Dyadic influences on awareness of condition in people with dementia: findings from the IDEAL cohort

Introduction

The discrepancy between caregiver-ratings and self-ratings of abilities is commonly used to assess awareness in people with dementia. We investigated the contribution of caregiver and dyadic characteristics to the difference in perspective between caregiver-informants and people with dementia about difficulties experienced, when considering awareness of condition.

Methods

We conducted exploratory cross-sectional analyses using data from the IDEAL cohort. Participants were 1,038 community-dwelling people with mild-to-moderate dementia, and coresident spouse/partner caregivers. The Representations and Adjustment to Dementia Index (RADIX) checklist reporting difficulties commonly experienced in dementia was completed by 960 caregiver-informants and 989 people with dementia. Difference in scores was calculated for 916 dyads. Demographic information, cognition, informant-rated functional ability and neuropsychiatric symptoms were recorded for the person with dementia. Self-reported data were collected on mood, comorbidity, religion, importance of religion, relationship quality, and caregiver stress.

Results

For most dyads, caregivers reported more RADIX difficulties than people with dementia. Caregiver RADIX ratings were more closely associated with informant-rated functional ability and neuropsychiatric symptoms than with cognition. More RADIX difficulties and higher stress were reported by female caregivers. Greater RADIX difference was associated with more caregiver stress, and older age but less depression in people with dementia.

Conclusion

Few dyadic characteristics were important, but caregiver stress was higher where caregivers reported more RADIX difficulties and/or the difference in perspective was greater, whereas partners with dementia reported better mood. In addition to offering information about awareness of condition, the caregiver rating and difference in perspectives could indicate where more support is needed.

Predictors of Awareness of Functional Ability in People with Dementia: The Contribution of Personality, Cognition, and Neuropsychiatric Symptoms - Findings from the IDEAL Program

INTRODUCTION

Discrepancy scores reflecting the difference between parallel ratings made by people living with dementia (PwD) in the mild-to-moderate stages and by their informants provide a way to investigate awareness of functional ability in relation to activities of daily living (ADL).

METHODS

Two measures of ADL (Functional Activities Questionnaire; Dependence Scale) were completed by 1,227 PwD and their informants in the IDEAL cohort study baseline assessment. Self-rated and informant-rated scores were used to calculate discrepancies, which were used as an indicator of awareness of functional ability. Smaller discrepancy scores were considered to reflect greater awareness on the part of PwD. PwD completed questionnaires on depression, personality, comorbidities, neuropsychiatric symptoms, and completed a measure of cognition. Informants provided ratings of stress. Univariable and multiple regressions were used to investigate factors related to ADL discrepancy.

RESULTS

A similar pattern of associations were found for both ADL discrepancy scores. Smaller discrepancy scores were associated with higher levels of depression, higher neuroticism, fewer neuropsychiatric symptoms, higher comorbidity, lower carer stress, and receipt of less than 1 hour of care per day from the informant.

DISCUSSION/CONCLUSION

There was a clear pattern of factors that were associated with greater awareness for both measures of functional ability. These factors associated with smaller discrepancy scores could be used to identify PwD who might benefit from targeted interventions to support their independence.

Changes in awareness of condition in people with mild-to-moderate dementia: Longitudinal findings from the IDEAL cohort

OBJECTIVES

Awareness of difficulties shown by people with dementia is known to vary, but few studies have explored changes in awareness over time. Investigating this could further the understanding of surrounding concepts and reasons for impaired awareness. Recognising emerging or diminishing awareness could facilitate discussions about diagnosis and appropriate post-diagnostic support.

METHODS

Using longitudinal data from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort, awareness in community-dwelling people with mild-to-moderate dementia was assessed at three timepoints over 2 years. A validated checklist was used to evaluate awareness of difficulties associated with dementia. We examined changes in awareness for people with low awareness at baseline, and used case-matching to describe differences in characteristics between people who gained awareness, and those who continued with low awareness.

RESULTS

At baseline, 83 people from a sample of 917 showed low awareness. The majority of those remaining in the study at later timepoints had gained awareness, some as late as four or more years after diagnosis. Case-matched comparisons revealed few distinguishing characteristics: cases with stable low awareness had similar or better cognitive and functional ability than those who gained and retained awareness at 12 and 24 months, but may have had more co-morbidities.

CONCLUSIONS

Self-reported awareness of difficulties can change and may increase over time in people with mild-to-moderate dementia. There may be individual reasons for ongoing low awareness, not explained by cognitive or functional ability. This challenges the view that a single record of low awareness represents a fixed disease-related symptom, and highlights the complex, individual and dynamic nature of awareness.

Contrasting recruitment of skin-associated adipose depots during cold challenge of mouse and human

KEY POINTS

Several distinct strategies produce and conserve heat to maintain the body temperature of mammals, each associated with unique physiologies, with consequences for wellness and disease susceptibility Highly regulated properties of skin offset the total requirement for heat production  We hypothesize that the adipose component of skin is primarily responsible for modulating heat flux; here we evaluate the relative regulation of adipose depots in mouse and human, to test their recruitment to heat production and conservation We found that insulating mouse dermal white adipose tissue accumulates in response to environmentally and genetically induced cool stress; this layer is one of two adipose depots closely apposed to mouse skin, where the subcutaneous mammary gland fat pads are actively recruited to heat production In contrast, the body-wide adipose depot associated with human skin produces heat directly, potentially creating an alternative to the centrally regulated brown adipose tissue ABSTRACT: Mammalian skin impacts metabolic efficiency system-wide, controlling the rate of heat loss and consequent heat production. Here we compare the unique fat depots associated with mouse and human skin, to determine whether they have corresponding functions and regulation. For humans, we assay a skin-associated fat (SAF) body-wide depot to distinguish it from the subcutaneous fat pads characteristic of the abdomen and upper limbs. We show that the thickness of SAF is not related to general adiposity; it is much thicker (1.6-fold) in women than men, and highly subject-specific. We used molecular and cellular assays of β-adrenergic-induced lipolysis and found that dermal white adipose tissue (dWAT) in mice is resistant to lipolysis; in contrast, the body-wide human SAF depot becomes lipolytic, generating heat in response to β-adrenergic stimulation. In mice challenged to make more heat to maintain body temperature (either environmentally or genetically), there is a compensatory increase in thickness of dWAT: a corresponding β-adrenergic stimulation of human skin adipose (in vivo or in explant) depletes adipocyte lipid content. We summarize the regulation of skin-associated adipocytes by age, sex and adiposity, for both species. We conclude that the body-wide dWAT depot of mice shows unique regulation that enables it to be deployed for heat preservation; combined with the actively lipolytic subcutaneous mammary fat pads they enable thermal defence. The adipose tissue that covers human subjects produces heat directly, providing an alternative to the brown adipose tissues.

Does awareness of condition help people with mild-to-moderate dementia to live well? Findings from the IDEAL programme

Background

People living with dementia vary in awareness of their abilities. We explored awareness of the condition and diagnosis in people with mild-to-moderate dementia, and how this relates to quality of life, well-being, life satisfaction, and caregiver stress.

Methods

This study was a cross-sectional exploratory analysis of data from the IDEAL cohort, which recruited people with dementia living at home and available caregivers from 29 research sites in Great Britain. Our study included 917 people with mild-to-moderate dementia and 755 carers. Low and high awareness groups were derived from self-reported responses to a dementia representation measure. Logistic regression was used to explore predictors of awareness of condition and diagnosis using demographic, cognitive, functional and psychological measures, and the relationship with quality of life, well-being and life satisfaction (‘living well’), and caregiver stress.

Results

There were 83 people with low awareness of their condition. The remaining 834 people showed some awareness and 103 of these had high awareness of their condition and diagnosis. Psychosocial factors were stronger predictors of awareness than cognitive and functional ability. Those with higher awareness reported lower mood, and lower scores on indices of living well as well as lower optimism, self-efficacy and self-esteem. Low awareness was more likely in those aged 80y and above, and living in more socially deprived areas. No relationship was seen between caregiver stress and awareness.

Conclusions

Awareness of the condition and diagnosis varies in people with mild-to-moderate dementia and is relevant to the capability to live well. Awareness should be considered in person-centered clinical care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02468-4.

Measuring Awareness in People With Dementia: Results of a Systematic Scoping Review

BACKGROUND

Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility.

METHOD

A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*.

RESULTS

We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use.

CONCLUSIONS

Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Evaluation of a personal protective equipment support programme for staff during the COVID-19 pandemic in London

BACKGROUND

The coronavirus disease 2019 pandemic has presented an enormous challenge to healthcare providers worldwide. The appropriate use of personal protective equipment (PPE) has been essential to ensure staff and patient safety. The 'PPE Helper Programme' was developed at a large London hospital group to counteract suboptimal PPE practice. Based on a behaviour change model of capability, opportunity and motivation (COM-B), the programme provided PPE support, advice and education to ward staff.

AIM

Evaluation of the PPE Helper Programme.

METHODS

Clinical and non-clinical ward staff completed a questionnaire informed by the Theoretical Domains Framework and COM-B model. The questionnaire was available in paper and electronic versions. Quantitative responses were analysed using descriptive and non-parametric statistics, and free-text responses were analysed thematically.

FINDINGS

Over a 6-week period, PPE helpers made 268 ward visits. Overall, 261 questionnaires were available for analysis. Across the Trust, 68% of respondents reported having had contact with a PPE helper. Staff who had encountered a PPE helper responded significantly more positively to a range of statements about using PPE than staff who had not encountered a PPE helper. Black and minority ethnic staff were significantly more anxious regarding the adequacy of PPE. Non-clinical and redeployed staff (e.g. domestic staff) were most positive about the impact of PPE helpers. Free-text comments showed that staff found the PPE Helper Programme supportive and would have liked it earlier in the pandemic.

CONCLUSION

The PPE Helper Programme is a feasible and beneficial intervention for providing support, advice and education to ward staff during infectious disease outbreaks.

Measuring awareness in people with dementia: protocol for a scoping review

BACKGROUND

People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person's awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods.

METHOD

We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia ("dement*" or "Alzheimer*" or "Pick's disease") and "awareness", "unawareness", "anosognosia", "insight", "denial", "metacognit*" or "discrepanc*" identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified.

DISCUSSION

This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted.

Evaporative cooling provides a major metabolic energy sink

Objective

Elimination of food calories as heat could help redress the excess accumulation of metabolic energy exhibited as obesity. Prior studies have focused on the induction of thermogenesis in beige and brown adipose tissues as the application of this principle, particularly because the β-adrenergic environment associated with thermogenic activation has been shown to have positive health implications. The counterpoint to this strategy is the regulation of heat loss; we propose that mammals with inefficient heat conservation will require more thermogenesis to maintain body temperature.

Methods

Surface temperature thermography and rates of trans-epidermal water loss were integrated to profile the total heat transfer of genetically-engineered and genetically variable mice.

Results

These data were incorporated with energy expenditure data to generate a biophysical profile to test the significance of increased rates of evaporative cooling.

Conclusions

We show that mouse skins vary considerably in their heat retention properties, whether because of naturally occurring variation (SKH-1 mice), or genetic modification of the heat-retaining lipid lamellae (SCD1, DGAT1 or Agouti A^y obese mice). In particular, we turn attention to widely different rates of evaporative cooling as the result of trans-epidermal water loss; higher rates of heat loss by evaporative cooling leads to increased demand for thermogenesis. We speculate that this physiology could be harnessed to create an energy sink to assist with strategies aimed at treating metabolic diseases.

Does interhemispheric communication relate to the bilateral function of muscles? A study of scapulothoracic muscles using transcranial magnetic stimulation

Interhemispheric connections have been demonstrated between the motor cortex controlling muscle pairs. However, these investigations have tended to concentrate upon hand muscles. We have extended these investigations to proximal muscles that control the scapula upon the trunk and help to move and stabilise the shoulder. Using a paired pulse transcranial magnetic stimulation protocol, the interhemispheric interactions between different shoulder girdle muscle pairs, serratus anterior, upper trapezius and lower trapezius were investigated. Test motor evoked potentials were conditioned using conditioning pulse intensities of 80% and 120% of active motor threshold at three different condition-test intervals, during three different tasks. Interhemispheric inhibition was observed in upper trapezius using a conditioning intensity of 120% and condition-test interval of 8 ms (17 ± 18%, p < 0.007). A trend towards inhibition was observed in lower trapezius and serratus anterior using a conditioning intensity of 120% and a condition-test interval of 8 ms (13 ± 22%; p < 0.07 and 10 ± 19% respectively; p < 0.07). No interhemispheric facilitation was evoked. The study demonstrates that a low level of interhemispheric inhibition rather than interhemispheric facilitation could be evoked between these muscle pairs.

Recent trends in the characteristics of patients prescribed sitagliptin and other oral antihyperglycaemic agents in a large U.S. claims database

AIM

This study was designed to determine if differences in baseline characteristics of patients with type 2 diabetes mellitus (T2DM) being treated with sitagliptin vs. other oral antihyperglycaemic agents (OAHA) during the initial 2 years following sitagliptin's introduction in the U.S. continued during the second 2 years of sitagliptin availability.

METHODS

Patients with T2DM and at least one new prescription for sitagliptin or another OAHA from Oct 2006 to April 2010 were identified in an insurance claims database. Multivariate logistic regression adjusting for age, gender, treatment type (monotherapy, dual or triple therapy), new or existing T2DM diagnosis, and comorbidities and diabetes complications in the prior 12 months was used to estimate odds ratios for sitagliptin vs. other OAHAs.

RESULTS

During 2006-2007 or 2008-2010, new sitagliptin users were older and more likely to be male, have prior diagnosis of T2DM, or initiating combination therapy compared with new users of other OAHAs. Prevalence of comorbidities and complications was consistently higher for new sitagliptin users across most of the conditions assessed during both time periods.

CONCLUSIONS

New sitagliptin users consistently tended to be older and have greater comorbidity/complication burden compared with new users of other OAHAs. These differences in baseline characteristics persisted up to 4 years postapproval. This observation has significant implications for observational studies using electronic medical record or insurance claims databases. Appropriate adjustment is needed to try to control for potential confounding and channelling bias resulting from this non-random prescribing pattern, and the limitations of such analyses acknowledged.

Impact of diabetes duration and chronic pancreatitis on the association between type 2 diabetes and pancreatic cancer risk

AIM

To examine the impact of diabetes duration, chronic pancreatitis and other factors on pancreatic cancer risk.

METHODS

This retrospective cohort study using the UK General Practice Research Database compared pancreatic cancer incidence and risk in patients with type 2 diabetes mellitus (T2DM) versus patients without diabetes. Multivariate Cox regression adjusting for age, sex, history of chronic pancreatitis, gallbladder disease, obesity, smoking and alcohol use and Charlson comorbidity index was used to estimate hazard ratio (HR) [95% confidence interval, CI]. Analyses were repeated using various time windows for diabetes duration.

RESULTS

A total of 1903 incident pancreatic cancers were identified, 436 in patients with T2DM (78.76 per 100 000 person-years [95% CI: 71.54, 86.51]) and 1467 in patients without diabetes (11.46 per 100 000 person-years [10.88, 12.06]). Pancreatic cancer risk was significant for T2DM (adjusted HR 1.80 [1.52, 2.14]), increasing age, history of chronic pancreatitis and tobacco use. For patients with chronic pancreatitis and T2DM, the adjusted HR was 12.12 [6.02, 24.40]. Incidence was highest in patients with ≥5 year duration of T2DM. In patient populations with duration of T2DM ranging from ≥1 to ≥5 years, adjusted HRs remained significant but point estimates attenuated slightly with longer duration of T2DM.

CONCLUSIONS

Patients with T2DM had an 80% increased risk of pancreatic cancer versus patients without diabetes. Patients with T2DM and chronic pancreatitis were 12 times more likely to develop pancreatic cancer.

Risk of acute renal failure in patients with Type 2 diabetes mellitus

AIMS

Progressive decline in renal function has been well described in patients with Type 2 diabetes mellitus, but few studies have assessed the risk of acute renal failure in a large population of patients with Type 2 diabetes. This study quantified the risk of acute renal failure associated with Type 2 diabetes in the General Practice Research Database from the UK.

METHODS

Patients with Type 2 diabetes (n = 119,966) and patients without diabetes (n = 1,794,516) were identified in the General Practice Research Database. Patients with end-stage renal disease were excluded. Crude incidence and multivariate-adjusted hazard ratios of acute renal failure were estimated for patients with diabetes relative to those without diabetes. Cox regression models were adjusted for a variety of comorbidities. Increase of acute renal failure risk resulting from additive effects of specific co-morbidities with Type 2 diabetes was also assessed.

RESULTS

Between 2003 and 2007, acute renal failure incidence was 198 per 100,000 person-years in patients with Type 2 diabetes compared with 27 per 100,000 patients-years among patients without diabetes (crude hazard ratio 8.0, 95% CI 7.4-8.7). Risk of acute renal failure for patients with Type 2 diabetes remained significant, but was attenuated in multivariate analyses adjusting for various comorbidities (adjusted hazard ratio 2.5, 95% CI 2.2-2.7). Age and specific comorbidities (chronic kidney disease, hypertension and congestive heart failure) were also associated with increased risk of acute renal failure in Type 2 diabetes.

CONCLUSIONS

Patients with Type 2 diabetes have increased risk for acute renal failure compared with patients without diabetes, even after adjustment for known risk factors, particularly in the elderly and those with other comorbidities such as chronic kidney disease, congestive heart failure and hypertension.

Effects of attachment position and shoulder orientation during calibration on the accuracy of the acromial tracker

The acromial tracker is used to measure scapular rotations during dynamic movements. The method has low accuracy in high elevations and is sensitive to its attachment location on the acromion. The aim of this study was to investigate the effect of the attachment position and shoulder orientation during calibration on the tracker accuracy. The tracker was attached to one of three positions: near the anterior edge of the acromion process, just above the acromial angle and the meeting point between the acromion and the scapular spine. The scapula locator was used to track the scapula during bilateral abduction simultaneously. The locator was used to calibrate the tracker at: no abduction, 30°, 60°, 90° and 120° humerothoracic abduction. ANOVA tests compared RMS errors for different attachment positions and calibration angles. The results showed that attaching the device at the meeting point between the acromion and the scapular spine gave the smallest errors and it was best to calibrate the device at 60° for elevations ≤90°, at 120° for elevations >90° and at 90°or 120° for the full range of abduction. The accuracy of the tracker is significantly improved if attached appropriately and calibrated for the range of movement being measured.

Characteristics of patients prescribed sitagliptin and other oral antihyperglycaemic agents in a large US claims database

BACKGROUND AND AIMS

Non-randomised comparative studies of pharmacological agents can be biased because of differences in baseline demographics, medical history and health status of patients prescribed different therapies. Characteristics of patients with type 2 diabetes mellitus (T2DM) taking sitagliptin were compared with patients taking other oral antihyperglycaemic agents (OAHA) in a large US insurance claims database.

MATERIALS AND METHODS

Using the United Health Care database, we identified T2DM patients with at least one OAHA prescription, and at least 1 year prior enrollment. Patients were classified into subcohorts including sitagliptin or other OAHA, add-on to monotherapy, and triple or more therapy. Comorbidities 12 months before the first OAHA prescription in study window were based on ICD-9 diagnostic codes and NDC codes for prescriptions.

RESULTS

Prevalence of comorbidities was consistently higher for patients with sitagliptin prescriptions across most comorbidities (p < 0.05 for 20 of 30 assessed comorbidities). Overall, baseline differences were apparent (p < 0.0001) for retinopathy (5.7% vs. 3.4%), renal failure (5.1% vs. 2.6%), proteinuria (2.8% vs. 2.0%), hypertension (76.9% vs. 68.2%), congestive heart failure (3.4% vs. 2.6%), myocardial infarction (18.0% vs. 14.4%) and chronic neurological conditions (8.1% vs. 6.6%). Differences were most pronounced for initial monotherapy subcohorts. A higher proportion of sitagliptin users had prescriptions for cardiovascular medication (84.2% vs. 74.9%).

CONCLUSION

Sitagliptin users had higher proportions of comorbidities and greater use of prescription medications and physician visits. Researchers should be aware that sitagliptin is prescribed to patients with seemingly worse health status. Ability to analyse observational, non-randomised studies may be limited by substantial differences in patient characteristics between different treatments.

Patients with type 2 diabetes mellitus have higher risk for acute pancreatitis compared with those without diabetes

AIM

The aetiology of acute pancreatitis (AP) is complex, and many risk factors for AP are shared by patients with type 2 diabetes mellitus (T2DM). However, few have assessed risk factors for AP specifically in T2DM patients.

METHODS

Patients in the General Practice Research Database (2 984 755, 5.0% with T2DM) were used to estimate incidence of AP for T2DM relative to non-diabetes, adjusting for prior pancreatitis, gallbladder disease, obesity, smoking and alcohol use. Multivariate Cox regression analysis adjusting for risk factors and Charlson comorbidity index (CCI) was used to estimate hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Between 2003 and 2007, 301 of 148 903 patients with T2DM and 2434 of almost 3 million patients without diabetes developed AP. Patients with T2DM had higher risk for AP compared with patients without diabetes (crude HR: 2.89, 95% CI: 2.56-3.27). Patients with T2DM had significantly higher rates of prior alcohol and tobacco exposure (44.2 and 61.9% vs. 34.1 and 35.9%, p < 0.001) and of comorbid conditions (14.7% with CCI > or =1 vs. 4.3%, p < 0.001). Histories of obesity, pancreatitis, gallbladder disease, smoking or alcohol use were significant predictors of AP. After adjusting for these factors, age, gender and comorbidities, the risk of developing AP remained elevated in patients with T2DM (adjusted HR: 1.49, 95% CI: 1.31-1.70).

CONCLUSION

After adjusting for risk factors, patients with T2DM had an elevated risk of AP compared with patients without diabetes. Physicians should be aware of the increased risk in patients with T2DM, particularly in those with prior pancreatitis.

Do hypermobile subjects without pain have alteration to the feedback mechanisms controlling the shoulder girdle?

OBJECTIVES

It has been reported that hypermobile subjects have proprioceptive deficits. However, it remains unclear whether pain-free subjects with hypermobility also have deficits.

METHODS

Ten subjects with hypermobility and nine without hypermobility were recruited following ethical approval and informed consent. Shoulder mobility, joint position sense (JPS) and a reflex of trapezius evoked from arm afferents were compared.

RESULTS

There was greater shoulder mobility in the hypermobile group (p = 0.004). There were no differences in shoulder JPS between the groups (p = 0.27), although, the hypermobile group displayed a larger degree of variability (p = 0.014). Finally, there were no differences in the latency of upper and lower trapezius reflexes evoked from arm afferents (p = 0.86 and 0.98, respectively).

CONCLUSIONS

In a group of people with hypermobility without shoulder problems, there was no difference in either shoulder JPS or reflex latency when compared with a non- hypermobile group. The relevance of pain to proprioceptive deficits is discussed.

Patient-reported outcomes in a survey of patients treated with oral antihyperglycaemic medications: associations with hypoglycaemia and weight gain

AIM

To examine the association between medication side-effects (SEs) and patient-reported outcomes (PROs) among patients with type 2 diabetes treated with oral antihyperglycaemic agents (OAHAs).

METHODS

A total of 1984 participants responded to an internet-based survey in the United States. Data were collected on hypoglycaemia 6 months and weight gain 12 months prior to the survey. Health-related quality of life (HRQoL) was measured using the EuroQol-5D (EQ-5D). Also administered were the Treatment Satisfaction Questionnaire for Medication v.1.4 (TSQM) and the Hypoglycaemia Fear Survey II (HFS).

RESULTS

Symptoms of hypoglycaemia were reported by 62.9% of participants, and 36.9% reported weight gain. For those reporting hypoglycaemia, mean scores were lower for TSQM and EQ-5D and higher for HFS when compared with those with no symptoms (TSQM: 69.7 vs. 75.1; EQ-5D: 0.78 vs. 0.86; HFS: 17.5 vs. 6.2; all p < 0.0001). The same remained true when accounting for symptom severity, where severity was monotonically related with PRO scores (all p < 0.0001). Similarly, reported weight gain was associated with lower treatment satisfaction (69.0 vs. 73.3) and HRQoL (0.77 vs. 0.83), and increased fear of hypoglycaemia (15.7 vs. 11.8) (all p < 0.0001). In mixed linear regression analysis, the associations between medication SEs and PROs remained significant after adjusting for patient and disease characteristics.

CONCLUSIONS

Among patients with type 2 diabetes treated with OAHAs, self-reported hypoglycaemia and weight gain were associated with decreased treatment satisfaction and HRQoL. In addition, the presence of these SEs was associated with increased fear of hypoglycaemia.

Baseline differences in A1C explain apparent differences in efficacy of sitagliptin, rosiglitazone and pioglitazone

AIM

Published studies of patients treated with rosiglitazone or pioglitazone have reported greater reductions in HbA1c (A1C) than studies of patients treated with sitagliptin. However, studies of thiazolidinediones tended to enroll patients with higher baseline A1C levels. This meta-analysis investigates the relationship between baseline A1C and perceived efficacy of treatment.

METHODS

This report describes a Bayesian random effects analysis of 23 published studies. We constructed a random effects model including a factor adjusting for between-study differences in baseline A1C levels.

RESULTS

The random effects model correctly predicts post-treatment A1C levels from baseline A1C within a 95% confidence interval (CI) for each of the 23 studies included in the meta-analysis. After applying the model to adjust for differences in baseline A1C, we found that the difference in efficacy between rosiglitazone and sitagliptin was not significantly different from zero (0.12; 95% CI -0.09 to 0.34). Similarly, no significant differences are observed between the effects of pioglitazone and sitagliptin (0.01; 95% CI -0.21 to 0.22) or between rosiglitazone and pioglitazone (0.11; 95% CI -0.37 to 0.146). When baseline values are omitted from the Bayesian model, the findings suggest that rosiglitazone is superior to pioglitazone or sitagliptin.

CONCLUSIONS

These results illustrate the necessity for careful application of appropriate methodology when comparing results of different studies. When between-study differences in treatment effects are adjusted for baseline differences, then the findings suggest that none of the treatments has an effect that is superior to any of the other treatments.

Treatment choice and effectiveness of adding sulphonylurea or glitazones to metformin for the treatment of type 2 diabetes mellitus

AIM

This study investigates the treatment choice between, and the effectiveness of, adding sulphonylurea or glitazone to ongoing metformin therapy for patients with type 2 diabetes mellitus in the clinical practice setting.

METHODS

A multicentre observational study using data from clinical records was conducted in Finland, France, Germany, Norway, Poland, Spain and the UK. Data were collected for patients who added sulphonylurea or glitazone to metformin. Effectiveness was defined as a change in haemoglobin A1c (HbA(1c)) from baseline to approximately 1 year after the initiation of additional therapy. To allow for comparisons between the two medication regimens, propensity score matching was employed. Treatment choice was analysed using a probit regression model. We hypothesized that treatment choice was associated with factors reflecting patient's characteristics, patient's experience with diabetes, patient's health or to physician's characteristics at baseline.

RESULTS

Compared with baseline, adding sulphonylurea to metformin reduced HbA(1c) by 0.8% (p < 0.0001), while adding glitazone to metformin reduced HbA(1c) by 0.9% (p < 0.0001). Percentage at HbA(1c) goal (6.5%) increased from 6.9 to 23.8% for the sulphonylurea group and 8.3 to 33.3% for the glitazone group. Both groups had similar changes in high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides. In the probit regression model, age, HbA(1c), weight, treatment for weight reduction, history of macrovascular complications and type of physician were significant factors associated with treatment choice.

CONCLUSIONS

This study is consistent with the results of long-term randomized clinical trials in a clinical practice setting. Both regimens were able to reduce HbA(1c) by about 1%.

Glycaemic control among patients with type 2 diabetes mellitus in seven European countries: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) study

OBJECTIVE

This study was undertaken to assess glycaemic control as well as changes in glycaemic control over time in patients with type 2 diabetes mellitus (T2DM) who added a sulphonylurea (SU) or thiazolidinedione (TZD) to their metformin monotherapy in typical treatment settings within seven European countries.

METHODS

An observational, cross-sectional multicentre study with retrospective medical chart review was conducted in Finland, France, Germany, Norway, Poland, Spain and UK. T2DM patients who added a SU or a TZD to metformin monotherapy between January 2001 and January 2006 (i.e. index date) and who had > or = 1 haemoglobin A1C (HbA1C) measurement within 12 months before the visit date, which occurred from June 2006 to February 2007, were included in the study. Demographic and clinical data were collected from medical records. The main study outcome measure was the proportion of patients with adequate glycaemic control (defined according to the International Diabetes Federation as HbA1C < 6.5%) using the most recent HbA1C measurement before the visit date. In addition, patients were grouped based upon the interval from the index date to the most recent HbA1C measurement to evaluate goal attainment and treatment changes over time.

FINDINGS

In this European cohort of 2023 T2DM patients on metformin and either an SU or a TZD (mean age = 60.4 years), 25.5% of patients had adequate glycaemic control. The average HbA1C level was 7.2% after a mean of 2.6 years of treatment with combination oral antihyperglycaemic agent (AHA) therapy. Among the patients (n = 227) with most recent HbA1C measurement within 1 year after first adding an SU or a TZD, 27% had adequate glycaemic control (HbA1C < 6.5%), with a mean (s.d.) HbA1C of 7.1% (1.0); 1.3% of these patients were using some type of insulin therapy. Among the patients (n = 176) with most recent HbA1C measurement occurring > or = 5 years after adding an SU or a TZD, 20% had adequate glycaemic control, with a mean (s.d.) HbA1C of 7.4% (1.17), and 29.6% of these patients were using insulin. Overall, patients with (vs. without) adequate glycaemic control had significantly (p < 0.05) lower HbA1C levels (7.6 vs. 8.2%) at the time of adding an SU or a TZD to ongoing metformin monotherapy, were less likely to report a history of macrovascular complications (20 vs. 26%) and were more often engaged in physical activity three to five times a week (29 vs. 23%).

CONCLUSIONS

Approximately one quarter of European out-patients with T2DM had adequate glycaemic control after a mean of 2.6 years following initiation of combination AHA therapy. Overall glycaemic control modestly declined over time, even though more patients were being treated with insulin. These findings highlight the progressive nature of the disease and need for more effective disease management/therapeutic alternatives.

The influence of age and body mass index on the metabolic syndrome and its components

OBJECTIVE

The aim of this study was to evaluate the influence of ageing and body mass index (BMI) on the revised National Cholesterol Education Program (NCEP)-defined metabolic syndrome, its components, diabetes and coronary heart disease prevalence using the Third National Health and Nutrition Examination Survey.

METHODS

Data from adults aged 20 and older who received morning physical examinations after a fast of at least 9 h (n = 7959), representing 196.8 million Americans were used in this analysis. The population was stratified by age deciles and BMI categories using standard definitions of overweight and obesity. Due to small sample size, those few individuals with BMI <18.5 were excluded.

RESULTS

Fasting glucose, diabetes and systolic blood pressure (SBP) seem to have a linear relationship with age and BMI, that is, increasing BMI seems to linearly reduce the age decile when the mean exceeds the NCEP cutpoint. Regardless of BMI, the prevalence of diabetes and hypertension increases with age. Triglyceride levels and prevalence of metabolic syndrome follow a pattern that is less linear. Fasting insulin and C-reactive protein (CRP) levels correlate better with BMI than age. Diastolic BP and HDL cholesterol for men and women (analysed separately) did not correlate with either age or BMI.

CONCLUSION

For each component of the metabolic syndrome and associated factors, there is a complex interaction between ageing and obesity. Some components are associated with obesity but not ageing (e.g. CRP), while others are associated with both obesity and ageing (e.g. glucose). Even when the association exists, the specific relationship can appear to be more (e.g. SBP) or less (e.g. triglycerides) linear.

Initial monotherapy with either metformin or sulphonylureas often fails to achieve or maintain current glycaemic goals in patients with Type 2 diabetes in UK primary care

AIMS

To describe initial achievement of glycaemic targets and subsequent hyperglycaemia in patients with Type 2 diabetes managed with oral agent monotherapy in UK primary care from 1998 to 2004.

METHODS

Electronic medical records of patients initiating metformin (n = 3362) or a sulphonylurea agent (n = 3070) in 290 UK primary care practices were retrieved from the General Practice Research Database (GPRD). Patients included had an HbA(1c) recorded 0-90 days before and 90-365 days after initiating monotherapy. The probability of achieving glycaemic thresholds in the first year, and for those achieving such targets, the probability of inadequate glycaemic control (HbA(1c) > 6.5%, > 7.0%, > 7.5%) over time is described.

RESULTS

Low baseline HbA(1c) and drug initiation within 3 months of diabetes diagnosis were the strongest predictors of initial achievement of glycaemic targets. The proportion of patients with diabetes duration > or = 4 months who achieved HbA(1c) < 7% in the first year ranged from 24% to 88% for highest to lowest baseline HbA(1c) category in sulphonylurea initiators and from 19% to 86% in metformin initiators, with slightly higher proportions for newly diagnosed patients. Kaplan-Meier analyses suggested that 55% and 70% of patients who initially achieved glycaemic targets had HbA(1c) measurements above these targets at 2 and 3 years.

CONCLUSIONS

Many patients fail to achieve glycaemic goals with initial monotherapy and, of those who achieve current goals, few consistently maintain these targets over 3 years. Research is needed to evaluate whether more aggressive treatment or alternative treatments can improve the long-term maintenance of glycaemic control in patients with Type 2 diabetes.

Simulating mouse mammary gland development: cell ageing and its relation to stem and progenitor activity

BACKGROUND

Somatic stem and progenitor cell division is likely to be an important determinant of tumor development. Each division is accompanied by a risk of fixing genetic mutations, and/or generating innately immortal cells that escape normal physiological controls.

AIM

Using biological information, we aimed to devise a theoretical model for mammary gland development that described the effect of various stem/progenitor cells activities on the demographics of adult mammary epithelial cell populations.

RESULTS

We found that mammary ductal trees should develop in juvenile mice despite widely variant levels of activity in the progenitor compartment. Sequestration (inactivation) of progenitor cells dramatically affected the aging-maturation of the population without affecting the total regenerative capacity of the gland. Our results showed that if stem and progenitor cells can be demonstrated in glands regenerated by serial transplantation, they originated in a canonical primary stem cell (providing a functional definition of mammary stem cells). Finally, when the probability of symmetric division of stem cells increased above a threshold, the mammary epithelial population overall was immortal during serial transplantation.

CONCLUSIONS

This model provides, (1) a theoretical framework for testing whether the phenotypes of genetically modified mice (many of which are breast cancer models) derive from changes of stem and progenitor activity, and (2) a means to evaluate the resolving power of functional assays of regenerative capacity in mammary epithelial cell populations.

Juvenile syndecan-1 null mice are protected from carcinogen-induced tumor development

We previously showed that mice with a null mutation in syndecan-1 (Sdc1; CD138) were resistant to Wnt1-induced mammary tumor initiation. The absence of Sdc1 inhibited the increase in the mammary stem cell fraction that is characteristic of preneoplasia in this model. As the tumor precursor cells are recruited from the stem/progenitor cell compartment, tumor development was also inhibited (Liu et al., 2004; PNAS 101, 4158). Although Sdc1-/- mice are grossly normal, they are systemically smaller, suggesting that developmental abnormalities may extend further than their mammary glands. We have therefore evaluated the multi-organ response of Sdc1-/- mice to carcinogen-induced tumor development (7,12-dimethylbenz[a]anthracene, DMBA), and find these mice to be resistant to tumorigenesis in all the predominant carcinogen-susceptible lineages. Thus, Sdc1-/- mice administered DMBA during juvenile development are resistant not only to epithelial tumors, including liver (60-80%) and lung tumors (C57BL6 mice, 60-80%), but also to lymphoma (over 70%, depending upon strain and carcinogen dose). We demonstrate that CD138 is expressed (heterogeneously) in the hematopoietic stem cell fraction (and not only in pre-B and plasma cells), and that tumors arise in both myeloid and lymphoid lineages. Furthermore, carcinogen-induced mammary tumors are bilineal, implying a bipotent precursor cell. Both observations imply that the DMBA-induced tumor precursor cells are drawn from the stem/progenitor fraction, and we suggest that pathogenic activation of these cells could be abnormal in Sdc1-/- mice.

Functional modulation of shoulder girdle stability

We have previously reported that electrical stimulation of the ulnar nerve at group I strength evokes reflex excitation of the trapezius muscle in normal human subjects. In the present study this reflex has been evoked while subjects were performing a number of different tasks. When subjects performed a task involving a high degree of manual dexterity, the reflex was larger. On the other hand, when subjects performed a task that can be achieved with virtually no movement of the hand or wrist musculature, the reflex does not appear to show any task dependency. These results support the view that in delicate tasks of the hand, such compensatory reflexes are more important than in basic mechanisms such as lifting an object. The functional consequences of these findings and their significance in relation to the possibility that these task-related reflex gain changes produce intention tremor is discussed.

An audit of an evidence-based assessment tool for the blue badge disabled parking scheme

Those who have difficulty walking are eligible for a ‘blue badge’, which gives extra parking rights. An evidence-based assessment was introduced to assess applicants' eligibility for this badge. The assessment consisted of an interview, symptom scaling, falls risk assessment (including functional reach) and a walk test. In total, 226 assessments were carried out in a 6-month period. The discriminant analysis using all parts of the assessment gave 95% compliance and a cross validation value of 88%.

Post-assessment, awards of badges decreased by 12% and appeals decreased by 25%. All parts of the assessment were found to be useful in helping to make a decision. Answers from the assessment could predict the eligibility for 88% of the time. Consequently, therapists' knowledge and experience is still necessary. Using a face-to-face evidence-based assessment reduced the potential for abuse, decreased the amount of appeals and made the decision-making process more transparent.

Reflex connections from forearm and hand afferents to shoulder girdle muscles in humans

Using surface electromyographic recordings from the trapezius and serratus anterior muscles and percutaneous electrical stimulation of the median, ulnar and radial nerves, the reflex connections from forearm and hand afferents to these shoulder girdle muscles have been investigated in normal human subjects. Stimulation of the median, ulnar and radial nerves at the shoulder, elbow and wrist evoked late, excitatory reflexes in the upper and lower parts of trapezius and in serratus anterior. These reflexes are not evoked by stimulation of cutaneous afferents alone, since there was no response to stimulation of the distal cutaneous branches of these three nerves. Measurements of the conduction velocity of afferents of the median, ulnar and radial nerve evoking these reflexes gave a mean conduction velocity of approximately 50 m/s. The lowest stimulus intensities at which these reflexes could be evoked were found to be 0.3 times motor threshold (MT). By taking into account the reflex latency, the length of the conduction path and that the reflex was mediated by low threshold, fast conducting afferents, it is proposed that group I muscle afferents from the forearm or hand evoke a supraspinal reflex to trapezius and serratus anterior. It appears that the functional significance of these reflexes is to aid in the stability of the shoulder girdle.

Does tape facilitate or inhibit the lower fibres of trapezius?

The application of tape to the skin overlying the lower fibres of trapezius is generally thought to facilitate this muscle. However, this facilitation has not been thoroughly investigated. In this study, the effect of tape upon trapezius motoneurone pool excitability was assessed using the trapezius H reflex. The amplitude of the H reflex was measured across four conditions: before tape application, with Endura Fix tape, with the addition of Endura Sports tape and finally with the tape removed. Instead of the expected facilitation of lower trapezius, this tape inhibited lower trapezius activity. On average, the application of Endura Fix tape inhibited trapezius by 4%. The application of Endura Sports tape overlaying the Endura Fix tape inhibited trapezius on average by 22%. This inhibition did not last once the tape was removed. This suggests that any change in shoulder girdle symptoms or movement, which occurs with the application of this particular tape, is not explicable on the basis of the facilitation of the lower fibres of trapezius.

The bilateral reflex control of the trapezius muscle in humans

Abstract. Electromyographic recordings were made from the trapezius muscle in 18 healthy subjects using surface electrodes placed bilaterally. A mechanical tap applied to the insertion of the lower fibres of trapezius evoked a reflex at 11.9 +/- 1.4 ms (mean plus minus SD) in the ipsilateral trapezius muscle. In addition and surprisingly, short latency, facilitatory reflexes were also seen on the contralateral side at a latency of 14.3 +/- 1.7 ms. Electrical stimulation of the afferent nerve to trapezius, the cervical nerve of C3/4, also evoked short latency, facilitatory reflexes from both the ipsilateral and contralateral muscles. Since this nerve carries the Ia fibres from trapezius, this reflex would appear to be the equivalent of the H reflex seen in the soleus muscle. The latency of this reflex was 10.9 +/- 1.4 ms ipsilaterally and 11.9 +/- 1.5 ms contralaterally, the difference being only 1.0 +/- 0.7 ms. Voluntary activity of the ipsilateral trapezius increased the amplitude of both mechanically and electrically evoked ipsilateral and crossed reflexes, and vibration of the ipsilateral trapezius decreased the amplitude of both reflexes. These results together suggest that the earliest parts of both ipsilateral and crossed reflexes are monosynaptic in origin. If the crossed reflex is, in part, due to a common Ia presynaptic input, correlation of bilateral trapezius activity should produce a peak in the cross-correlogram. Indeed, cross-correlation of the bilateral trapezius activity during elevation of the arms produced a short duration peak. Moreover, this was significantly larger when compared to that constructed from activity of the upper and lower fibres of trapezius from one side. These results imply that muscle spindle afferents from the ipsilateral trapezius monosynaptically activate motoneurones contralaterally.

Epithelial development and differentiation in the mammary gland is not dependent on alpha 3 or alpha 6 integrin subunits

In the mammary gland, both laminin and integrins have been shown to be required for normal ductal morphogenesis during development in vivo, and for functional differentiation in culture models. Major integrin receptors for laminins in the mammary gland are alpha 3 beta 1, alpha 6 beta 1, and alpha 6 beta 4. However, the specific subunits that contribute to laminin-mediated mammary cell function and development have not been identified. In this study, we use a genetic approach to test the hypothesis that laminin-binding integrins are required for the function of the mammary gland in vivo. Rudiments of embryonic mammary gland were shown to develop in the absence of these integrin subunits. Postnatal development of the mammary gland was studied in integrin null tissue that had been transplanted into the mammary fat pads of syngeneic hosts. In mammary epithelium lacking alpha 6 integrin, the beta 4 subunit was not apparent and hemidesmosome formation was only rudimentary. However, despite this deficiency, normal ductal morphogenesis and branching of the mammary gland occurred and myoepithelial cells were distributed normally with respect to luminal cells. Mammary alveoli devoid of alpha 3 or alpha 6 integrin formed in pregnancy and were histologically and functionally identical to those in wild-type mammary gland. The tissue underwent full morphological differentiation, and the epithelial cells retained the ability to synthesize beta-casein. This work demonstrates that mammary tissue genetically lacking major laminin-binding integrin receptors is still able to develop and function.

A new astrophysical setting for chondrule formation

Chondrules in the metal-rich meteorites Hammadah al Hamra 237 and QUE 94411 have recorded highly energetic thermal events that resulted in complete vaporization of a dusty region of the solar nebula (dust/gas ratio of about 10 to 50 times solar). These chondrules formed under oxidizing conditions before condensation of iron-nickel metal, at temperatures greater than or equal to 1500 K, and were isolated from the cooling gas before condensation of moderately volatile elements such as manganese, sodium, potassium, and sulfur. This astrophysical environment is fundamentally different from conventional models for chondrule formation by localized, brief, repetitive heating events that resulted in incomplete melting of solid precursors initially residing at ambient temperatures below approximately 650 K.

Improved cholesterol management in coronary heart disease patients enrolled in an HMO

The purpose of the study was to describe the effect of physician reminders on the measurement of low-density lipoprotein cholesterol (LDL-C) levels and treatment to achieve an LDL-C goal of < or = 100 mg/dL in coronary heart disease (CHD) patients. After reminders were initiated, the number of CHD patients without a documented LDL-C was reduced from 30% to 18%, between January 1997 and July 1998, and the percentage of CHD patients achieving the LDL-C goal improved from 10% to 27%. Thus, reminders can be an effective tool in improving cholesterol management of CHD patients. In contrast, a cholesterol-lowering clinic made available to some physicians, in addition to the reminders, was rarely used.

Stromelysin-1 regulates adipogenesis during mammary gland involution

The matrix metalloproteinase MMP-3/stromelysin-1 (Str1) is highly expressed during mammary gland involution induced by weaning. During involution, programmed cell death of the secretory epithelium takes place concomitant with the repopulation of the mammary fat pad with adipocytes. In this study, we have used a genetic approach to determine the role of Str1 during mammary involution. Although Str1 has been shown to induce unscheduled apoptosis when expressed ectopically during late pregnancy (Alexander, C.M., E.W. Howard, M.J. Bissell, and Z. Werb. 1996. J. Cell Biol. 135:1669-1677), we found that during post-lactational involution, mammary glands from transgenic mice that overexpress the tissue inhibitor of metalloproteinases, TIMP-1 (TO), or mice carrying a targeted mutation in Str1 showed accelerated differentiation and hypertrophy of adipocytes, while epithelial apoptosis was unaffected. These data suggest that matrix metalloproteinases (MMPs) do not induce unscheduled epithelial cell death after weaning, but instead alter the stromal microenvironment. We used adipogenic 3T3-L1 cells as a cell culture model to test the function of MMPs during adipocyte differentiation. Fibroblastic 3T3-L1 progenitor cells expressed very low levels of MMPs or TIMPs. The transcription of a number of MMP and TIMP mRNAs [Str1, MT1-MMP, (MMP-14) collagenase-3 (MMP-13), gelatinase A (MMP-2), and TIMP-1, -2 and -3] was induced in committed preadipocytes, but only differentiated adipocytes expressed an activated MMP, gelatinase A. The addition of MMP inhibitors (GM 6001 and TIMP-1) dramatically accelerated the accumulation of lipid during differentiation. We conclude that MMPs, especially Str1, determine the rate of adipocyte differentiation during involutive mammary gland remodeling.

How cost-effective is the treatment of dyslipidemia in patients with diabetes but without cardiovascular disease?

OBJECTIVE

Epidemiological studies have shown that the risk of myocardial infarction (MI) in diabetic patients without cardiovascular disease (CVD) is comparable to the risk of MI in patients with CVD. We used a validated Markov model to compare the long-term costs and benefits of treating dyslipidemia in diabetic patients without CVD versus treating CVD patients without diabetes in the U.S. The generalizability and robustness of these results were also compared across six other countries (Canada, France, Germany, Italy, Spain, and the U.K.).

RESEARCH DESIGN AND METHODS

With use of the Cardiovascular Disease Life Expectancy Model, cost effectiveness simulations of simvastatin treatment were performed for men and women who were 40-70 years of age and had dyslipidemia. We forecast the long-term risk reduction in CVD events after treatment. On the basis of the Scandinavian Simvastatin Survival Study results, we assumed a 35% reduction in LDL cholesterol and an 8% rise in HDL cholesterol.

RESULTS

In the U.S., treatment with simvastatin for CVD patients without diabetes was cost-effective, with estimates ranging from $8,799 to $21,628 per year of life saved (YOLS). Among diabetic individuals without CVD, lipid therapy also appeared to be cost-effective, with estimates ranging from $5,063 to $23,792 per YOLS. In the other countries studied, the cost effectiveness of treating diabetes in the absence of CVD was comparable to the cost effectiveness of treating CVD in the absence of diabetes.

CONCLUSIONS

Among diabetic men and women who do not have CVD, lipid therapy is likely to be as effective and cost-effective as treating nondiabetic individuals with CVD.

Effect of lovastatin on cardiovascular resource utilization and costs in the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS). AFCAPS/TexCAPS Research Group

This cost-consequences analysis of the Air Force/Texas Coronary Atherosclerosis Prevention Study compares the costs of lovastatin treatment with the costs of cardiovascular hospitalizations and procedures. The cost of lovastatin treatment was defined as the average retail price and the cost of drug safety monitoring and adverse experiences. Costs were determined by actual rates of hospitalizations and procedures. Within a trial, lovastatin treatment cost approximately $4,654/patient. Lovastatin treatment significantly reduced the cumulative rate of cardiovascular hospitalizations and procedures (p = 0.002). Over the duration of the study, the cumulative number of cardiovascular hospitalizations and related therapeutic procedures was significantly reduced by 29%. The time to first cardiovascular-related hospitalization or procedure was significantly extended by lovastatin (p = 0.002). Lovastatin reduced the frequency of cardiovascular hospitalization (28%), and cardiovascular therapeutic (32%) and diagnostic procedures (23%). Among therapeutic procedures, treatment reduced coronary artery bypass graft surgery by 19% and percutaneous transluminal coronary angioplasty by 37%. Total cardiovascular-related hospital days were reduced by 26% (p = 0.025). The between-group offset in direct medical costs was $524, which resulted in a 11% cost offset of lovastatin therapy over the mean study duration of 5.2 years. Lovastatin provides meaningful reductions in cardiovascular-related resource utilization and reductions in direct cardiovascular-related costs associated with the onset of coronary disease.

Diabetes mellitus, impaired fasting glucose, atherosclerotic risk factors, and prevalence of coronary heart disease

Patients with diabetes mellitus (DM), both diagnosed (history of) and undiagnosed (by fasting glucose [FG] only), as well as impaired FG have an increased risk of coronary heart disease (CHD), compared with those with normal FG. Elevations in FG levels, even in normoglycemic subjects (<110 mg/dl), may be significantly related to CHD morbidity and mortality. Improving lipid profiles and blood pressure can decrease both CHD morbidity and mortality in these patients. We evaluated the relation of glucose status to lipid levels, other risk factors, and prevalence of CHD using the 1997 American Diabetes Association diagnostic criteria in a representative sample of United States adults studied in the Third National Health and Nutrition Examination Survey from 1988 to 1994. Impaired FG, diagnosed DM, and undiagnosed DM were more prevalent in older age groups; those > or =65 years had increased prevalence compared with those <50 years old (rate ratios for IFG, DM-FG, and history of DM were 3.5, 4.8, and 10.8, respectively). Glycosylated hemoglobin levels were increased by glucose status. The frequency of known CHD risk factors also increased with worsening glucose status. Age-adjusted CHD prevalence was increased with impaired FG (rate ratio 1.47), DM-FG (rate ratio 1.56), and history of DM (rate ratio 1.72), compared with normal FG. Adjusting for age and other CHD risk factors, hyperglycemia was no longer significantly associated with CHD prevalence. Lipid values, especially high-density lipoprotein cholesterol, hypertension, and other CHD risk factors were more strongly associated with CHD than glucose status. Thus, patients with impaired FG, DM-FG, and history of DM should be considered at higher risk for CHD morbidity and mortality. However, hyperglycemia, per se, does not explain the excess risk. In addition to glucose, lipid profiles and blood pressure should be periodically monitored and appropriate treatment provided to reduce morbidity and mortality from CHD.

Use of simvastatin treatment in patients with combined hyperlipidemia in clinical practice. For the Simvastatin Combined Hyperlipidemia Registry Group

OBJECTIVE

To describe and understand current care of simvastatin-treated patients with combined hyperlipidemia in routine clinical practice.

DESIGN

A 6-month prospective observational study. Demographics, simvastatin dosage, cardiac risk factors, and lipid profile were collected from August 1997 to December 1998 at 20 sites (230 patients) across the United States.

RESULTS

Overall mean percentage of reduction in total cholesterol levels was 27% (P<.001), low-density lipoprotein cholesterol (LDL-C) was 35% (P<.001), and triglyceride values was 28% (P<.001). Among those patients with low baseline high-density lipoprotein cholesterol (HDL-C) values (<0.91 mmol/L [<35 mg/dL]) (N = 49), there was a 17% increase in HDL-C (P< or =.001); 35% of these patients achieved National Cholesterol Education Program HDL-C goal (ie, < or =0.91 mmol/L [> or =35 mg/dL]). Coronary heart disease (CHD) patients were given significantly higher initial doses (mean, 15.1 mg) compared with non-CHD patients (mean, 11.5 mg) (P< or =.001). Overall, 74% of patients achieved LDL-C goal (52% on starting dose, 22% after 1 titration). Among those patients who were not at goal and had a follow-up lipid profile result available, only 1 patient (2%) was at the maximum dose (80 mg); 69% were receiving 20 mg or less. Approximately 63% of patients with CHD, 80% of patients with 2 or more risk factors, and 91% of patients with fewer than 2 risk factors achieved LDL-C goal.

CONCLUSIONS

Multiple factors contribute to LDL-C goal achievement in a usual care setting. A significant opportunity exists to increase the number of patients who achieve LDL-C goal by appropriate dose titration and/or give patients a higher initial dose of simvastatin.

Syndecan-1 is required for Wnt-1-induced mammary tumorigenesis in mice

Syndecan-1 is a cell-surface, heparan-sulphate proteoglycan (HSPG) predominantly expressed by epithelial cells. It binds specifically to many proteins, including oncoproteins. For example, it induces the assembly of a signalling complex between FGF ligands and their cognate receptors. But so far there has been no direct evidence that this proteoglycan contributes to tumorigenesis. Here we have examined the role of syndecan-1 (encoded by Sdc1) during mammary tumour formation in response to the ectopic expression of the proto-oncogene Wnt1. We crossed syndecan-1-deficient mice with transgenic mice that express Wnt1 in mammary gland (TgN(Wnt-1)1Hev; ref. 2). Ectopic Wnt-1 expression induces generalized mammary hyperplasia, followed by the development of solitary tumours (median time 22 weeks). We show that in Sdc1-/- mice, Wnt-1-induced hyperplasia in virgin mammary gland was reduced by 70%, indicating that the Wnt-1 signalling pathway was inhibited. Of the 39 tumours that developed in a test cohort of mice, only 1 evolved in the Sdc1-/- background. In addition, we show that soluble syndecan-1 ectodomain purified from mouse mammary epithelial cells stimulates the activity of a Wnt-1 homologue in a tissue culture assay. Our results provide both genetic and biochemical evidence that syndecan-1 can modulate Wnt signalling, and is critical for Wnt-1-induced tumorigenesis of the mouse mammary gland.

Reduced coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose levels: subgroup analyses in the Scandinavian Simvastatin Survival Study

BACKGROUND

Patients with diabetes mellitus (DM) have a marked increase in coronary heart disease (CHD) events relative to those without DM. In a previous report from the Scandinavian Simvastatin Survival Study using a clinical case definition of DM (n = 202), simvastatin-treated patients had significantly fewer CHD events compared with placebo-treated control subjects.

OBJECTIVE

To examine the effect of simvastatin therapy on CHD in patients with DM and impaired fasting glucose levels.

METHODS

Using the 1997 American Diabetes Association diagnostic criteria, we assessed the effect of simvastatin therapy post hoc for an average of 5.4 years in Scandinavian Simvastatin Survival Study patients with normal fasting glucose (n = 3237), impaired fasting glucose (n = 678), and DM (n = 483).

RESULTS

Simvastatin-treated patients with DM had significantly reduced numbers of major coronary events (relative risk [RR] = 0.58; P = .001) and revascularizations (RR = 0.52; P = .005). Total (RR = 0.79; P = .34) and coronary (RR = 0.72; P = .26) mortality were also reduced in DM, but not significantly, due to small sample size. In impaired fasting glucose (IFG) subjects, simvastatin use significantly reduced the number of major coronary events (RR = 0.62; P = .003), revascularizations (RR = 0.57; P = .009), and total (RR = 0.57; P = .02) and coronary (RR = 0.45; P = .007) mortality.

CONCLUSION

Our results extend previous findings in patients with DM to a larger cohort, confirming the benefit of cholesterol lowering with simvastatin treatment on CHD events. In addition, significant decreases in total mortality, major coronary events, and revascularizations were observed in simvastatin-treated patients with impaired fasting glucose levels. These results strongly support the concept that cholesterol lowering with simvastatin therapy improves the prognosis of patients with elevated fasting glucose levels (> or =6.0 mmol/L [> or =110 mg/ dL]) or DM and known CHD.

Effect of simvastatin treatment on cardiovascular resource utilization in impaired fasting glucose and diabetes. Findings from the Scandinavian Simvastatin Survival Study

OBJECTIVE

The Scandinavian Simvastatin Survival Study showed that simvastatin treatment reduced cardiovascular events in hypercholesterolemic subjects with coronary heart disease. The clinical benefits of therapy were similar in all three subgroups: normal fasting glucose (NFG, n = 3,237), impaired fasting glucose (IFG, n = 678), and diabetes (n = 483). This analysis compared the costs of simvastatin treatment with the costs of cardiovascular disease-related hospitalizations in the three subgroups.

RESEARCH DESIGN AND METHODS

The cost of simvastatin treatment was defined as the average retail price and the cost of drug safety monitoring and adverse experiences. The costs of cardiovascular disease-related hospitalizations were determined by actual rates of hospitalization and 1995 MEDSTAT diagnosis-related group costs.

RESULTS

Within trial, simvastatin treatment cost approximately $6,000 per patient. Simvastatin treatment reduced cardiovascular disease-related hospitalizations by 23% in NFG (P = 0.001), 30% in IFG (P = 0.015), and 40% in diabetic subjects (P = 0.007) within trial (median follow-up of 5.4 years). Average length of stay was reduced by 2.4 days in diabetic subjects (P = 0.021). Total cardiovascular disease-related hospital days were reduced by 28% (P < 0.001) in NFG, 38% (P = 0.005) in IFG, and 55% (P < 0.001) in diabetic subjects. For NFG subjects, simvastatin reduced the average cost of cardiovascular disease-related hospitalizations by $3,585, which offset 60% of the cost of simvastatin therapy. For IFG subjects, average cardiovascular disease-related hospitalization costs were reduced by $4,478, which offset 74% of the drug cost. For diabetic subjects, there was a net cost savings of $1,801 per subject within trial.

CONCLUSIONS

Simvastatin significantly reduced cardiovascular disease-related hospitalizations and total hospital days for all three groups and significantly reduced length of stay for the diabetic group in addition to providing significant clinical benefits. The benefits were greatest in the diabetic group, with estimated cost savings within trial from simvastatin treatment.

Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease

There is a lack of data evaluating the implementation of guidelines in the management of coronary artery disease (CAD) or congestive heart failure (CHF) in the outpatient setting. We analyzed an administrative data set from the Merck & Co. sponsored national Quality Assurance Program, a retrospective outpatient chart audit of 58,890 adult outpatients from 140 medical practices (80% cardiology only) in the USA with diagnoses of CAD and/or CHF identified from medical claims data. We determined the (1) frequency of lipid documentation and prescription of lipid-lowering agents in patients with CAD, (2) frequency of assessment of left ventricular function and prescription of an angiotensin-converting enzyme inhibitor in patients with CHF, and (3) predictors of medication prescription. Of the 48,586 patients with CAD, 44% had annual diagnostic testing of low-density lipoprotein cholesterol. Only 25% of these patients reached the target low-density lipoprotein cholesterol of < or = 100 mg/dl, and only 39% were taking lipid-lowering therapy, which was less among the elderly than in the younger patients. Of the 16,603 patients with CHF, 64% had diagnostic testing of left ventricular function, and 50% of patients were taking an angiotensin-converting enzyme inhibitor; 67% of patients received medication if they had documented systolic dysfunction. Significant predictors of medication prescription included diagnostic testing, younger age, history of myocardial infarction or coronary artery bypass grafting, hypertension, cardiology specialty, and geographic region. Thus, current practice patterns in the management of CAD and CHF are inadequate. Patient age, diagnostic testing, and practice environment influence medication prescription.

The origin of chondritic macromolecular organic matter: a carbon and nitrogen isotope study

The N and C abundances and isotopic compositions of acid-insoluble carbonaceous material in thirteen primitive chondrites (five unequilibrated ordinary chondrites, three CM chondrites, three enstatite chondrites, a CI chondrite and a CR chondrite) have been measured by stepped combustion. While the range of C isotopic compositions observed is only delta 13C = 30%, the N isotopes range from delta 15N approximately -40 to 260%. After correction for metamorphism, presolar nanodiamonds appear to have made up a fairly constant 3-4 wt% of the insoluble C in all the chondrites studied. The apparently similar initial presolar nanodiamond to organic C ratios, and the correlations of elemental and isotopic compositions with metamorphic indicators in the ordinary and enstatite chondrites, suggest that the chondrites all accreted similar organic material. This original material probably most closely resembles that now found in Renazzo and Semarkona. These two meteorites have almost M-shaped N isotope release profiles that can be explained most simply by the super-position of two components, one with a composition between delta 15N = -20 and -40% and a narrow combustion interval, the other having a broader release profile and a composition of delta 15N approximately 260%. Although isotopically more subdued, the CI and the three CM chondrites all appear to show vestiges of this M-shaped profile. How and where the components in the acid-insoluble organics formed remains poorly constrained. The small variation in nanodiamond to organic C ratio between the chondrite groups limits the local synthesis of organic matter in the various chondrite formation regions to at most 30%. The most 15N-rich material probably formed in the interstellar medium, and the fraction of organic N in Renazzo in this material ranges from 40 to 70%. The isotopically light component may have formed in the solar system, but the limited range in nanodiamond to total organic C ratios in the chondrite groups is consistent with most of the organic material being, presolar.

Targeted mutagenesis of Timp-1 reveals that lung tumor invasion is influenced by Timp-1 genotype of the tumor but not by that of the host

Timp-1 has been implicated as a suppressor of tumor metastasis. To study the relative importance of Timp-1 expression by tumor vs host during tumor invasion, three pairs of co-isogenic, tumorigenic cells containing wild-type or mutant Timp-1 alleles were generated. These were used in experimental metastasis assays in wild-type or Timp-1-deficient mice. Timp-1 expression in tumorigenic cells could either increase or decrease tumor invasion of lungs in a tumor cell-specific manner. This suggests that depending on the tumor, Timp-1 can either suppress or potentiate metastasis. Mice deficient for Timp-1 were indistinguishable from wild-type mice in metastasis assays with all tumorigenic cells tested. Although Timp-1 is a secreted protein, and lung produces other Timps, the influence of Timp-1 on lung invasion by the tumorigenic cells tested is cell-autonomous, depending only on Timp-1 genotype of tumor and not that of host.

Rescue of mammary epithelial cell apoptosis and entactin degradation by a tissue inhibitor of metalloproteinases-1 transgene

We have used transgenic mice overexpressing the human tissue inhibitor of metalloproteinases (TIMP)-1 gene under the control of the ubiquitous beta-actin promoter/enhancer to evaluate matrix metalloproteinase (MMP) function in vivo in mammary gland growth and development. By crossing the TIMP-1 transgenic animals with mice expressing an autoactivating stromelysin-1 transgene targeted to mammary epithelial cells, we obtained a range of mice with genetically engineered proteolytic levels. The alveolar epithelial cells of mice expressing autoactivating stromelysin-1 underwent unscheduled apoptosis during late pregnancy. When stromelysin-1 transgenic mice were crossed with mice overexpressing TIMP-1, apoptosis was extinguished. Entactin (nidogen) was a specific target for stromelysin-1 in the extracellular matrix. The enhanced cleavage of basement membrane entactin to above-normal levels was directly related to the apoptosis of overlying mammary epithelial cells and paralleled the extracellular MMP activity. These results provide direct evidence for cleavage of an extracellular matrix molecule by an MMP in vivo.

VH repertoire in human B lymphocytes stimulated by CD40 ligand and IL-4: evidence for positive and negative selection mechanisms coupled to CD40 activation

In the normal immune system, B cells are thought to be negatively or positively selected at various checkpoints during their maturation; a process that maintains a broad immunoglobulin repertoire while eliminating non-functional or potentially harmful autoreactive antibodies. This study tested the hypothesis that utilization of certain immunoglobulin heavy chain variable region (VH) genes, possibly as a consequence of intrinsic affinity for various ligands, directs positive or negative B cell selection coupled to B cell activation in the periphery during the immune response. The specific prediction that the VH repertoire of CD40-activated B cells would differ from the repertoire of unstimulated cells from the same donor, was tested by assessing VH utilization among human B cell clones grown in vitro, following stimulation with CD40 ligand (CD40L) and IL-4. The results showed that, although utilization of the known VH families and of individual VH3 genes was similar to that found in unstimulated B lymphocytes of the same donor, utilization of individual VH4 genes in CD40-activated B cells displayed a pattern that was markedly different from that of the unstimulated B cells. An allele of V4-61, V4-61b, was over-represented among the activated cells and, in contrast, the V4-34 gene (known to encode cold agglutinins with strong autoreactive properties) was modestly represented among the VH4 activated B cells, although V4-34 was overwhelmingly predominant in the repertoire of resting B cells. These results point to the existence of selection mechanisms that operate during B cell activation in the periphery. These mechanisms may favor B cells utilizing certain VH genes and disfavor the cells that utilize other genes, possibly because utilization of the latter confers autoreactivity.

Expression and function of matrix metalloproteinases and their inhibitors at the maternal-embryonic boundary during mouse embryo implantation

Gelatinase B, a matrix metalloproteinase (MMP) of high specific activity, is highly expressed and activated by mouse blastocysts in culture, and inhibition of this enzyme activity inhibits lysis of extracellular matrix (Behrendtsen, O., Alexander, C. M. and Werb, Z. (1992) Development 114, 447–456). Because gelatinase B expression is linked to invasive potential, we studied the expression of gelatinase B mRNA and protein in vivo, in implanting trophoblast giant cells, and found that it was expressed and activated during colonization of the maternal decidua. mRNAs for several other MMPs (stromelysin-1, stromelysin-3 and gelatinase A) and MMP inhibitors (TIMP-1 and TIMP-2) were expressed in the undifferentiated stroma toward the outside of the decidua, and TIMP-3 mRNA was expressed in primary and some mature decidual cells during their differentiation. Both mRNA and TIMP-3 protein were present at high concentrations transiently, and declined from 6.5 days post coitum onward, as the cells underwent apoptosis during the main period of gelatinase B expression and ectoplacental growth and expansion. To assess the function of MMPs during implantation and decidual development, we either injected a peptide hydroxamate MMP inhibitor into normal mice or studied transgenic mice overexpressing TIMP-1. In both cases, decidual length and overall size were reduced, and the embryo was displaced mesometrially. Embryo orientation was less strictly regulated in inhibitor-treated deciduae than in control deciduae. Morphogenesis and development of oil-induced deciduomas were also slowed in the presence of the inhibitor. We conclude that administration of MMP inhibitors retards decidual remodeling and growth, and we suggest that the MMPs expressed in precursor stromal cells promote their differentiation and expansion.