytopenia (HIT) requiring cardiopulmonary bypass (CPB). There are a limited number of reports of pediatric patients in which bivalirudin has been used for anticoagulation for CPB. We present the case of an 11 year old male with acute onset heart failure secondary to idiopathic dilated cardiomyopathy that developed heparin induced thrombocytopenia with thrombosis (HITT). The patient was anticoagulated in the operating room with bivalirudin and placed on CPB for insertion of a HeartWare(®) Ventricular Assist Device (Heartware(®)). Modified techniques were utilized. This included use of the Terumo CDI 500 (Terumo Cardiovascular Systems, Inc.) in-line blood gas monitor which contains a heparin coated arterial shunt sensor. We flushed this sensor with buffered saline preoperatively and noted no significant decrease in platelet count postoperatively. The patient was successfully placed on the ventricular assist device and was subsequently listed for heart transplantation.

TEG and ROTEM: technology and clinical applications

Initially described in 1948 by Hertert thromboelastography (TEG) provides a real-time assessment of viscoelastic clot strength in whole blood. Rotational thromboelastometry (ROTEM) evolved from TEG technology and both devices generate output by transducing changes in the viscoelastic strength of a small sample of clotting blood (300 µl) to which a constant rotational force is applied. These point of care devices allow visual assessment of blood coagulation from clot formation, through propagation, and stabilization, until clot dissolution. Computer analysis of the output allows sophisticated clot formation/dissolution kinetics and clot strength data to be generated. Activation of clot formation can be initiated with both intrinsic (kaolin, ellagic acid) and extrinsic (tissue factor) activators. In addition, the independent contributions of platelets and fibrinogen to final clot strength can be assessed using added platelet inhibitors (abciximab and cytochalasin D). Increasingly, ROTEM and TEG analysis is being incorporated in vertical algorithms to diagnose and treat bleeding in high-risk populations such as those undergoing cardiac surgery or suffering from blunt trauma. Some evidence suggests these algorithms might reduce transfusions, but further study is needed to assess patient outcomes.

Miniaturized Hairs Maintain Contact with the Arrector Pili Muscle in Alopecia Areata but not in Androgenetic Alopecia: A Model for Reversible Miniaturization and Potential for Hair Regrowth

BACKGROUND

Hair follicle miniaturization is the hallmark of male pattern hair loss (MPHL), female pattern hair loss (FPHL), and alopecia areata (AA). AA has the potential for complete hair regrowth and reversal of miniaturization. MPHL and FPHL are either irreversible or show only partial regrowth and minimal reversal of miniaturization.

HYPOTHESIS

The arrector pili muscle (APM) attachment to the hair follicle bulge, a recognized repository of stem cells may be necessary for reversal of hair follicle miniaturization.

MATERIALS AND METHODS

Sequential histological sections from MPHL, FPHL, AA, and telogen effluvium were used to create three-dimensional images to compare the relationship between the APM and bulge.

RESULTS

In AA, contact was maintained between the APM and the bulge of miniaturized follicles while in MPHL and FPHL contact was lost.

DISCUSSION

Contact between the APM and the bulge in AA may be required for reversal of hair follicle miniaturization. Maintenance of contact between miniaturized follicles in AA could explain the complete hair regrowth while loss of contact between the APM and the bulge in MPHL and FPHL may explain why the hair loss is largely irreversible. This loss of contact may reflect changes in stem cell biology that also underlie irreversible miniaturization.

FAP-related desmoid tumors: a series of 44 patients evaluated in a cancer referral center

Desmoid tumors (DTs), the commonest extra-intestinal manifestation of familial adenomatosis polyposis (FAP), are monoclonal neoplasms demonstrating fibroblastic - myofibroblastic differentiation; they are locally invasive without metastatic capacity. FAP-associated DT natural history knowledge is limited; we examined patient and tumor characteristics for a FAP-DT cohort and evaluated anti-DT therapy molecular target expression levels (immunohistochemical analyses, FAP-DT tissue microarray; TMA). Forty-four patients were classified as intra-abdominal (IA; n=26), abdominal wall (AW)/extra-abdominal (EA; n=12) or concomitant IA/AW (n=6) based on DT primary diagnosis location. Positive family histories were found in 62% of FAP versus 10% of DT patients. Surgery was the mainstay therapy for AW/EW patients, whereas IA DTs received surgery, chemotherapy, radiotherapy, tamoxifen, NSAIDs, and/or imatinib. Eight of 20 completely resected DTs in the IA and AW/EA groups recurred; 12 of 38 patients in these groups (33%) developed secondary lesions elsewhere. Two intestinal mesenteric DT patients died of disease, three from other cancers, 27 are alive with disease and 12 are alive without disease. All evaluable FAP-DT exhibited nuclear β-catenin, 65% were positive for cyclin D1, and 66% expressed nuclear p53. No ERα expression was observed, but ERβ was expressed in 72%. COX2 was expressed in all evaluable FAP-DTs. KIT was rarely found in DTs but both PDGFRs and their ligands were expressed. Comparing biomarker expression (IA vs. EA DTs), only nuclear ER-ß staining was significantly higher in EA lesions (p=0.0070); no other markers were site informative. Enhanced knowledge of FAP-DT molecular underpinnings will facilitate development of novel therapeutic strategies.

The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults

INTRODUCTION

Diabetes is a major cause of morbidity and mortality and its global prevalence is growing rapidly. A simple and robust approach to estimate the prevalence of diabetes is essential for governments to set priorities on how to meet the challenges of the disease. The International Diabetes Federation has developed a methodology for generating country-level estimates of diabetes prevalence in adults (20-79 years).

METHODS

Using country-level data sources from peer-reviewed studies, national health statistics reports, commissioned studies on diabetes prevalence, and unpublished data obtained through personal communication, we use logistic regression to generate estimates of the prevalence of diabetes. An approach matching countries on ethnicity, geography, and income group is used to fill in gaps where original data sources are not available. The methodology also uses changes in urbanization and population to generate estimates and projections on the prevalence of diabetes in adults.

CONCLUSION

Diabetes prevalence estimates are very sensitive to the data from which they are derived. The revised IDF methodology for estimating diabetes prevalence is a transparent, reproducible approach that will be updated annually. It takes data-driven approaches to filling in gaps where data are not available and where assumptions have to be made. It uses a qualification system to rank data sources so that only the highest quality data are used.

New USEPA water quality criteria by 2012: GOMA concerns and recommendations

The Gulf of Mexico Alliance (GOMA) was tasked by the five Gulf State Governors to identify major issues affecting the Gulf of Mexico (GoM) and to set priorities for ameliorating these problems. One priority identified by GOMA is the need to improve detection methods for water quality indicators, pathogens and microbial source tracking. The United States Environmental Protection Agency (USEPA) is tasked with revising water quality criteria by 2012; however, the locations traditionally studied by the USEPA are not representative of the GoM and this has raised concern about whether or not the new criteria will be appropriate. This paper outlines a number of concerns, including deadlines associated with the USEPA Consent Decree, which may prevent inclusion of research needed to produce a well-developed set of methods and criteria appropriate for all regulated waters. GOMA makes several recommendations including ensuring that criteria formulation use data that include GoM-specific conditions (e.g. lower bather density, nonpoint sources), that rapid-testing methods be feasible and adequately controlled, and that USEPA maintains investments in water quality research once the new criteria are promulgated in order to assure that outstanding scientific questions are addressed and that scientifically defensible criteria are achieved for the GoM and other regulated waterbodies.

The 3C study: coverage cost and care of type 1 diabetes in China--study design and implementation

AIM

To describe coverage, cost and care of type 1 diabetes (T1D) in 2 regions of China--Beijing and Shantou--including:

METHODS

This is a mixed-methods descriptive study with three arms--coverage, cost and care. It is taking place in 4 tertiary hospitals, 3 secondary hospitals and 4 primary health facilities in Beijing, and 2 tertiary hospitals, 2 secondary hospitals and 2 primary health centres in Shantou, China. Two additional hospitals are involved in the coverage arm of the study. T1D participants are recruited from a 3-year list generated by each hospital and from those attending the outpatient clinic or admitted to the inpatient ward. Participants also include health care professionals and government officials. To determine coverage of care, a list of people with T1D is being developed including information on diagnosis, age, sex and vital status. The age and sex distribution will be compared with the expected distribution. To estimate the economic burden of T1D three groups of costs will be calculated - direct medical costs, direct non-medical costs and indirect costs from different perspectives of analysis (patients and their families, health system, insurer and societal perspective). The data are being collected from people with T1D (patient-parents face-to-face interviews), hospital billing departments, medical records and government officials using a combined "top-down, bottom-up" approach developed to validate the data. Quality of life is assessed using the EQ-5D tool and burden of disease is measured based on clinical outcomes and complications. Standard care will be defined, costed and compared to the cost of current care identified within the study to determine the investment required to improve outcomes. The third arm includes three components - health policy, clinical care and education, and information management. Face-to-face, semi-structured interviews are conducted with people with T1D (for those <15 years of age parents are interviewed), health care professionals, senior hospital management and government officials. The core Summary of Diabetes Self-Care Activities Measure plus an additional 6 questions from the revised SDSCA scale are used to assess patient self-care. A medical records audit tool is used to assess care [7]. Clinical outcomes and self-care activities will be analysed for associations with care and education. Information management and care processes will be described using the Standard for Integration Definition for Function Modelling (IDEF0) [8].

PROGRESS TO DATE

At the time of writing (early October) the 3-year case list includes 1269 people with type 1 diabetes from Beijing and 481 people for Shantou, a total of 1750. In addition, two hundred and twenty people with T1D or their parents participated in face-to-face interviews in Beijing and 183 in Shantou, a total of 403.

PRACTICAL PRELIMINARY CONCLUSIONS

Key implementation considerations were identified early in the project. Project success is dependent on strong local partnerships with local opinion leaders and key officials. It is important that a physician is the first point of contact to build the case list and recruit participants. July, August and January are peak months for recruiting school-age children in the Children's Hospital as this is school vacation period when they are more likely to attend clinics.

Post-stroke case fatality within an incident population in rural Tanzania

BACKGROUND AND PURPOSE

To establish post-stroke case fatality rates within a community based incident stroke population in rural Tanzania.

METHODS

Incident stroke cases were identified by the Tanzanian Stroke Incidence Project and followed-up over the next 3-6 years. In order to provide a more complete picture, verbal autopsy (VA) was also used to identify all stroke deaths occurring within the same community and time period, and a date of stroke was identified by interview with a relative or friend.

RESULTS

Over 3 years, the Tanzanian Stroke Incidence Project identified 130 cases of incident stroke, of which 31 (23.8%, 95% CI 16.5 to 31.2) died within 28 days and 78 (60.0%, 95% CI 51.6 to 68.4) within 3 years of incident stroke. Over the same time period, an additional 223 deaths from stroke were identified by VA; 64 (28.7%, 95% CI 20.9 to 36.5) had died within 28 days of stroke and 188 (84.3%, 95% CI 78.1 to 90.6) within 3 years.

CONCLUSIONS

This is the first published study of post-stroke mortality in sub-Saharan Africa from an incident stroke population. The 28 day case fatality rate is at the lower end of rates reported for other low and middle income countries, even when including those identified by VA, although CIs were wide. Three year case fatality rates are notably higher than seen in most developed world studies. Improving post-stroke care may help to reduce stroke case fatality in sub-Saharan Africa.

Central hair loss in African American women: incidence and potential risk factors

BACKGROUND

Although central scalp hair loss is a common problem in African American women, data on etiology or incidence are limited.

OBJECTIVE

We sought to determine the frequency of various patterns and degree of central scalp hair loss in African American women and to correlate this with information on hair care practices, family history of hair loss, and medical history.

METHODS

Five hundred twenty-nine subjects at six different workshops held at four different sites in the central and/or southeast United States participated in this study. The subjects' patterns and degree of central scalp hair loss were independently assessed by both subject and investigator using a standardized photographic scale. Subjects also completed a detailed questionnaire and had standardized photographs taken. Statistical analysis was performed evaluating answers to the questionnaire relative to pattern of central hair loss.

RESULTS

Extensive central scalp hair loss was seen in 5.6% of subjects. There was no obvious association of extensive hair loss with relaxer or hot comb use, history of seborrheic dermatitis or reaction to a hair care product, bacterial infection, or male pattern hair loss in fathers of subjects; however, there was an association with a history of tinea capitis.

LIMITATIONS

There was no scalp biopsy correlation with clinical pattern of hair loss and further information on specifics of hair care practices is needed.

CONCLUSIONS

This central scalp photographic scale and questionnaire provide a valid template by which to further explore potential etiologic factors and relationships to central scalp hair loss in African American women.

High impact actions: preventing falls and encouraging exercise

This article, the second in a series on the NHS Institute for Innovation and Improvement's eight high impact actions, reviews the roles played by nurses and local organisations in preventing falls among older people through early intervention and the promotion of active lifestyles.

Stroke incidence in rural and urban Tanzania: a prospective, community-based study

BACKGROUND

There are no methodologically rigorous studies of the incidence of stroke in sub-Saharan Africa. We aimed to provide reliable data on the incidence of stroke in rural and urban Tanzania.

METHODS

The Tanzania Stroke Incidence Project (TSIP) recorded stroke incidence in two well defined demographic surveillance sites (DSS) over a 3-year period from June, 2003. The Hai DSS (population 159,814) is rural and the Dar-es-Salaam DSS (population 56,517) is urban. Patients with stroke were identified by use of a system of community-based investigators and liaison with local hospital and medical centre staff. Patients who died from stroke before recruitment into the TSIP were identified via verbal autopsy, which was done on all those who died within the study areas.

FINDINGS

There were 636 strokes during the 3-year period (453 in Hai and 183 in Dar-es-Salaam). Overall crude yearly stroke incidence rates were 94.5 per 100,000 (95% CI 76.0-115.0) in Hai and 107.9 per 100,000 (88.1-129.8) in Dar-es-Salaam. When age-standardised to the WHO world population, yearly stroke incidence rates were 108.6 per 100 000 (95% CI 89.0-130.9) in Hai and 315.9 per 100,000 (281.6-352.3) in Dar-es-Salaam.

INTERPRETATION

Age-standardised stroke incidence rates in Hai were similar to those seen in developed countries. However, age-standardised incidence rates in Dar-es-Salaam were higher than seen in most studies in developed countries; this could be because of a difference in the prevalence of risk factors and emphasises the importance of health screening at a community level. Health policy makers must continue to monitor the incidence of stroke in sub-Saharan Africa and should base future funding decisions on such data.

FUNDING

The Wellcome Trust.

Defining the research agenda to reduce the joint burden of disease from diabetes mellitus and tuberculosis

The steadily growing epidemic of diabetes mellitus poses a threat for global tuberculosis (TB) control. Previous studies have identified an important association between diabetes mellitus and TB. However, these studies have limitations: very few were carried out in low-income countries, with none in Africa, raising uncertainty about the strength of the diabetes mellitus-TB association in these settings, and many critical questions remain unanswered. An expert meeting was held in November 2009 to discuss where there was sufficient evidence to make firm recommendations about joint management of both diseases, to address research gaps and to develop a research agenda. Ten key research questions were identified, of which 4 were selected as high priority: (i) whether, when and how to screen for TB in patients with diabetes mellitus and vice versa; (ii) the impact of diabetes mellitus and non-diabetes mellitus hyperglycaemia on TB treatment outcomes and deaths, and the development of strategies to improve outcomes; (iii) implementation and evaluation of the tuberculosis 'DOTS' model for diabetes mellitus management; and (iv) the development and evaluation of better point-of-care diagnostic and monitoring tests, including measurements of blood glucose and glycated haemoglobin A(1c) (HbA(1c)) for patients with diabetes mellitus. Implementation of this research agenda will benefit the control of both diseases.

Irregular respiration as a marker of wakefulness during titration of CPAP

STUDY OBJECTIVES

Regularity of respiration is characteristic of stable sleep without sleep disordered breathing. Appearance of respiratory irregularity may indicate onset of wakefulness. The present study examines whether one can detect transitions from sleep to wakefulness using only the CPAP flow signal and automate this recognition.

DESIGN

Prospective study with blinded analysis

SETTING

Sleep disorder center, academic institution.

PARTICIPANTS

74 subjects with obstructive sleep apnealhypopnea syndrome (OSAHS) INTERVENTIONS: n/a.

MEASUREMENTS AND RESULTS

74 CPAP titration polysomnograms in patients with OSAHS were examined. First we visually identified characteristic patterns of ventilatory irregularity on the airflow signal and tested their relation to conventional detection of EEG defined wake or arousal. To automate recognition of sleep-wake transitions we then developed an artificial neural network (ANN) whose inputs were parameters derived exclusively from the airflow signal. This ANN was trained to identify the visually detected ventilatory irregularities. Finally, we prospectively determined the accuracy of the ANN detection of wake or arousal against EEG sleep/wake transitions. A visually identified irregular respiratory pattern (IrREG) was highly predictive of appearance of EEG wakefulness (Positive Predictive Value [PPV] = 0.89 to 0.98 across subjects). Furthermore, we were able to automate identification of this irregularity with an ANN which was highly predictive for wakefulness by EEG (PPV 0.66 to 0.86).

CONCLUSIONS

Despite not detecting all wakefulness, the high positive predictive value suggests that analysis of the respiration signal alone may be a useful indicator of CNS state with potential utility in the control of CPAP in OSAHS. The present study demonstrates the feasibility of automating the detection of IrREG.

The role of scalp dermoscopy in the diagnosis of alopecia areata incognita

BACKGROUND

Alopecia areata incognita is a variety of alopecia areata characterized by acute diffuse shedding of telogen hairs without typical patches.

OBJECTIVE

We sought to report the clinical, pathological, and dermoscopic features of alopecia areata incognita.

METHODS

Seventy patients with alopecia areata incognita were evaluated clinically and with videodermoscopy during the period of 2002 to 2006. Pathology was performed in 50 patients.

RESULTS

The presence of numerous, diffuse, round or polycyclic yellow dots, different in size and uniform in color and distribution, was a typical dermoscopic feature in all patients. Short regrowing hairs were also present. The dermoscopic findings were correlated and supported by the histologic features of the scalp specimens.

LIMITATIONS

Scalp biopsy was performed only in 50 patients.

CONCLUSION

Videodermoscopy is a first step before performing a biopsy. It can help the clinician to find the right place to take the sample, but can also avoid unnecessary biopsies.

A multicenter, randomized, placebo-controlled, double-blind clinical trial of a novel formulation of 5% minoxidil topical foam versus placebo in the treatment of androgenetic alopecia in men

BACKGROUND

An alternative to currently marketed topical minoxidil solutions is desirable.

OBJECTIVE

To assess the efficacy and safety of a new 5% minoxidil topical formulation in a propylene glycol-free foam vehicle in men with androgenetic alopecia (AGA).

METHODS

This was a 16-week, double-blind, placebo-controlled trial of 5% minoxidil topical foam (MTF) in 352 men, 18 to 49 years old. At week 16, 143 subjects continued on an open-label phase to collect 52 weeks of safety information on 5% MTF.

RESULTS

At week 16 compared with baseline, there was a statistically significant increase in (1) hair counts in the 5% MTF group versus placebo (P < .0001) and (2) subjective assessment of improved hair loss condition (P < .0001) in the 5% MTF group versus placebo. The 5% MTF was well tolerated over a 52-week period.

LIMITATIONS

There was no collection of efficacy data beyond 16 weeks.

CONCLUSIONS

We believe that 5% MTF is a safe and effective treatment for men with AGA.

The importance of dual 5alpha-reductase inhibition in the treatment of male pattern hair loss: results of a randomized placebo-controlled study of dutasteride versus finasteride

BACKGROUND

Male pattern hair loss (MPHL) is a potentially reversible condition in which dihydrotestosterone is an important etiologic factor.

OBJECTIVE

Our aim was to evaluate the efficacy of the type 1 and 2 5alpha-reductase inhibitor dutasteride in men with MPHL.

METHODS

Four hundred sixteen men, 21 to 45 years old, were randomized to receive dutasteride 0.05, 0.1, 0.5 or 2.5 mg, finasteride 5 mg, or placebo daily for 24 weeks.

RESULTS

Dutasteride increased target area hair count versus placebo in a dose-dependent fashion and dutasteride 2.5 mg was superior to finasteride at 12 and 24 weeks. Expert panel photographic review and investigator assessment of hair growth confirmed these results. Scalp and serum dihydrotestosterone levels decreased, and testosterone levels increased, in a dose-dependent fashion with dutasteride.

LIMITATIONS

The study was limited to 24 weeks.

CONCLUSION

Dutasteride increases scalp hair growth in men with MPHL. Type 1 and type 2 5alpha-reductase may be important in the pathogenesis and treatment of MPHL.

The use of cDNA microarray to identify differentially expressed labor-associated genes within the human myometrium during labor

OBJECTIVE

Microarray technology was used to comprehensively analyze gene expression during human labor in the myometrium.

STUDY DESIGN

cDNA micro-array was used to compare the transcriptomes of myometrium obtained from patients in spontaneous labor and those not in labor. Expression of four labor-specific genes was confirmed in the myometrium obtained from patients in spontaneous labor using RT-PCR, Northern blot analysis, and in-situ hybridization.

RESULTS

Of the >6000 cDNAs evaluated, 56 were found to be differentially expressed during labor. The labor-specific expression of 4 genes was confirmed using RT-PCR and Northern blot analysis. The relative increased expression of thrombospondin-1 in myometrium obtained from patients in spontaneous labor was also confirmed using in-situ hybridization.

CONCLUSION

cDNA microarray was used to identify 56 differentially expressed genes in myometrium obtained from patients in spontaneous labor. The up-regulation of four genes was confirmed by multiple methods. Elucidation of the role(s) of the genes identified by microarray should improve our understanding of normal labor physiology and may ultimately lead to more effective treatments for abnormal labor.

Cost and results of information systems for health and poverty indicators in the United Republic of Tanzania

OBJECTIVE

To examine the costs of complementary information generation activities in a resource-constrained setting and compare the costs and outputs of information subsystems that generate the statistics on poverty, health and survival required for monitoring, evaluation and reporting on health programmes in the United Republic of Tanzania.

METHODS

Nine systems used by four government agencies or ministries were assessed. Costs were calculated from budgets and expenditure data made available by information system managers. System coverage, quality assurance and information production were reviewed using questionnaires and interviews. Information production was characterized in terms of 38 key sociodemographic indicators required for national programme monitoring.

FINDINGS

In 2002-03 approximately US$ 0.53 was spent per Tanzanian citizen on the nine information subsystems that generated information on 37 of the 38 selected indicators. The census and reporting system for routine health service statistics had the largest participating populations and highest total costs. Nationally representative household surveys and demographic surveillance systems (which are not based on nationally representative samples) produced more than half the indicators and used the most rigorous quality assurance. Five systems produced fewer than 13 indicators and had comparatively high costs per participant.

CONCLUSION

Policy-makers and programme planners should be aware of the many trade-offs with respect to system costs, coverage, production, representativeness and quality control when making investment choices for monitoring and evaluation. In future, formal cost-effectiveness studies of complementary information systems would help guide investments in the monitoring, evaluation and planning needed to demonstrate the impact of poverty-reduction and health programmes.

Prevalence of wheeze and self-reported asthma and asthma care in an urban and rural area of Tanzania and Cameroon

We investigated the prevalence of wheeze, self-reported asthma, and asthma care via four cross-sectional surveys among adults and children (5-15 years) in urban and rural populations from Tanzania and Cameroon. Age-standardized prevalence of current wheeze (in the previous year) was 2.2% to 5.0% in adults and 1.9% to 5.2% in children in Tanzania, and 1.3% to 2.5% (adults) and 0.8% to 5.4% (children) in Cameroon. There were no consistent patterns of urban:rural prevalence. Peak flow rates varied with age, peaking at 25-34 years, and were higher in urban areas (age adjusted difference 22-70 L/min) and in the Tanzania populations. Awareness (83%-86% versus 52%-58%) and treatment (43%-71% versus 30%-44%) of asthma was higher among those with current wheeze in rural areas. Use of inhaled drugs, particularly steroids, was rare. Diagnosis by traditional healers (15%) and use of traditional remedies (62% of those recalling any treatment) were common only among self-reported asthmatic patients in rural Cameroon. Asthma is an importantclinical condition in sub-Saharan Africa. There were major gaps in clinical care, particularly in urban areas. Sustainable methods for delivering accessible and effective asthma care in sub-Saharan Africa are required.

CD8 Lymphocytes are Sufficient for the Development of Chronic Rejection

BACKGROUND

The role of CD8 lymphocytes, in chronic rejection or cardiac allograft vasculopathy (CAV), is incompletely understood. The purposes of this study were to determine whether CD8 lymphocytes, in the absence of CD4 lymphocytes, are capable of causing the intimal lesions of CAV; and if so, to define the effector mechanism(s) of CD8 lymphocytes.

METHODS

We modified a previously characterized major histocompatibility complex class II mismatched murine model of CAV. Wild-type CD8 lymphocytes were transferred to nude mice followed by heterotopic heart transplantation. Recipient mice were then treated with a CD40 activating antibody, which is known to provide help for CD8 lymphocyte activation, in the absence of CD4 lymphocytes. Donor hearts were harvested on day 40 posttransplantation and analyzed for cellular infiltrates and intimal thickening. In separate experiments, isolated perforin -/-, Fas ligand (FasL) -/-, and interferon (IFN)-gamma -/- CD8 lymphocytes were transferred to nude mice followed by identical experimented protocol.

RESULTS

With adaptive transfer of wild-type CD8 lymphocytes, the donor hearts were infiltrated with activated CD8 lymphocytes and displayed significant intimal lesions. Adoptive transfer of perforin -/- and FasL -/- CD8 lymphocytes to nude mice resulted in similar patterns of CD8 lymphocyte infiltration and similar severity of intimal lesions. The donor hearts from IFN-gamma -/- CD8 lymphocyte reconstituted recipients displayed minimal intimal lesions, although CD8 lymphocytes were present in the allografts.

CONCLUSIONS

Unprimed CD8 lymphocytes in the absence of CD4 lymphocytes can cause intimal lesions of CAV. CD8 lymphocytes production of IFN-gamma, but not the perforin or the FasL-mediated cytotoxicity, is the critical step in the development of intimal lesions.

A systemic type I 5 alpha-reductase inhibitor is ineffective in the treatment of acne vulgaris

Excessive sebum production is a central aspect of the pathophysiology of acne vulgaris. Sebaceous gland function is under androgen control and it is hypothesized that dihydrotestosterone is formed by the action of 5 alpha-reductase. Type I is the controlling isoenzyme. This study describes a 3-month, multicenter, randomized, placebo-controlled clinical trial with a potent, selective inhibitor of type I 5 alpha-reductase used alone and in combination with systemic minocycline. Inhibition of type I 5 alpha-reductase was not associated with clinical improvement of acne when used alone and did not enhance the clinical benefit of systemic minocycline. These results indicate the need for further work at the molecular level to better understand the action of androgens on sebaceous gland function.

Chemokine Monokine Induced by IFN-γ/CXC Chemokine Ligand 9 Stimulates T Lymphocyte Proliferation and Effector Cytokine Production

Monokine induced by IFN-gamma (MIG; CXC chemokine ligand (CXCL)9) is important in T lymphocyte recruitment in organ transplantation. However, it is not known whether this chemokine, in addition to its chemotactic properties, exerts any effect on T lymphocyte effector functions. For in vivo studies, we used a previously characterized murine model of chronic rejection. The recipient mice were treated with anti-MIG/CXCL9 Ab; graft-infiltrating cells were analyzed for IFN-gamma production. For in vitro studies, exogenous CXCR3 ligands were added to CD4 lymphocytes in MLRs, and the proliferative responses were measured. Separate experiments quantitated the number of IFN-gamma-producing cells in MLRs by ELISPOT. Neutralization of MIG/CXCL9, in the in vivo model, resulted in significant reduction in the percentage of IFN-gamma-producing graft-infiltrating T lymphocytes. In vitro experiments demonstrated that 1) exogenous MIG/CXCL9 stimulated CD4 lymphocyte proliferation in a MHC class II-mismatched MLR, 2) MIG/CXCL9 also increased the number of IFN-gamma-producing CD4 lymphocytes in ELISPOT, 3) neutralization of MIG/CXCL9 in MLR reduced T lymphocyte proliferation, 4) IFN-gamma-inducible protein 10/CXCL10 and IFN-inducible T cell alpha chemoattractant/CXCL11 had similar effects on T lymphocyte proliferation, 5) MIG/CXCL9 stimulated T lymphocyte proliferation in MHC class I- and total MHC-mismatched MLRs, 6) neutralization of CXCR3 reduced MIG/CXCL9-induced T lymphocyte proliferation and the number of IFN-gamma-positive spots on ELISPOT, and 7) the proliferative effects of MIG/CXCL9 were mediated via an IL-2-independent pathway and were controlled by IFN-gamma. This study demonstrates that MIG/CXCL9 stimulates T lymphocyte proliferation and effector cytokine production, in addition to its chemotactic effects. This novel observation expands our current understanding of MIG/CXCL9 biology beyond that of mediating T cell trafficking.

Imiquimod 5% cream for the treatment of actinic keratosis: results from two phase III, randomized, double-blind, parallel group, vehicle-controlled trials

BACKGROUND

The immune system plays a critical role in the development and pathogenesis of actinic keratosis (AK). Imiquimod has been shown to stimulate the cutaneous immune response and be effective for the treatment of nonmelanoma skin cancers.

OBJECTIVE

Two phase III, randomized, double-blind, vehicle-controlled studies evaluated the efficacy of imiquimod 5% cream compared with vehicle in the treatment of AK lesions on the face and balding scalp.

METHODS

A total of 436 participants at 24 centers in the United States and Canada were randomized to either imiquimod 5% or vehicle cream. Study cream was applied one time per day, 2 days per week for 16 weeks. Clearance of AK lesions was clinically assessed at an 8-week posttreatment visit.

RESULTS

The complete clearance rate was 45.1% for the imiquimod group and 3.2% for the vehicle group. The difference in complete clearance rates (imiquimod minus vehicle) was 41.9% with a 95% confidence interval of 34.9% to 49%. The partial (> or =75%) clearance rate was 59.1% for the imiquimod group and 11.8% for the vehicle group. The difference in partial clearance rates (imiquimod minus vehicle) was 47.3% with a 95% confidence interval of 39.5% to 55.1%. The median percent reduction in AK lesions was 83.3% for the imiquimod group and 0% for the vehicle group. Local skin reactions were common. Severe erythema was reported by 17.7% of participants who received imiquimod and 2.3% of participants who received vehicle. Overall, imiquimod was very well tolerated.

CONCLUSION

Imiquimod 5% cream used 2 times per week for 16 weeks is an effective and well-tolerated treatment for AK.

Combined blockade of the chemokine receptors CCR1 and CCR5 attenuates chronic rejection

BACKGROUND

Chemokine-chemokine receptor interaction and the subsequent recruitment of T-lymphocytes to the graft are early events in the development of chronic rejection of transplanted hearts or cardiac allograft vasculopathy (CAV). In this study, we sought to determine whether blockade of chemokine receptors CCR1 and CCR5 with Met-RANTES affects the development of CAV in a murine model.

METHODS AND RESULTS

B6.CH-2(bm12) strain donor hearts were transplanted heterotopically into wild-type C57BL/6 mice (myosin heavy chain II mismatch). Recipients were treated daily with either Met-RANTES or vehicle starting on postoperative day 4 and were euthanized on postoperative days 24 and 56. We found that Met-RANTES significantly reduced intimal thickening in this model of chronic rejection and that Met-RANTES markedly decreased the infiltration of CD4 and CD8 T lymphocytes and MOMA-2+ monocytes/macrophages into transplanted hearts. Met-RANTES also suppressed the ex vivo and in vitro proliferative responses of recipient splenocytes to donor antigens. Finally, Met-RANTES treatment was associated with a marked reduction in RANTES/CCL5 and monocyte chemoattractant protein-1 gene transcript levels in the donor hearts.

CONCLUSIONS

Antagonism of the chemokine receptors CCR1 and CCR5 with Met-RANTES attenuates CAV development in vivo by reducing mononuclear cell recruitment to the transplanted heart, proliferative responses to donor antigens, and intragraft RANTES/CCL5 and monocyte chemoattractant protein-1 gene transcript levels. These findings suggest that chemokine receptors CCR1 and CCR5 play significant roles in the development of chronic rejection and may serve as potential therapeutic targets.

Liberalization of Donor Criteria in Lung Transplantation

Donor shortage remains a major obstacle to widespread application of lung transplantation. In region 5, including California, Nevada, New Mexico, Utah, and Arizona, the United Network of Organ Sharing (UNOS) database median waiting time for lung transplant candidates in 2000–2001 exceeded 17 months. The purpose of this study was to determine the impact of liberalization of donor criteria on median waiting time and short-term outcome of lung transplantation. From September 1999 to October 2002, 42 patients underwent lung transplantation from nonstandard donors. The donors were classified as nonstandard due to (1) infiltrate on chest radiograph (n = 33), (2) PaO2 < 300 on FiO2 1.0 and PEEP 5 (n = 3), (3) PaO2 < 100 on FiO2 0.4 and PEEP 5 (n = 3), (4) purulent sputum on bronchoscopy (n = 22), and (5) smoking history greater than 50 pack-years (n = 1). Perioperative characteristics and short-term outcome of this group was analyzed. The median waiting time for this cohort was 114 days (range, 10–1267), as compared with the national UNOS database median waiting time of 24 months between 1996 and 2001. The incidence of ischemia reperfusion injury was 2.3 per cent. None of the recipients developed pneumonia. The median ventilator support time was 2 days (range, 1–95). The median ICU stay and hospital stay were 4 days (range, 2–103) and 14 days (range, 5–194), respectively. The 3-month survival was 97.6 per cent. Selective liberalization of donor lung criteria can decrease the waiting time and is associated with favorable short-term outcome. Utilization of nonstandard lungs can expand the donor pool.