Trained Volunteers With Type 2 Diabetes Experience Significant Health Benefits When Providing Peer Support

Trained lay volunteers may have value in supporting lifestyle change programs in the prevention of type 2 diabetes, but the potential health benefits (or harms) experienced by these lay volunteers have not been well described. This is important, as this is an appealing model in terms of workforce planning. The aim of the prespecified quantitative study reported here, was to examine the possible health benefits or harms experienced by these trained lay volunteers with type 2 diabetes. In a large type 2 diabetes prevention program, we recruited and trained 104 lay volunteers with type 2 diabetes themselves, to act as diabetes prevention mentors and codeliver the lifestyle intervention. Mentors made motivational telephone calls to 461 participants randomized to one of the trial arms to encourage lifestyle changes. Weight, diet, physical activity, well-being, quality of life, diabetes-specific self-efficacy, and glycaemic control were measured at baseline, 12 and 24 months. Average mentor age was 62.0 years, 57 (54.8%) were male, 92 (88.5%) were overweight or obese (BMI>30 kg/m²). At 12 months, mentor dietary behaviors (fat and fiber intake) improved significantly, sedentary time spent fell significantly, and diabetes specific self-efficacy scores significantly increased. These significant improvements, with no evidence of harms, suggest lay volunteers with type 2 diabetes codelivering a lifestyle intervention, may themselves experience health benefits from volunteering.

COVID-19 wastewater based epidemiology: long-term monitoring of 10 WWTP in France reveals the importance of the sampling context

SARS-CoV-2 wastewater-based epidemiology (WBE) has been advanced as a relevant indicator of distribution of COVID-19 in communities, supporting classical testing and tracing epidemiological approaches. An extensive sampling campaign, including ten municipal wastewater treatment plants, has been conducted in different cities of France over a 20-week period, encompassing the second peak of COVID-19 outbreak in France. A well-recognised ultrafiltration - RNA extraction - RT-qPCR protocol was used and qualified, showing 5.5 +/- 0.5% recovery yield on heat-inactivated SARS-CoV-2. Importantly the whole, solid and liquid, fraction of wastewater was used for virus concentration in this study. Campaign results showed medium- to strong- correlation between SARS-CoV-2 WBE data and COVID-19 prevalence. To go further, statistical relationships between WWTP inlet flow rate and rainfall were studied and taken into account for each WWTP in order to calculate contextualized SARS-CoV-2 loads. This metric presented improved correlation strengths with COVID-19 prevalence for WWTP particularly submitted and sensitive to rain. Such findings highlighted that SARS-CoV-2 WBE data ultimately require to be contextualized for relevant interpretation.

PP37 Use of capillary blood ketone meters to improve ambulance service care of hyperglycaemic patients: protocol for a stepped-wedge, controlled feasibility study (KARMA2)

Background

Diabetic ketoacidosis (DKA) is a potentially life-threatening condition associated with diabetes (Type 1 and Type 2), certain medications (i.e. SGLT2 inhibitors), and other health conditions. Hospital-based guidelines advocate immediate start of intravenous fluid therapy upon DKA diagnosis, which does not reliably happen in the pre-hospital setting. Ambulance clinicians do not routinely have access to ketone meters to determine presence of ketones; they rely on non-specific clinical signs and symptoms for care strategies. The aims of this feasibility study are to determine whether ambulance clinicians can reliably and safely identify patients with DKA using capillary blood ketone meters, commence fluid therapy, and gather necessary study data.

Methods

During an 8-month period (4-month control: 4-month intervention), 120 ambulance clinicians from one UK ambulance service will receive training to determine presence of ketones using capillary blood testing from 800 consenting patients with hyperglycaemia and unwell patients with diabetes. Subsequent patient care will depend on the ketone value obtained: high-risk DKA patients will receive fluid therapy. Twenty ambulance and hospital clinicians will be invited to an interview to share their views of DKA care and the impact of capillary blood ketone meters.

Results

Information collated will include completion of study training, patient recruitment, intervention adherence, service call activity, and ambulance and hospital patient clinical data. Prevalence and severity of hyperglycaemia, incidence of DKA and ability of paramedics to commence fluid therapy for DKA will be explored. Quantitative findings will be analysed using descriptive statistics, whilst the qualitative study interviews will be thematically analysed.

Conclusions

Study findings will be used to inform the need and feasibility to proceed to a full stepped-wedge, controlled trial. If warranted, we will develop a research funding proposal evaluating the clinical and cost-effectiveness of ambulance ketone meters and further explore meter provision for improved ambulance patient care.

The Rowan Hillson Inpatient Safety Award 2019 for the best perioperative pathway for people with diabetes

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of insulin errors in patients admitted to hospital with diabetes. New initiatives are urgently required to mitigate this risk.Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the sixth national Rowan Hillson Inpatient Safety Award on the theme of the best perioperative pathway for people with diabetes.Result: The winner was the team from Aneurin Bevan University Health Board led by Dr David Burckett-St Laurent for their innovative re-design of the perioperative pathway by a cross-specialty working group. The main elements of the new system were standardised patient assessment, optimisation of perioperative diabetes control, personalised diabetes management plans generated from a drop-down menu with information on usual drug treatment, pre-op/day of surgery diabetes medication modification, advice on hypoglycaemia management and sick-day rules, anaesthetic review for people with HbA1c >69 mmol/mol, secondary care diabetes review for people with suboptimal diabetes control, new inpatient charts with guidance on diabetes drug management, streamlining of time and place of admission and greater engagement and education of people with diabetes and staff looking after them. This resulted in significant improvement in outcomes and reduction in risks.The Newcastle upon Tyne NHS Foundation Trust team led by Dr Nicola Leech and colleagues received the runners-up award for their 3-year quality improvement project involving multiple specialties. The project included development of trust-wide policies and protocols, educational initiatives, targeted diabetes specialist nurse in-reach, innovative electronic whiteboard alerts for glycaemic control and electronic hypo alerts. The result was a reduction in insulin errors and hypoglycaemia on surgical wards by over 50%, a reduction in Datix incidents and fewer patients suffering harm events.Summary and conclusion: These and similar schemes need to be developed, promoted and shared to reduce insulin errors in hospitalised patients with diabetes.

The Rowan Hillson Inpatient Safety Award 2018 for the best inpatient diabetes educational programme for healthcare professionals

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of insulin errors in patients admitted to hospital with diabetes. It is clear that new initiatives are urgently required to mitigate this risk.Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the fifth national Rowan Hillson Inpatient Safety Award on the theme of the best inpatient diabetes educational initiative to improve patient safety in hospitals.Result: The winner was Kath Higgins and the team from the University Hospitals of Leicester NHS Trust for their ITS Diabetes – Inpatient Diabetes Training & Support programme – an educational toolkit accessible to medical, nursing and pharmacy staff. Components included face-to-face training, e-learning module, monthly newsletter social media communications with competency document and flashcards. The initiative reduced insulin errors and in-hospital diabetic ketoacidosis. There were two teams in second position. Michael Lloyd and colleagues from St Helens and Knowsley Teaching Hospitals NHS Trust received the award for their individualised and shared insulin prescribing error feedback system, Safe Insulin TipS (SIPS), and multi-professional simulation-based training. Ruth Miller and colleagues in North West London were commended for the project to implement Diabetes 10 Point Training in Acute Hospitals across North West London. This clinically-based teaching programme provided quick training specifically designed for all hospital settings to address the commonest diabetes errors.Conclusion: These and similar schemes need to be developed, promoted and shared to reduce insulin errors in hospitalised patients with diabetes.

Efficacy and safety of disinfectants for decontamination of N95 and SN95 filtering facepiece respirators: a systematic review

BACKGROUND

Decontaminating and reusing filtering facepiece respirators (FFRs) for healthcare workers is a potential solution to address inadequate FFR supply during a global pandemic.

AIM

The objective of this review was to synthesize existing data on the effectiveness and safety of using chemical disinfectants to decontaminate N95 FFRs.

METHODS

A systematic review was conducted on disinfectants to decontaminate N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined study eligibility and extracted predefined data fields. Original research reporting on N95 FFR function, decontamination, safety, or FFR fit following decontamination with a disinfectant was included.

FINDINGS AND CONCLUSION

A single cycle of vaporized hydrogen peroxide (H₂O₂) successfully removes viral pathogens without affecting airflow resistance or fit, and maintains an initial filter penetration of <5%, with little change in FFR appearance. Residual hydrogen peroxide levels following decontamination were within safe limits. More than one decontamination cycle of vaporized H₂O₂ may be possible but further information is required on how multiple cycles would affect FFR fit in a real-world setting before the upper limit can be established. Although immersion in liquid H₂O₂ does not appear to adversely affect FFR function, there is no available data on its ability to remove infectious pathogens from FFRs or its impact on FFR fit. Sodium hypochlorite, ethanol, isopropyl alcohol, and ethylene oxide are not recommended due to safety concerns or negative effects on FFR function.

Decontamination interventions for the reuse of surgical mask personal protective equipment: a systematic review

BACKGROUND

The high demand for personal protective equipment during the novel coronavirus outbreak has prompted the need to develop strategies to conserve supply. Little is known regarding decontamination interventions to allow for surgical mask reuse.

AIM

To identify and synthesize data from original research evaluating interventions to decontaminate surgical masks for the purpose of reuse.

METHODS

MEDLINE, Embase, CENTRAL, Global Health, the WHO COVID-19 database, Google Scholar, DisasterLit, preprint servers, and prominent journals from inception to April 8^th, 2020, were searched for prospective original research on decontamination interventions for surgical masks. Citation screening was conducted independently in duplicate. Study characteristics, interventions, and outcomes were extracted from included studies by two independent reviewers. Outcomes of interest included impact of decontamination interventions on surgical mask performance and germicidal effects.

FINDINGS

Seven studies met eligibility criteria: one evaluated the effects of heat and chemical interventions applied after mask use on mask performance, and six evaluated interventions applied prior to mask use to enhance antimicrobial properties and/or mask performance. Mask performance and germicidal effects were evaluated with heterogeneous test conditions. Safety outcomes were infrequently evaluated. Mask performance was best preserved with dry heat decontamination. Good germicidal effects were observed in salt-, N-halamine-, and nanoparticle-coated masks.

CONCLUSION

There is limited evidence on the safety or efficacy of surgical mask decontamination. Given the heterogeneous methods used in studies to date, we are unable to draw conclusions on the most efficacious and safe intervention for decontaminating surgical masks.

Decontamination interventions for the reuse of surgical mask personal protective equipment: a systematic review

BACKGROUND

The high demand for personal protective equipment during the novel coronavirus outbreak has prompted the need to develop strategies to conserve supply. Little is known regarding decontamination interventions to allow for surgical mask reuse.

AIM

To identify and synthesize data from original research evaluating interventions to decontaminate surgical masks for the purpose of reuse.

METHODS

MEDLINE, Embase, CENTRAL, Global Health, the WHO COVID-19 database, Google Scholar, DisasterLit, preprint servers, and prominent journals from inception to April 8^th, 2020, were searched for prospective original research on decontamination interventions for surgical masks. Citation screening was conducted independently in duplicate. Study characteristics, interventions, and outcomes were extracted from included studies by two independent reviewers. Outcomes of interest included impact of decontamination interventions on surgical mask performance and germicidal effects.

FINDINGS

Seven studies met eligibility criteria: one evaluated the effects of heat and chemical interventions applied after mask use on mask performance, and six evaluated interventions applied prior to mask use to enhance antimicrobial properties and/or mask performance. Mask performance and germicidal effects were evaluated with heterogeneous test conditions. Safety outcomes were infrequently evaluated. Mask performance was best preserved with dry heat decontamination. Good germicidal effects were observed in salt-, N-halamine-, and nanoparticle-coated masks.

CONCLUSION

There is limited evidence on the safety or efficacy of surgical mask decontamination. Given the heterogeneous methods used in studies to date, we are unable to draw conclusions on the most efficacious and safe intervention for decontaminating surgical masks.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H₂O (7.97-11.70 mm H₂O) vs 9.85 mm H₂O (8.33-11.44 mm H₂O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m² resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m². Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m²) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m² or greater, and confirm appropriate mask fit following decontamination.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H₂O (7.97-11.70 mm H₂O) vs 9.85 mm H₂O (8.33-11.44 mm H₂O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m² resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m². Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m²) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m² or greater, and confirm appropriate mask fit following decontamination.

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review

There is ongoing controversy regarding the borderline personality disorder (BPD) diagnosis. Whilst the experiences of people living with BPD have been widely acknowledged, the process of receiving the diagnosis is poorly described. This systematic review aimed to synthesize the existing research exploring people's experiences of receiving a diagnosis of BPD, as well as examining what is considered best practice in the diagnostic delivery process. The findings from 12 qualitative studies were synthesized using thematic analysis, generating two overarching themes: negative and positive experiences of receiving a diagnosis of BPD. These themes were described using the following sub-themes: the communication of diagnosis and meaning made of it, validity around diagnosis and attitudes of others. Results indicate that there is a substantial difference between a well-delivered and poorly delivered diagnosis. The diagnostic delivery process is fundamental to how people understand and interpret the BPD diagnosis. The way in which the BPD diagnosis is shared with people can ultimately shape their views about hope for recovery and their subsequent engagement with services. © 2020 John Wiley & Sons, Ltd.

Determinants of diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes using paired glycated haemoglobin measurements in a large English primary care population: cross-sectional study

AIM

To investigate factors influencing diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes.

METHODS

Some 10 000 adults at increased risk of diabetes were screened with HbA_1c and fasting plasma glucose (FPG). The 2208 participants with initial HbA_1c ≥ 42 mmol/mol (≥ 6.0%) or FPG ≥ 6.1 mmol/l were retested after a median 40 days. We compared the first and second HbA_1c results, and consequent diagnoses of non-diabetic hyperglycaemia and Type 2 diabetes, and investigated predictors of discordant diagnoses.

RESULTS

Of 1463 participants with non-diabetic hyperglycaemia and 394 with Type 2 diabetes on first testing, 28.4% and 21.1% respectively had discordant diagnoses on repeated testing. Initial diagnosis of non-diabetic hyperglycaemia and/or impaired fasting glucose according to both HbA_1c and FPG criteria, or to FPG only, made reclassification as Type 2 diabetes more likely than initial classification according to HbA_1c alone. Initial diagnosis of Type 2 diabetes according to both HbA_1c and FPG criteria made reclassification much less likely than initial classification according to HbA_1c alone. Age, and anthropometric and biological measurements independently but inconsistently predicted discordant diagnoses and changes in HbA_1c .

CONCLUSIONS

Diagnosis of non-diabetic hyperglycaemia or Type 2 diabetes with a single measurement of HbA_1c in a screening programme for entry to diabetes prevention trials is unreliable. Diagnosis of non-diabetic hyperglycaemia and Type 2 diabetes should be confirmed by repeat testing. FPG results could help prioritise retesting. These findings do not apply to people classified as normal on a single test, who were not retested.

The best joint pharmacy and diabetes team initiative to improve insulin and prescribing safety in hospital

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of insulin errors in patients admitted to hospital with diabetes. It is clear that new initiatives are urgently required to address this risk.Methods: The Joint British Diabetes Societies for In-Patient Care (JBDS-IP) organised the third national Rowan Hillson Insulin Safety Award on the theme of the best joint pharmacy and diabetes team initiative to improve insulin and prescribing safety in hospital.Results: There were two winners (Derby and Sheffield teams) and one runner up (St George’s Hospital team). The Derby team won by showing improvements in NaDIA-reported data on medication, prescription, glucose management and insulin errors by a combination of electronic prescribing, staff education and regular audits. The Sheffield team improved self-administration of insulin by a pharmacist-led programme. The St George’s Hospital team improved patient safety by a dedicated pharmacist-supported programme for peri-operative patients.Conclusions: These and similar schemes need to be developed, promoted and shared to reduce insulin errors in hospitalised patients with diabetes.

The Rowan Hillson Inpatient Diabetes Safety Award 2017 for the best digital initiative

Introduction: The annual National Diabetes Inpatient Audit (NaDIA) in the UK continues to show a high incidence of errors in patients admitted to hospital with diabetes. It is clear that new initiatives are urgently required to address this risk.Methods: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the fourth national Rowan Hillson Insulin Safety Award on the theme of the best digital initiative to improve insulin and prescribing safety in hospital.Results: The winner was Western General Hospital team (Edinburgh). The team created diabetes dashboards which helped collect high quality accurate data on capillary blood glucose from patients admitted to the hospital and deliver specific and concise messages to various wards. The team from King’s College Hospital secured runner-up prize for their initiative which enabled reduction in hypoglycaemia during treatment of hyperkalaemia by adding a personalised dose of dextrose to insulin infusion.Conclusions: These and similar innovations need to be developed, promoted and shared to improve patient safety in hospitalised patients with diabetes.

Young people's experiences of managing Type 1 diabetes at university: a national study of UK university students

AIM

Little is known about the challenges of transitioning from school to university for young people with Type 1 diabetes. In a national survey, we investigated the impact of entering and attending university on diabetes self-care in students with Type 1 diabetes in all UK universities.

METHODS

Some 1865 current UK university students aged 18-24 years with Type 1 diabetes, were invited to complete a structured questionnaire. The association between demographic variables and diabetes variables was assessed using logistic regression models.

RESULTS

In total, 584 (31%) students from 64 hospitals and 37 university medical practices completed the questionnaire. Some 62% had maintained routine diabetes care with their home team, whereas 32% moved to the university provider. Since starting university, 63% reported harder diabetes management and 44% reported higher HbA_1c levels than before university. At university, 52% had frequent hypoglycaemia, 9.6% reported one or more episodes of severe hypoglycaemia and 26% experienced diabetes-related hospital admissions. Female students and those who changed healthcare provider were approximately twice as likely to report poor glycaemic control, emergency hospital admissions and frequent hypoglycaemia. Females were more likely than males to report stress [odds ratio (OR) 4.78, 95% confidence interval (CI) 3.19-7.16], illness (OR 3.48, 95% CI 2.06-5.87) and weight management issues (OR 3.19, 95% CI 1.99-5.11) as barriers to self-care. Despite these difficulties, 91% of respondents never or rarely contacted university support services about their diabetes.

CONCLUSION

The study quantifies the high level of risk experienced by students with Type 1 diabetes during the transition to university, in particular, female students and those moving to a new university healthcare provider.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes

Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7 mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30 min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1 h after meals for up to 24 h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth.

Metformin in non-diabetic hyperglycaemia: the GLINT feasibility RCT

BACKGROUND

The treatment of people with diabetes with metformin can reduce cardiovascular disease (CVD) and may reduce the risk of cancer. However, it is unknown whether or not metformin can reduce the risk of these outcomes in people with elevated blood glucose levels below the threshold for diabetes [i.e. non-diabetic hyperglycaemia (NDH)].

OBJECTIVE

To assess the feasibility of the Glucose Lowering In Non-diabetic hyperglycaemia Trial (GLINT) and to estimate the key parameters to inform the design of the full trial. These parameters include the recruitment strategy, randomisation, electronic data capture, postal drug distribution, retention, study medication adherence, safety monitoring and remote collection of outcome data.

DESIGN

A multicentre, individually randomised, double-blind, parallel-group, pragmatic, primary prevention trial. Participants were individually randomised on a 1 : 1 basis, blocked within each site.

SETTING

General practices and clinical research facilities in Cambridgeshire, Norfolk and Leicestershire.

PARTICIPANTS

Males and females aged ≥ 40 years with NDH who had a high risk of CVD.

INTERVENTIONS

Prolonged-release metformin (500 mg) (Glucophage® SR, Merck KGaA, Bedfont Cross, Middlesex, UK) or the matched placebo, up to three tablets per day, distributed by post.

MAIN OUTCOME MEASURES

Recruitment rates; adherence to study medication; laboratory results at baseline and 3 and 6 months; reliability and acceptability of study drug delivery; questionnaire return rates; and quality of life.

RESULTS

We sent 5251 invitations, with 511 individuals consenting to participate. Of these, 249 were eligible and were randomised between March and November 2015 (125 to the metformin group and 124 to the placebo group). Participants were followed up for 0.99 years [standard deviation (SD) 0.30 years]. The use of electronic medical records to identify potentially eligible individuals in individual practices was resource intensive. Participants were generally elderly [mean age 70 years (SD 6.7 years)], overweight [mean body mass index 30.1 kg/m2 (SD 4.5 kg/m2)] and male (88%), and the mean modelled 10-year CVD risk was 28.8% (SD 8.5%). Randomisation, postal delivery of the study drug and outcome assessment using registers/medical records were feasible and acceptable to participants. Most participants were able to take three tablets per day, but premature discontinuation of the study drug was common (≈30% of participants by 6 months), although there were no differences between the groups. All randomised participants returned questionnaires at baseline and 67% of participants returned questionnaires by the end of the study. There was no between-group difference in Short Form questionnaire-8 items or EuroQol-5 Dimensions scores. Compared with placebo, metformin was associated with small improvements in the mean glycated haemoglobin level [-0.82 mmol/mol, 95% confidence interval (CI) -1.39 to -0.24 mmol/mol], mean estimated glomerular filtration rate (2.31 ml/minute/1.73 m2, 95% CI -0.2 to 4.81 ml/minute/1.73 m2) and mean low-density lipoprotein cholesterol level (-0.11 mmol/l, 95% CI -0.25 to 0.02 mmol/l) and a reduction in mean plasma vitamin B12 level (-16.4 ng/l, 95% CI -32.9 to -0.01 ng/l). There were 35 serious adverse events (13 in the placebo group, 22 in the metformin group), with none deemed to be treatment related.

LIMITATIONS

Changes to sponsorship reduced the study duration, the limited availability of information in medical records reduced recruitment efficiency and discontinuation of study medication exceeded forecasts.

CONCLUSIONS

A large, pragmatic trial comparing the effects of prolonged-release metformin and placebo on the risk of CVD events is potentially feasible. However, changes to the study design and conduct are recommended to enable an efficient scaling up of the trial. Recommendations include changing the inclusion criteria to recruit people with pre-existing CVD to increase the recruitment and event rates, using large primary/secondary care databases to increase recruitment rates, conducting follow-up remotely to improve efficiency and including a run-in period prior to randomisation to optimise trial adherence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN34875079.

FUNDING

The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 18. See the NIHR Journals Library website for further project information. Merck KGaA provided metformin and matching placebo.

Study Protocol: The Norfolk Diabetes Prevention Study [NDPS]: a 46 month multi - centre, randomised, controlled parallel group trial of a lifestyle intervention [with or without additional support from lay lifestyle mentors with Type 2 diabetes] to prevent transition to Type 2 diabetes in high risk groups with non - diabetic hyperglycaemia, or impaired fasting glucose

Background

This 7 year NIHR programme [2011–2018] tests the primary hypothesis that the NDPS diet and physical activity intervention will reduce the risk of transition to type 2 diabetes (T2DM) in groups at high risk of Type 2 diabetes. The NDPS programme recognizes the need to reduce intervention costs through group delivery and the use of lay mentors with T2DM, the realities of normal primary care, and the complexity of the current glycaemic categorisation of T2DM risk.

Methods

NDPS identifies people at highest risk of T2DM on the databases of 135 general practices in the East of England for further screening with ab fasting plasma glucose and glycosylated haemoglobin [HbA1c]. Those with an elevated fasting plasma glucose [impaired fasting glucose or IFG] with or without an elevated HbA1c [non -diabetic hyperglycaemia; NDH] are randomised into three treatment arms: a control arm receiving no trial intervention, an arm receiving an intensive bespoke group-based diet and physical activity intervention, and an arm receiving the same intervention with enhanced support from people with T2DM trained as diabetes prevention mentors [DPM]. The primary end point is cumulative transition rates to T2DM between the two intervention groups, and between each intervention group and the control group at 46 months. Participants with screen detected T2DM are randomized into an equivalent prospective controlled trial with the same intervention and control arms with glycaemic control [HbA1c] at 46 months as the primary end point. Participants with NDH and a normal fasting plasma glucose are randomised into an equivalent prospective controlled intervention trial with follow up for 40 months. The intervention comprises six education sessions for the first 12 weeks and then up to 15 maintenance sessions until intervention end, all delivered in groups, with additional support from a DPM in one treatment arm.

Discussion

The NDPS programme reports in 2018 and will provide trial outcome data for a group delivered diabetes prevention intervention, supported by lay mentors with T2DM, with intervention in multiple at risk glycaemic categories, and that takes into account the realities of normal clinical practice.

Trial registration

ISRCTN34805606 (Retrospectively registered 16.3.16)

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3929-5) contains supplementary material, which is available to authorized users.

Are mental health services getting better at responding to abuse, assault and neglect?

OBJECTIVE

To determine whether staff responses to abuse disclosures had improved since the introduction of a trauma policy and training programme.

METHOD

The files of 250 clients attending four New Zealand mental health centres were audited.

RESULTS

There was a significant improvement, compared to an audit prior to the introduction of the policy and training, in the proportion of abuse cases included in formulations, and, to a lesser extent, in treatment plans. There was no significant improvement in the proportion referred for relevant treatment, which remained at less than 25% across abuse categories. The proportion of neglect disclosures responded to was significantly lower than for abuse cases. Fifty percent of the files in which abuse/neglect was recorded noted whether the client had been asked about previous disclosure, and 22% noted whether the client thought there was any connection between the abuse/neglect and their current problems. Less than 1% of cases were reported to legal authorities. People diagnosed with a psychotic disorder were significantly less likely to be responded to appropriately.

CONCLUSION

Future training may need to focus on responding well to neglect and people diagnosed with psychosis, on making treatment referrals, and on initiating discussions about reporting to authorities.

Lipoprotein Particles in Adolescents and Young Women With PCOS Provide Insights Into Their Cardiovascular Risk

CONTEXT

Adult women with polycystic ovarian syndrome (PCOS) have an increased risk for cardiovascular disease, but the evidence for this is controversial in adolescents and young women with PCOS. Measurement of low-density lipoprotein (LDL) particle number, measured by nuclear magnetic resonance spectroscopy is a novel technology to assess cardiovascular risk.

OBJECTIVE

The objective of the study was to evaluate lipoprotein particle number and size in young women with PCOS and its relationship with insulin resistance and hyperandrogenism.

DESIGN

This was a cross-sectional case control study.

SETTING

The study was conducted at a clinical research center.

PARTICIPANTS

Women with PCOS (n = 35) and normal controls (n = 20) participated in the study.

INTERVENTIONS

Blood samples and anthropometric measures were obtained.

MAIN OUTCOME MEASURES

LDL particle size and number were measured using nuclear magnetic resonance spectroscopy. A secondary outcome was to investigate the correlation of LDL particle number with high-sensitivity C-reactive protein, waist to hip ratio, hyperandrogenism, insulin resistance, and adiponectin.

RESULTS

Women with PCOS had higher LDL particle number when compared with healthy controls (935 ± 412 vs 735 ± 264, P = .032); LDL particle number correlated strongly with high-sensitivity C-reactive protein (r = 0.37, P = .006) and waist-to-hip (r = 0.57, P = .0003). The higher LDL particle number was driven mainly due to differences in the small LDL particle number (sLDLp), with PCOS patients having more sLDLp (348 ± 305 vs 178 ± 195, P = .015). The sLDLp correlated with the Matsuda index (r = -0.51, P = .0001), homeostasis model assessment index of insulin resistance (r = 0.41, P = .002), and adiponectin (r = -0.46, P = .0004) but not with T.

CONCLUSION

Adolescent and young women with PCOS have an atherogenic lipoprotein profile suggestive of increased cardiovascular risk that appears to be driven by the degree of visceral adiposity and insulin resistance.

Season's appreciations

To follow the tradition set by the late Franz Halberg, highlights of research performed over the last year from his Minnesota Center are summarized. They illustrate the broad international cooperation enjoyed by his center and the diversity of applications of the discipline he founded. The results briefly summarized herein in the form of an annotated bibliography are a testimony that his legacy continues to live on and constitutes a tribute to his memory.

A chiral HPLC-MS/MS method for simultaneous quantification of warfarin enantiomers and its major hydroxylation metabolites of CYP2C9 and CYP3A4 in human plasma

Warfarin is an oral anticoagulant that requires frequent therapeutic drug monitoring due to a narrow therapeutic window, considerable interindividual variability in drug response, and susceptibility to drug-drug and drug-diet interactions. Enantiomeric separation and quantification of warfarin enantiomers and clinically important major hydroxylation metabolites are essential for drug interaction studies and phenotypic characterization of CYP2C9 and CYP3A4, the major cytochrome P450 (CYP) enzymes involved in warfarin metabolism. Here, we describe the development and validation of a chiral high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS)-based quantification of R-warfarin, S-warfarin, S-7-hydroxywarfarin (the major CYP2C9 metabolite) and (9R;10S)-10-hydroxywarfarin (the CYP3A4 metabolite) in human plasma. Simple protein precipitation-based extraction showed good recovery of analytes (82.9 - 96.9%). The developed method exhibited satisfactory intra-day and inter-day accuracy and precision. The lower limits of detection were 0.25 nM (or ~0.08 ng/mL) for the warfarin enantiomers and 0.1 nM (or ~0.04 ng/mL) for S-7-hydroxywarfarin and (9R;10S)-10-hydroxywarfarin using only 50 µL plasma during extraction. The validated method was successfully applied to analyze plasma samples obtained from a healthy human subject who enrolled in a clinical drug interaction study involving warfarin.

Changes in cerebral glucose metabolism with normal aging

The pattern of changes in cerebral glucose metabolism occurring with normal aging has been unclear. Advances in imaging technology, such as improved resolution and anatomical referencing, allow for more precise regional measurement than previously possible. This study explored cerebral glucose metabolism in 17 normal controls ranging in age from 20 to 74 years. High resolution PET scanning, with MRI-based regions of interest correcting for partial volume and atrophy effects, revealed a linear association between advancing age and declining cerebral glucose metabolism. The decline averaged 8% per decade for the whole brain. Changes were most pronounced in limbic structures, and could be implicated in age-associated memory loss.

Vascular function and atherosclerosis progression after 1 y of flavonoid intake in statin-treated postmenopausal women with type 2 diabetes: a double-blind randomized controlled trial

BACKGROUND

In healthy participants, short-term flavan-3-ol and isoflavone intakes improve vascular function; however, the potential combined benefit of these compounds on atherosclerosis progression remains unclear for those at elevated risk of cardiovascular disease.

OBJECTIVE

The objective was to examine whether combined isoflavone and flavan-3-ol intake alters vascular function in postmenopausal women with type 2 diabetes mellitus (T2DM).

DESIGN

A double-blind, parallel-design, placebo-controlled 1-y trial was conducted in postmenopausal T2DM patients randomly assigned to a split dose of 27 g flavonoid-enriched chocolate/d [850 mg flavan-3-ols (90 mg epicatechin) + 100 mg isoflavones (aglycone equivalents)/d] or matched placebo. Intima-media thickness of the common carotid artery (CCA-IMT), pulse wave velocity (PWV), augmentation index, blood pressure (BP), and vascular biomarkers were assessed.

RESULTS

A total of 93 patients completed the trial. Overall, the flavonoid intervention did not significantly change CCA-IMT, augmentation index, or BP, but pulse pressure variability improved (flavonoid: -0.11 ± 0.07 mm Hg/min; placebo: 0.10 ± 0.11 mm Hg/min; P = 0.04). In a subgroup with PWV data, net improvements were observed [flavonoid (n = 18): -0.07 ± 0.38 m/s; placebo (n = 17): 0.68 ± 0.25 m/s; P = 0.01], which equated to a 10% CV risk reduction. Equol producers (n = 17) had larger reductions in diastolic BP, mean arterial pressure, and PWV (-2.24 ± 1.31 mm Hg, -1.24 ± 1.30 mm Hg, and -0.68 ± 0.40 m/s, respectively; P < 0.01) compared with non-equol producers (n = 30).

CONCLUSIONS

Although the 1-y intervention did not change CCA-IMT or BP, clinically relevant improvements in arterial stiffness were observed; equol producers were particularly responsive. Flavonoids may augment existing therapeutic strategies to reduce cardiovascular disease risk in postmenopausal T2DM patients, and longer studies are needed to examine the effects on atherosclerosis progression. This trial was registered at clinicaltrials.gov as NCT00677599.

Chronic ingestion of flavan-3-ols and isoflavones improves insulin sensitivity and lipoprotein status and attenuates estimated 10-year CVD risk in medicated postmenopausal women with type 2 diabetes: a 1-year, double-blind, randomized, controlled trial

OBJECTIVE

To assess the effect of dietary flavonoids on cardiovascular disease (CVD) risk in postmenopausal women with type 2 diabetes on established statin and hypoglycemic therapy.

RESEARCH DESIGN AND METHODS

Despite being medicated, patients with type 2 diabetes have elevated CVD risk, particularly postmenopausal women. Although dietary flavonoids have been shown to reduce CVD risk factors in healthy participants, no long-term trials have examined the additional benefits of flavonoids to CVD risk in medicated postmenopausal women with type 2 diabetes. We conducted a parallel-design, placebo-controlled trial with type 2 diabetic patients randomized to consume 27 g/day (split dose) flavonoid-enriched chocolate (containing 850 mg flavan-3-ols [90 mg epicatechin] and 100 mg isoflavones [aglycone equivalents)]/day) or matched placebo for 1 year.

RESULTS

Ninety-three patients completed the trial, and adherence was high (flavonoid 91.3%; placebo 91.6%). Compared with the placebo group, the combined flavonoid intervention resulted in a significant reduction in estimated peripheral insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR] -0.3 ± 0.2; P = 0.004) and improvement in insulin sensitivity (quantitative insulin sensitivity index [QUICKI] 0.003 ± 0.00; P = 0.04) as a result of a significant decrease in insulin levels (-0.8 ± 0.5 mU/L; P = 0.02). Significant reductions in total cholesterol:HDL-cholesterol (HDL-C) ratio (-0.2 ± 0.1; P = 0.01) and LDL-cholesterol (LDL-C) (-0.1 ± 0.1 mmol/L; P = 0.04) were also observed. Estimated 10-year total coronary heart disease risk (derived from UK Prospective Diabetes Study algorithm) was attenuated after flavonoid intervention (flavonoid +0.1 ± 0.3 vs. placebo 1.1 ± 0.3; P = 0.02). No effect on blood pressure, HbA(1c), or glucose was observed.

CONCLUSIONS

One-year intervention with flavan-3-ols and isoflavones improved biomarkers of CVD risk, highlighting the additional benefit of flavonoids to standard drug therapy in managing CVD risk in postmenopausal type 2 diabetic patients.

Cost-effectiveness of a lifestyle intervention in preventing Type 2 diabetes

OBJECTIVES

Previous research has suggested people with impaired fasting glucose (IFG) are less likely to develop Type 2 diabetes (T2DM) if they receive prolonged structured diet and exercise advice. This study examined the within-trial cost-effectiveness of such lifestyle interventions.

METHODS

Screen-detected participants with either newly diagnosed T2DM or IFG were randomized 2:1 to intervention versus control (usual care) between February and December 2009, in Norfolk (UK). The intervention consisted of group based education, physiotherapy and peer support sessions, plus telephone contacts from T2DM volunteers. We monitored healthcare resource use, intervention costs, and quality of life (EQ-5D). The incremental cost per quality-adjusted life-year (QALY) gain (incremental cost effectiveness ratio [ICER]), and cost effectiveness acceptability curves (CEAC) were estimated.

RESULTS

In total, 177 participants were recruited (118 intervention, 59 controls), with a mean follow-up of 7 months. Excluding screening and recruitment costs, the mean cost was estimated to be £551 per participant in the intervention arm, compared with £325 in the control arm. The QALY gains were -0.001 and -0.004, respectively. The intervention was estimated to have an ICER of £67,184 per QALY (16 percent probability of being cost-effective at the £20,000/QALY threshold). Cost-effectiveness estimates were more favorable for IFG participants and those with longer follow-up (≥ 4 months) (ICERs of £20,620 and £17,075 per QALY, respectively).

CONCLUSIONS

Group sessions to prevent T2DM were not estimated to be within current limits of cost-effectiveness. However, there was a large degree of uncertainty surrounding these estimates, suggesting the need for further research.

Calpainopathy presenting as foot drop in a 41 year old

Mutations in the gene encoding muscle-specific calpain 3 protease cause limb girdle muscular dystrophy type 2A. Calpainopathy is characterised by progressive symmetrical atrophy of pelvic, scapular and trunk muscles with an elevated creatine kinase. Most patients develop symptoms in childhood and lose the ability to walk by the age of 40 years. We describe a man who presented with foot drop at the age of 41 years, together with neurophysiological, histopathological and genetic data. This is the first report of calpainopathy presenting as foot drop, and widens the phenotype associated with this disease.

Egeson's (George's) transtridecadal weather cycling and sunspots

In the late 19th century, Charles Egeson, a map compiler at the Sydney Observatory, carried out some of the earliest research on climatic cycles, linking them to about 33-year cycles in solar activity, and predicted that a devastating drought would strike Australia at the turn of the 20th century. Eduard Brückner and William J. S. Lockyer, who, like Egeson, found similar cycles, with notable exceptions, are also, like the map compiler, mostly forgotten. But the transtridecadal cycles are important in human physiology, economics and other affairs and are particularly pertinent to ongoing discusions of climate change. Egeson's publication of daily weather reports preceded those officially recorded. Their publication led to clashes with his superiors and his personal life was marked by run-ins with the law and, possibly, an implied, but not proven, confinement in an insane asylum and premature death. We here track what little is known of Egeson's life and of his bucking of the conventional scientific wisdom of his time with tragic results.

Genetic evidence that raised sex hormone binding globulin (SHBG) levels reduce the risk of type 2 diabetes

Epidemiological studies consistently show that circulating sex hormone binding globulin (SHBG) levels are lower in type 2 diabetes patients than non-diabetic individuals, but the causal nature of this association is controversial. Genetic studies can help dissect causal directions of epidemiological associations because genotypes are much less likely to be confounded, biased or influenced by disease processes. Using this Mendelian randomization principle, we selected a common single nucleotide polymorphism (SNP) near the SHBG gene, rs1799941, that is strongly associated with SHBG levels. We used data from this SNP, or closely correlated SNPs, in 27 657 type 2 diabetes patients and 58 481 controls from 15 studies. We then used data from additional studies to estimate the difference in SHBG levels between type 2 diabetes patients and controls. The SHBG SNP rs1799941 was associated with type 2 diabetes [odds ratio (OR) 0.94, 95% CI: 0.91, 0.97; P = 2 x 10(-5)], with the SHBG raising allele associated with reduced risk of type 2 diabetes. This effect was very similar to that expected (OR 0.92, 95% CI: 0.88, 0.96), given the SHBG-SNP versus SHBG levels association (SHBG levels are 0.2 standard deviations higher per copy of the A allele) and the SHBG levels versus type 2 diabetes association (SHBG levels are 0.23 standard deviations lower in type 2 diabetic patients compared to controls). Results were very similar in men and women. There was no evidence that this variant is associated with diabetes-related intermediate traits, including several measures of insulin secretion and resistance. Our results, together with those from another recent genetic study, strengthen evidence that SHBG and sex hormones are involved in the aetiology of type 2 diabetes.

Clinical Management Factors Contribute to the Decision for Contralateral Prophylactic Mastectomy (CPM)

INTRODUCTION:Rates of CPM are reported to be increasing, yet factors driving this trend are unclear. We performed this analysis to determine if increasing rates of CPM are being driven by increased recognition of risk factors for contralateral breast cancer (CBC) or by treatment factors related to the index lesion.METHODS:From 1997-2005, 2967 patients with Stage 0-III primary unilateral breast cancer underwent mastectomy at MSKCC and were entered into a prospectively maintained database. Demographic, tumor and treatment factors were abstracted and comparisons made between patients who did and did not undergo CPM within one year of treatment for their index cancer. Generalized estimating equations were used to fit logistic regression models to identify independent predictors of CPM.RESULTS:The overall rate of CPM was 13.8%(n=408), increasing from 6.7% in 1997 to 24.4% in 2005 (p&lt;0.0001). The median age of CPM pts was 44.9 vs 53.2 in the non-CPM group (p&lt;.001) and only 7% of CPM pts were non-white compared to 25% of non-CPM pts (p&lt;.001). Although 69% of CPM pts had a family history (FH) of breast cancer (vs 40% non-CPM; p&lt;.001) only 8% had 2 or more first degree relatives affected. Genetic testing was performed in 29% of CPM pts; of those 37 (31%) were positive. The use of MRI increased from 1.3% to 36.3%of cases over the study period. MRI at diagnosis (43% vs 16%) and MRI generated biopsy in the contralateral or bilateral breasts (29% vs 4%) were strongly associated with CPM (p&lt;.0001). Prior attempts at breast conservation (BCT) (28% vs 16%; p&lt;.001) were more common in the CPM group, but number of attempts did not differ between groups. Patients undergoing CPM were more likely to have DCIS versus an invasive histology (p&lt;0.0001), and of those with invasive disease, CPM patients had smaller tumors (1.2cm vs. 1.8cm, p&lt;0.0001) and were more likely to be node negative (53% vs 43%, p&lt;0.0001). ER, PR, and HER2 status were not associated with CPM. CPM rates among surgeons ranged from 9.8% to 26%. Multivariate analysis of predictors of CPM for 2387 patients with complete data is shown in the Table.VariableORp95%CIWhite race3.6&lt;0.00012.4-5.4Age&lt;502.3&lt;0.00011.8-3.1FH breast cancer2.9&lt;0.00012.3-3.7MRI at Dx2.2&lt;0.00011.7-2.8BCT attempted1.60.000081.2-2.1Reconstruction3.2&lt;0.00012.3-4.5DCIS histology1.40.021.1-1.9*adjusted for surgeonCONCLUSIONS: Factors associated with clinical management of the index cancer such as preoperative MRI with the potential for additional biopsy, failed attempt at BCT, and breast reconstruction were strongly associated with CPM. Age and FH were also independent predictors; however the FH profiles of CPM pts in this series do not support increased recognition of mutation carriers and truly high risk FH as a major cause of increasing rates of CPM. The lack of association with ER status, which results in treatment that decreases the risk of CBC, provides additional support that patients may be choosing CPM for reasons other than future risk. These data suggest that the need for additional procedures during management of the index cancer may be contributing to the increasing use of CPM among a relatively moderate risk patient population. Efforts to optimize BCT and minimize unnecessary tests may help to curb this trend.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 38.

When and how to update systematic reviews

BACKGROUND

Systematic reviews are most helpful if they are up-to-date. We did a systematic review of strategies and methods describing when and how to update systematic reviews.

OBJECTIVES

To identify, describe and assess strategies and methods addressing: 1) when to update systematic reviews and 2) how to update systematic reviews.

SEARCH STRATEGY

We searched MEDLINE (1966 to December 2005), PsycINFO, the Cochrane Methodology Register (Issue 1, 2006), and hand searched the 2005 Cochrane Colloquium proceedings.

SELECTION CRITERIA

We included methodology reports, updated systematic reviews, commentaries, editorials, or other short reports describing the development, use, or comparison of strategies and methods for determining the need for updating or updating systematic reviews in healthcare.

DATA COLLECTION AND ANALYSIS

We abstracted information from each included report using a 15-item questionnaire. The strategies and methods for updating systematic reviews were assessed and compared descriptively with respect to their usefulness, comprehensiveness, advantages, and disadvantages.

MAIN RESULTS

Four updating strategies, one technique, and two statistical methods were identified. Three strategies addressed steps for updating and one strategy presented a model for assessing the need to update. One technique discussed the use of the "entry date" field in bibliographic searching. Statistical methods were cumulative meta-analysis and predicting when meta-analyses are outdated.

AUTHORS' CONCLUSIONS

Little research has been conducted on when and how to update systematic reviews and the feasibility and efficiency of the identified approaches is uncertain. These shortcomings should be addressed in future research.

Mitochondrial DNA haplogroups and type 2 diabetes: a study of 897 cases and 1010 controls

Mitochondria play a central role in the secretion of insulin by pancreatic beta-cells, and pathogenic mutations of mitochondrial DNA (mtDNA) can cause diabetes. The aetiology of type 2 diabetes has a strong genetic component, raising the possibility that genetic variants of mtDNA alter the risk of developing the disorder. Recent studies have produced conflicting results. By studying 897 UK cases of type 2 diabetes and 1010 population-matched controls, it is shown that European mtDNA haplogroups are unlikely to play a major role in the risk of developing the disorder.

GAD antibodies in probands and their relatives in a cohort clinically selected for Type 2 diabetes

AIMS

A subset of patients who present as if they have Type 2 diabetes have positive pancreatic autoantibodies, and have been referred to as having latent autoimmune diabetes in adults (LADA). We assessed the prevalence and clinical characteristics of patients with glutamic acid decarboxylase antibodies (GADA) in a cohort clinically selected for Type 2 diabetes and determined the presence of diabetes and GADA in their first-degree relatives.

METHODS

GADA were measured in 2059 subjects, not known to be related, and clinically selected as having Type 2 diabetes for genetic studies. Clinical characteristics were compared in GADA positive and GADA negative subjects. Diabetes and GAD antibody status were compared in 208 first-degree relatives of GADA positive and GADA negative probands.

RESULTS

Of the subjects, 136 (7%) were GADA positive. Compared with the GADA negative subjects, they were slimmer (P < 0.001), diagnosed at a younger age (P = 0.011) and progressed to insulin faster (P < 0.001). Thirty-three per cent of GADA positive subjects had a first-degree relative with diabetes compared with 42% of GADA negative subjects (P = 0.034). The overall prevalence of GADA was similar in the first-degree relatives of GADA positive and GADA negative probands (4 v 5%), and 19 of 22 (86%) diabetic relatives of GADA positive probands were GADA negative.

CONCLUSION

Despite clinically selecting a Type 2 diabetes cohort, 7% were GADA positive with an altered phenotype. These GADA positive patients had a strong family history of non-autoimmune diabetes. This suggests that, in this subgroup of patients, autoimmune pancreatic beta-cell destruction occurs on a background of Type 2 diabetes genetic susceptibility.

Reduced beta cell function in offspring of mothers with young-onset type 2 diabetes

AIMS/HYPOTHESIS

Animal models indicate that even exposure to mild maternal hyperglycaemia in utero is detrimental to the beta cell function of the offspring, but evidence of this in humans is limited. In Europids who are diagnosed with type 2 diabetes before the age of 50 years, the risk of diabetes in the offspring of the diabetic mothers is greatly increased compared with the risk in those born to diabetic fathers. We hypothesised that offspring born to mothers with young-onset type 2 diabetes would have been exposed to mild hyperglycaemia in utero, so we studied the impact of this on their beta cell function.

SUBJECTS AND METHODS

We measured beta cell function using early insulin response (EIR) after oral glucose; insulin resistance using HOMA; and HbA(1c) in 568 non-diabetic adult offspring born to parents with type 2 diabetes (mean age 55.8 years), split according to which parent was affected (in 327 it was the mother) and parental age of diagnosis: <50 years (n=117) or > or =50 years. To reduce the impact of genetic susceptibility, the offspring of affected fathers were used as control subjects.

RESULTS

Offspring of mothers with young-onset type 2 diabetes had lower EIR (log EIR 4.32, 95% CI [4.14-4.51] vs 4.63 [4.43-4.83] p=0.02) and higher HbA(1c) (4.89% [4.79-4.99] vs 4.68% [4.57-4.79] p=0.02) than the offspring of fathers with young-onset type 2 diabetes. Insulin sensitivity was similar in the two groups. There were no differences in EIR or HbA(1c) between the offspring born to mothers and fathers who were diagnosed after the age of 50 years.

CONCLUSIONS/INTERPRETATION

We conclude that the offspring of mothers with young-onset type 2 diabetes have a reduction in beta cell function. This is consistent with exposure to mild maternal hyperglycaemia programming beta cell function.

Treating asthma with omega-3 fatty acids: where is the evidence? A systematic review

Background

Considerable interest exists in the potential therapeutic value of dietary supplementation with the omega-3 fatty acids. Given the interplay between pro-inflammatory omega-6 fatty acids, and the less pro-inflammatory omega-3 fatty acids, it has been thought that the latter could play a key role in treating or preventing asthma. The purpose was to systematically review the scientific-medical literature in order to identify, appraise, and synthesize the evidence for possible treatment effects of omega-3 fatty acids in asthma.

Methods

Medline, Premedline, Embase, Cochrane Central Register of Controlled Trials, CAB Health, and, Dissertation Abstracts were searched to April 2003. We included randomized controlled trials (RCT's) of subjects of any age that used any foods or extracts containing omega-3 fatty acids as treatment or prevention for asthma. Data included all asthma related outcomes, potential covariates, characteristics of the study, design, population, intervention/exposure, comparators, and co interventions.

Results

Ten RCT's were found pertinent to the present report.

Conclusion

Given the largely inconsistent picture within and across respiratory outcomes, it is impossible to determine whether or not omega-3 fatty acids are an efficacious adjuvant or monotherapy for children or adults. Based on this systematic review we recommend a large randomized controlled study of the effects of high-dose encapsulated omega-3 fatty acids on ventilatory and inflammatory measures of asthma controlling diet and other asthma risk factors. This review was limited because Meta-analysis was considered inappropriate due to missing data; poorly or heterogeneously defined populations, interventions, intervention-comparator combinations, and outcomes. In addition, small sample sizes made it impossible to meaningfully assess the impact on clinical outcomes of co-variables. Last, few significant effects were found.