Program for the use of antipsychotics with metabolic monitoring in North Carolina medicaid children

Introduction

Children are at greater risk than adults for weight gain and metabolic disorders including hyperlipidemia and diabetes with newer antipsychotics. A web-based safety-monitoring program using a prior documentation model required submission of patient safety data (prior documentation) for insurance coverage at the pharmacy point of sale. This program launched in April of 2011, covering all NC Medicaid and Health Choice recipients under age 18. Clinical monitoring parameters and interactive educational features were developed with pediatric psychiatric experts and key mental health stakeholder groups.

Objectives

Using a four-year run in period and a full 9 months of post implementation claims data, evaluate the rates of antipsychotic prescribing and safety monitoring before and after the implementation of the A + KIDS program.

Results

Implementation of this program was associated with a consistent monthly decrease in overall antipsychotic use and increases in patient monitoring of glucose and lipid (Figure. 1, Table 1).

Conclusions

The prior documentation registry was effective in decreasing antipsychotic use and increasing safety monitoring. The impact of changing to more traditional prior authorization on the same clinical endpoints is currently under evaluation.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Wood structural differences between northern and southern beech provenances growing at a moderate site

Planting provenances originating from southern to northern locations has been discussed as a strategy to speed up species migration and mitigate negative effects of climate change on forest stability and productivity. Especially for drought-susceptible species such as European beech (Fagus sylvatica L.), the introduction of drought-tolerant provenances from the south could be an option. Yet, beech has been found to respond plastically to environmental conditions, suggesting that the climate on the plantation site might be more important for tree growth than the genetic predisposition of potentially drought-adapted provenances. In this study, we compared the radial growth, wood-anatomical traits and leaf phenology of four beech provenances originating from southern (Bulgaria, France) and northern locations (Sweden, the Netherlands) and planted in a provenance trial in the Netherlands. The distribution of precipitation largely differs between the sites of origin. The northern provenances experience a maximum and the southern provenances experience a minimum of rainfall in summer. We compared tree productivity and the anatomy of the water-conducting system for the period from 2000 to 2010, including the drought year 2003. In addition, tree mortality and the timing of leaf unfolding in spring were analysed for the years 2001, 2007 and 2012. Comparison of these traits in the four beech provenances indicates the influence of genetic predisposition and local environmental factors on the performance of these provenances under moderate site conditions. Variation in radial growth was controlled by environment, although the growth level slightly differed due to genetic background. The Bulgarian provenance had an efficient water-conducting system which was moreover unaffected by the drought in 2003, pointing to a high ability of this provenance to cope well with dry conditions. In addition, the Bulgarian provenance showed up as most productive in terms of height and radial growth. Altogether, we conclude that the similarity in ring-width variation among provenances points to environmental control of this trait, whereas the differences encountered in wood-anatomical traits between the well-performing Bulgarian provenance and the other three provenances, as well as the consistent differences in flushing pattern over 3 years under various environmental conditions, support the hypothesis of genetic control of these features.

Missing medical records: an obstacle to archival survey-research in a rural community in South Africa

Keeping good quality medical records is an essential yet oftenneglected part of a health-care practitioner’s workload. In South Africa, by lawall health care facilities are required to retain medical records for a minimum ofsix years after the cessation of a patient’s treatment. In an archival survey thatwas attempted in a rural community in South Africa, only 39% of the recordsthat were requested were located. The procedure that was followed in order toobtain the records to be included in the survey is briefly described in this paper,highlighting the challenges experienced in four district hospitals in this community.The phenomenon has serious implications not only for the quality of healthcare,incidence of iatrogenic injuries and the future of the health-care practitioner’s career, but it also impacts on the ability to conductresearch to inform practice. An aspect that is not often considered is the impact of poor record keeping on the research and teachingcomponent of the broader medical profession.

High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women

Vaginal rings (VRs) are new methods for continuous delivery of microbicides. This is the first study to quantitatively and qualitatively explore the acceptability of rings in Africa: 157 HIV-negative, sexually active women aged 18-35 used a placebo silicone elastomer ring for 12 weeks. They completed product acceptability questionnaires every 4 weeks. We conducted 6 exit focus group discussions with a subset of 48 women and 19 in-depth interviews with male partners. Retention in the study was high (97 %). Initial insertion at the clinic was successful on first attempt for 81 % of participants. Most women were comfortable using the ring, and very few (≤2 %) could feel it during daily activities or had ring-related physical or emotional problems. In the qualitative interviews many participants reported that they initially had concerns about using the ring. However, only a minority of women actually reported concerns with the ring during the study. The most frequent concern was that the ring would get lost inside the body (20 %), and this was significantly correlated with study site, frequently thinking about the ring and reporting that the ring was not very easy to remove. Qualitative data suggest that informants grew to like the ring because it felt securely placed, was unnoticeable during daily activities, and felt "normal" during sex. The ring appeared to be highly acceptable for women and men. Initial concerns with this novel method suggest a need for enhanced product counseling when VRs are introduced.

LMNA rs4641 and the muscle lamin A and C isoforms in twins--metabolic implications and transcriptional regulation

CONTEXT

Lamins are essential for nuclear shape and function. Polymorphisms in LMNA may associate with fat and muscle development and aging.

OBJECTIVE

Our aim was to determine the influence of LMNA rs4641 on lean body mass (LBM) and fat mass (FM), in vivo metabolism, and expression of LMNA transcripts in human skeletal muscle.

DESIGN

We genotyped LMNA rs4641 in 196 Danish twins who were extensively phenotypically characterized. We measured mRNA levels of LMNA transcripts, lamin A and C, in basal and insulin-stimulated skeletal muscle biopsies.

RESULTS

The rs4641 T-allele was associated with increased weight and body mass index (P=0.02), including increased FM (P=0.03) and LBM (P=0.004). Impact of rs4641 on FM was seen primarily among elderly twins. The T-allele was associated with elevated fasting plasma insulin levels (P=0.01) and homeostasis model of insulin resistance (P=0.02) in young twins. T-allele carriers did not exhibit consistent changes of first phase insulin secretion, nor did they exhibit significant peripheral or hepatic insulin resistance, and rs4641 did not influence muscle lamin A or C mRNA levels. The lamin A-to-C mRNA ratio was increased with acute insulin stimulation (P<0.0005), and the lamin A and C mRNA levels were diminished in young compared to elderly twins (P<0.001).

CONCLUSIONS

The LMNA rs4641 T-allele is associated with increased LBM and FM with more fat relative to muscle in elderly twins, which may impact risk of type 2 diabetes. Increased mRNA levels of lamins with age may counteract muscle wasting, and influence of insulin on lamin A-to-C ratio suggests a role in cytoskeletal muscle protein regulation.

A variant in the G6PC2/ABCB11 locus is associated with increased fasting plasma glucose, increased basal hepatic glucose production and increased insulin release after oral and intravenous glucose loads

AIMS/HYPOTHESIS

An association between elevated fasting plasma glucose and the common rs560887 G allele in the G6PC2/ABCB11 locus has been reported. In Danes we aimed to examine rs560887 in relation to plasma glucose and serum insulin responses following oral and i.v. glucose loads and in relation to hepatic glucose production during a hyperinsulinaemic-euglycaemic clamp. Furthermore, we examined rs560887 for association with impaired fasting glycaemia (IFG), impaired glucose tolerance (IGT), type 2 diabetes and components of the metabolic syndrome.

METHODS

rs560887 was genotyped in the Inter99 cohort (n = 5,899), in 366 young, healthy Danes, in non-diabetic relatives of type 2 diabetic patients (n = 196), and in young and elderly twins (n = 159). Participants underwent an OGTT, an IVGTT or a 2 h hyperinsulinaemic-euglycaemic clamp.

RESULTS

The rs560887 G allele associated with elevated fasting plasma glucose (p = 2 x 10(-14)) but not with plasma glucose levels at 30 min (p = 0.9) or 120 min (p = 0.9) during an OGTT. G allele carriers had elevated levels of serum insulin at 30 min during an OGTT (p = 1 x 10(-4)) and relatives of type 2 diabetes patients carrying the G allele had an increased acute insulin response (p = 4 x 10(-4)) during an IVGTT. Among elderly twins, G allele carriers had higher basal hepatic glucose production (p = 0.04). Finally, the G allele associated with the risk of having IFG (OR 1.26, 95% CI 1.08-1.47, p = 0.002), but not with IGT (OR 0.94, 95% CI 0.82-1.08, p = 0.4) or type 2 diabetes (OR 0.93, 95% CI 0.84-1.04, p = 0.2).

CONCLUSIONS/INTERPRETATION

The common rs560887 G allele in the G6PC2/ABCB11 locus is associated with increased fasting glycaemia and increased risk of IFG, associations that may be partly related to an increased basal hepatic glucose production rate.

The T allele of rs7903146 TCF7L2 is associated with impaired insulinotropic action of incretin hormones, reduced 24 h profiles of plasma insulin and glucagon, and increased hepatic glucose production in young healthy men

AIMS/HYPOTHESIS

We studied the physiological, metabolic and hormonal mechanisms underlying the elevated risk of type 2 diabetes in carriers of TCF7L2 gene.

METHODS

We undertook genotyping of 81 healthy young Danish men for rs7903146 of TCF7L2 and carried out various beta cell tests including: 24 h glucose, insulin and glucagon profiles; OGTT; mixed meal test; IVGTT; hyperglycaemic clamp with co-infusion of glucagon-like peptide (GLP)-1 or glucose-dependent insulinotropic polypeptide (GIP); and a euglycaemic-hyperinsulinaemic clamp combined with glucose tracer infusion to study hepatic and peripheral insulin action.

RESULTS

Carriers of the T allele were characterised by reduced 24 h insulin concentrations (p < 0.05) and reduced insulin secretion relative to glucose during a mixed meal test (beta index: p < 0.003), but not during an IVGTT. This was further supported by reduced late-phase insulinotropic action of GLP-1 (p = 0.03) and GIP (p = 0.07) during a 7 mmol/l hyperglycaemic clamp. Secretion of GLP-1 and GIP during the mixed meal test was normal. Despite elevated hepatic glucose production, carriers of the T allele had significantly reduced 24 h glucagon concentrations (p < 0.02) suggesting altered alpha cell function.

CONCLUSIONS/INTERPRETATION

Elevated hepatic glucose production and reduced insulinotropic effect of incretin hormones contribute to an increased risk of type 2 diabetes in carriers of the rs7903146 risk T allele of TCF7L2.

Healthwise South Africa: cultural adaptation of a school-based risk prevention programme

There is a need for effective prevention programmes aimed at reducing risk behaviour among South African adolescents. HealthWise South Africa is a school-based programme designed to reduce sexual and substance use risk behaviour, and promote positive use of leisure time among high-school learners (students). Based on successful programmes in the United States of America, HealthWise was developed for use in South Africa and pilot tested in four South African high schools. We carried out a process evaluation to establish the fidelity of implementation and make sure HealthWise was culturally relevant. Data sources comprised focus groups with educators and learners, lesson evaluations and observations, and interviews with school principals. Qualitative analysis of data highlighted pertinent cultural and contextual factors and identified areas for modifying HealthWise in order to promote better programme-consumer fit. These areas centred on time, language, and leisure. We noted a dynamic tension between the educators' desire to adhere to plan, and to make adaptations in accordance with learners' needs and the context. Ultimately, researchers need to find a balance between fidelity of implementation and programme adaptation to obtain effective programmes that are culturally acceptable to local consumers.

Polymorphisms in AHI1 are not associated with type 2 diabetes or related phenotypes in Danes: non-replication of a genome-wide association result

AIMS/HYPOTHESIS

A genome-wide association study recently identified an association between common variants, rs1535435 and rs9494266, in the AHI1 gene and type 2 diabetes. The aim of the present study was to investigate the putative association between these polymorphisms and type 2 diabetes or type 2 diabetes-related metabolic traits in Danish individuals.

METHODS

The previously associated polymorphisms were genotyped in the population-based Inter99 cohort (n=6162), the Danish ADDITION study (n=8428), a population-based sample of young healthy participants (n=377) and in additional type 2 diabetes (n=2107) and glucose-tolerant participants (n=483) using Taqman allelic discrimination. The case-control study involved 4,104 type 2 diabetic patients and 5,050 glucose-tolerant control participants. Type 2 diabetes-related traits were investigated in 17,521 individuals.

RESULTS

rs1535435 and rs9494266 were not associated with type 2 diabetes. Odds ratios (OR) were OR(add) 1.0 (95% C.I. 0.9-1.2; p(add)=0.7) and OR(add) 1.1 (0.9-1.2; p(add)=0.4), respectively, a finding supported by meta-analyses: OR(add) 1.0 (0.9-1.1; p(add)=0.6) and OR(add) 1.0 (0.9-1.1; p(add)=0.6), respectively. Neither rs1535435 nor rs9494266 were consistently associated with any of the tested type 2 diabetes-related metabolic traits.

CONCLUSIONS/INTERPRETATION

Data from large samples of Danish individuals do not support a role for AHI1 rs1535435 nor rs9494266 as major type 2 diabetes variants. This study highlights the importance of independent and well-powered replication studies of the recent genome-wide association scans before a locus is robustly validated as being associated with type 2 diabetes.

Impact of the peroxisome proliferator activated receptor-gamma coactivator-1beta (PGC-1beta) Ala203Pro polymorphism on in vivo metabolism, PGC-1beta expression and fibre type composition in human skeletal muscle

AIMS/HYPOTHESIS

Peroxisome proliferator activated receptor-gamma coactivator-1beta (PGC-1beta, also known as PPARGC1B) expression is reduced in skeletal muscle from patients with type 2 diabetes mellitus and in elderly subjects. Ala203Pro, a common variant in the PGC-1beta gene is associated with obesity. The aim of this study was to investigate whether the PGC-1beta Ala203Pro polymorphism influences the age-related decline in skeletal muscle PGC-1beta expression, in vivo metabolism and markers for muscle fibre type composition.

MATERIALS AND METHODS

The PGC-1beta Ala203Pro polymorphism was genotyped in 110 young (age 28.0 +/- 1.9 years) and 86 elderly (age 62.4 +/- 2.0 years) twins and related to muscle PGC-1beta expression, in vivo metabolism and markers for fibre type composition.

RESULTS

Insulin-stimulated non-oxidative glucose metabolism (NOGM; p = 0.025) and glycolytic flux rate (GF; p = 0.026) were reduced in young Ala/Ala carriers compared with carriers of a 203Pro allele. In addition, a regression analysis, correcting for covariates, showed that the PGC-1beta 203Pro allele was positively related to insulin-stimulated NOGM and GF in the young twins. While muscle expression of PGC-1beta was reduced in elderly compared with young carriers of the Ala/Ala genotype (p < or = 0.001), there was no significant age-related decline in PGC-1beta expression in carriers of the 203Pro allele (p > or = 0.4). However, a regression analysis, correcting for covariates, showed that only age was significantly related to muscle PGC-1beta expression. Finally, PGC-1beta expression correlated positively with markers for oxidative fibres in human muscle.

CONCLUSIONS/INTERPRETATION

This study suggests that young carriers of a PGC-1beta 203Pro allele have enhanced insulin-stimulated glucose metabolism and may be protected against an age-related decline in PGC-1beta expression in muscle.

Large-scale study of the -232C > G polymorphism of PCK1 in Type 2 diabetes

AIMS

Phosphoenolpyruvate carboxykinase (PEPCK) is a catalyst of the rate-limiting step in the gluconeogenic pathway and is regulated at the transcriptional level predominantly by insulin, glucocorticoids, glucagon, and cAMP. The -232C > G polymorphism in the gene encoding PEPCK (PCK1) is reported to associate with Type 2 diabetes in Canadian Caucasians and Oji-Cree populations. We have estimated the impact of the PCK1-232C > G polymorphism in a relatively large-scale case-control study of Type 2 diabetes and in association studies of common metabolic phenotypes. Interaction studies of the PCK1-232C > G polymorphism with variants in the genes encoding peroxisome proliferator-activated receptor-gamma co-activator (PGC)-1alpha and hepatic nuclear factor (HNF)-4alpha were also performed.

METHODS

PCK1-232C > G was genotyped in a total of 7467 Danish white subjects using TaqMan allelic discrimination. A case-control study of Type 2 diabetes was performed using 6057 of the participants, and quantitative trait studies of metabolic variables were carried out in a subgroup of 5718 non-diabetic subjects. Additionally, variants in PGC-1alpha (Gly482Ser) and HNF-4alpha (Thr130Ile, Val255Met, and rs1884614) were investigated for epistatic interaction with the PCK1-232C > G polymorphism.

RESULTS

In the case-control study of Type 2 diabetes of 1377 Type 2 diabetic patients and 4680 normoglycaemic and normal glucose-tolerant subjects we found no association of the PCK1-232C > G polymorphism with diabetes. In addition, the variant was not associated with age of clinical onset of Type 2 diabetes. In the study of 5718 non-diabetic subjects, we found no relationships of quantitative metabolic traits with the PCK1-232C > G polymorphism. We failed to demonstrate any convincing epistatic effects of the variants in the genes encoding PGC-1alpha and HNF-4alpha with the PCK1-232C > G polymorphism.

CONCLUSIONS

The PCK1-232C > G polymorphism is not a major contributor to the pathogenesis of Type 2 diabetes in the Danish population.

Evidence of an association between genetic variation of the coactivator PGC-1beta and obesity

BACKGROUND

Peroxisome proliferator activated receptor-gamma coactivator-1beta (PGC-1beta) is a recently identified homologue of the tissue specific coactivator PGC-1alpha, a coactivator of transcription factors such as the peroxisome proliferators activated receptors and nuclear respiratory factors. PGC-1alpha is involved in adipogenesis, mitochondrial biogenesis, fatty acid beta oxidation, and hepatic gluconeogenesis.

METHODS

We studied variation in the coding region of human PPARGC1B in Danish whites and related these variations to the prevalence of obesity and type 2 diabetes in population based samples.

RESULTS

Twenty nucleotide variants were identified. In a study of 525 glucose tolerant subjects, the Ala203Pro and Val279Ile variants were in almost complete linkage disequilibrium (R2 = 0.958). In a case-control study of obesity involving a total of 7790 subjects, the 203Pro allele was significantly less frequent among obese participants (p = 0.004; minor allele frequencies: normal weight subjects 8.1% (95% confidence interval: 7.5 to 8.8), overweight subjects 7.6% (7.0 to 8.3), obese subjects 6.5% (5.6 to 7.3)). In a case-control study involving 1433 patients with type 2 diabetes and 4935 glucose tolerant control subjects, none of the examined variants were associated with type 2 diabetes.

CONCLUSIONS

Variation of PGC-1beta may contribute to the pathogenesis of obesity, with a widespread Ala203 allele being a risk factor for the development of this common disorder.

[Pharmacokinetic studies after oral application of radioactively labelled D-penicillamine]

14C-labelled D-penicillamine was given orally to healthy test subjects in different dosages. The time course of serum activity was followed up to 5 weeks and the urinary activity was measured for 4 days. The obtained results equalled the sum of active substance and its 14C-labelled biotransformation products. The maximal serum concentration appeared about 2 hours after ingestion, the obtained concentrations being proportional to the dosis. Thereafter the concentration declined first relatively fast, then increasingly slower. From the 4th day after ingestion the half time of elimination was 8 days. The urinary excretion was dose dependent; the urinary concentration increasing with higher dosage. The later long half time of elimination corresponded to disappearance from the blood of the portion of the drug firmly getting attached to collagen and elastic tissue structures. The several weeks latency of onset of antirheumatic effect may be due to the fact that the portion of the drug getting attached to connective tissue accumulates slowly.