1c Values Research Articles

Genome size variation and evolution in Dipterocarpaceae

Background: Dipterocarpaceae is a pantropical tree family that plays an important role in our understanding of the ecology of Asian tropical rain forests. However, genome sizes for members of the Dipterocarpaceae are still poorly known.Aims: To report the genome size of 115 dipterocarp species and examine the variation and evolution of genome size in this family.Methods: Genome size was estimated using flow cytometry. Both the rpoB and trnL intron were sequenced to uncover the evolution of genome size within a phylogenetic framework.Results: The 1C genome size varied between 0.267 and 0.705 pg in Shorea hemsleyana and Shorea ovalis, respectively, a 2.64-fold variation across the family. Most dipterocarps are characterised by very small genomes with a mean 1C value of 0.416 pg (sd = 0.075) and five polyploids are recorded. The ancestral genome size for dipterocarps was reconstructed as 1Cx = 0.481 pg (95% CI = 0.433–0.534).Conclusions: Genome size variation in dipterocarps was characterised by very small values with a narrow range. Overall, genome size reduction from the ancestral state is a general trend in Dipterocarpaceae.

Ploidy analysis of Helianthus species by flow cytometry and its use in hybridity confirmation

Sunflower (Helianthus annuus L.) is one of the most important oilseed crops cultivated worldwide. It is one of the few crops that has been improved for several characteristics through interspecific hybridization. In the present investigation, the ploidy of 43 Helianthus species belonging to diploid, tetraploid and hexaploid status along with 2 accessions of cultivated sunflower was determined. As wide variation exists in the Helianthus species for vegetative characteristics including pigmentation, processing of the leaf samples was tried with incorporation of 1 % polyvinylpyrrolidone while chopping the leaf which gave sharp peaks with low coefficient of variation. Ploidy as determined by flow cytometry was in agreement with the reported status of the Helianthus species used in the study. The mean 1C values for diploids, tetraploids and hexaploids were 3.67, 6.73 and 10.07 pg, respectively. The technique was validated on an interspecific hybrid of cultivated sunflower (2n = 2x) with H. hirsutus (2n = 4x) which confirmed the triploid status of the hybrid.

DNA content in species of Vernonia and Vernonanthura from South America: An approach to systematics and evolution of the Vernonieae (Asteraceae)

There are relatively few studies of DNA content in the Vernonieae (Asteraceae) tribe. The first studies were realized in the Lessingianthus genus and determined the DNA content of 25 species. After DNA content, ploidy level and the total karyotype were compared in 6 Chrysolaena species. The aim of this study was to present, for the first time, the DNA content values of Vernonanthura and Vernonia and to thereby expand knowledge of the Vernonieae tribe. A total of 19 natural populations belonging to the genera Vernonanthura and Vernonia were studied for the first time. The results were compared with other Vernonieae genera and with other Asteraceae tribes. Our results found that Vernonieae have the smallest range of 1C value variation in Asteraceae. Furthermore, there were differences in the DNA content of Vernonia and Vernonanthura. These results show that low DNA content and herbaceous habit in Vernonia are characters derived from the higher DNA content and woody habit present in Vernonanthura. These results could indicate a hybrid origin of one species and allow the determination of both the ploidy and chromosome number of other taxa. The results observed in Vernonanthura species showed a highly significant correlation between 1C-value and latitude.

Haemoglobin J-Baltimore can be detected by HbA1c electropherogram but with underestimated HbA1c value.

Glycated haemoglobin (HbA1c) is considered the gold standard for assessing diabetes compensation and treatment. In addition, fortuitous detection of haemoglobin variants during HbA1c measurement is not rare. Recently, two publications reported different conclusions on accuracy of HbA1c value using capillary electrophoresis method in presence of haemoglobin J-Baltimore (HbJ). Here we describe the fortuitous detection of unknown HbJ using capillary electrophoresis for measurement of HbA1c. A patient followed for gestational diabetes in our laboratory presented unknown haemoglobin on Capillarys 2 Flex Piercing analyser which was identified as HbJ. HbJ is not associated with haematological abnormalities. High Performance Liquid Chromatography methods are known to possibly underestimate HbA1c value in the presence of this variant. This variant and its glycated form are clearly distinguished on electropherogram but HbJ was responsible for underestimating the true area of HbA1c. Capillary electrophoresis is a good method for detecting HbJ but does not seem suitable for evaluation of HbA1C value in patients in presence of HbJ variant.

Comparative Genome Analysis Reveals Divergent Genome Size Evolution in a Carnivorous Plant Genus.

The C-value paradox remains incompletely resolved after >40 yr and is exemplified by 2,350-fold variation in genome sizes of flowering plants. The carnivorous Lentibulariaceae genus Genlisea, displaying a 25-fold range of genome sizes, is a promising subject to study mechanisms and consequences of evolutionary genome size variation. Applying genomic, phylogenetic, and cytogenetic approaches, we uncovered bidirectional genome size evolution within the genus Genlisea. The Genlisea nigrocaulis Steyerm. genome (86 Mbp) has probably shrunk by retroelement silencing and deletion-biased double-strand break (DSB) repair, from an ancestral size of 400 to 800 Mbp to become one of the smallest among flowering plants. The G. hispidula Stapf genome has expanded by whole-genome duplication (WGD) and retrotransposition to 1550 Mbp. Genlisea hispidula became allotetraploid after the split from the G. nigrocaulis clade ∼29 Ma. Genlisea pygmaea A. St.-Hil. (179 Mbp), a close relative of G. nigrocaulis, proved to be a recent (auto)tetraploid. Our analyses suggest a common ancestor of the genus Genlisea with an intermediate 1C value (400-800 Mbp) and subsequent rapid genome size evolution in opposite directions. Many abundant repeats of the larger genome are absent in the smaller, casting doubt on their functionality for the organism, while recurrent WGD seems to safeguard against the loss of essential elements in the face of genome shrinkage. We cannot identify any consistent differences in habitat or life strategy that correlate with genome size changes, raising the possibility that these changes may be selectively neutral.

Interaction of rhenium(I) complex carrying long alkyl chain with Calf Thymus DNA: Cytotoxic and cell imaging studies

The interaction of three rhenium(I)-diimine complexes carrying long alkyl chain fac-[Re(CO)3(α-diimine){4-C11py}] CF3SO31a–1c (α-diimine=2,2′-bipyridine (1a), 4,4′-di-tert-butyl-2,2′-bipyridine (1b), 4,4′-dinonyl-2,2′-bipyridine (1c); 4-C11py=(4-undecylpyridine) and fac-[Re(CO)3(α-diimine)(4-Etpy)]CF3SO3 (1d) (α-diimine=2,2′-bipyridine, 4-Etpy=4-Ethylpyridine) with Calf Thymus DNA (CT DNA) is studied by UV–vis absorption, luminescence and CD spectral techniques at pH 7.2. Spectral, viscosity and molecular docking studies unambiguously establish the formation of a groove binding between the Re(I) complex and CT DNA. The binding constant values of 1b and 1c are one order more than that of 1a and 1d indicating the importance of hydrophobic interaction of alkyl groups on bpy and py ligands with DNA. The complexes 1b and 1c exhibit the most pronounced antibacterial activity against four different microorganisms and all Re(I) complexes inhibit the growth of T and B cell lymphoma (Raji and Jurkat) cancer cells. Complex 1c exhibits the moderate cytotoxicity and cellular uptake of cancer cell lines attributed to the lipophilic alkyl chain on bpy and pyridine ligands which facilitate the hydrophobic interaction with DNA and healthy membrane permeability.

Assessing Potential Glycemic Overtreatment in Persons at Hypoglycemic Risk

Importance Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment. Objective To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia. Design, Setting, and Participants Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009. Main Outcomes and Measures Intensive control was defined as the last hemoglobin A 1c (HbA 1c ) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA 1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks. Results There were 652 378 patients who received insulin and/or a sulfonylurea with an HbA 1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205 857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA 1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA 1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA 1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA 1c less than 6.0%, followed by 2.25-fold for HbA 1c less than 6.5% and less than 2-fold for HbA 1c less than 7.0%. When comorbid conditions were included, 430 178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA 1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%. Conclusions and Relevance Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.

Evolution of genome size and chromosome number in the carnivorous plant genus Genlisea (Lentibulariaceae), with a new estimate of the minimum genome size in angiosperms.

Some species of Genlisea possess ultrasmall nuclear genomes, the smallest known among angiosperms, and some have been found to have chromosomes of diminutive size, which may explain why chromosome numbers and karyotypes are not known for the majority of species of the genus. However, other members of the genus do not possess ultrasmall genomes, nor do most taxa studied in related genera of the family or order. This study therefore examined the evolution of genome sizes and chromosome numbers in Genlisea in a phylogenetic context. The correlations of genome size with chromosome number and size, with the phylogeny of the group and with growth forms and habitats were also examined. Nuclear genome sizes were measured from cultivated plant material for a comprehensive sampling of taxa, including nearly half of all species of Genlisea and representing all major lineages. Flow cytometric measurements were conducted in parallel in two laboratories in order to compare the consistency of different methods and controls. Chromosome counts were performed for the majority of taxa, comparing different staining techniques for the ultrasmall chromosomes. Genome sizes of 15 taxa of Genlisea are presented and interpreted in a phylogenetic context. A high degree of congruence was found between genome size distribution and the major phylogenetic lineages. Ultrasmall genomes with 1C values of <100 Mbp were almost exclusively found in a derived lineage of South American species. The ancestral haploid chromosome number was inferred to be n = 8. Chromosome numbers in Genlisea ranged from 2n = 2x = 16 to 2n = 4x = 32. Ascendant dysploid series (2n = 36, 38) are documented for three derived taxa. The different ploidy levels corresponded to the two subgenera, but were not directly correlated to differences in genome size; the three different karyotype ranges mirrored the different sections of the genus. The smallest known plant genomes were not found in G. margaretae, as previously reported, but in G. tuberosa (1C ≈ 61 Mbp) and some strains of G. aurea (1C ≈ 64 Mbp). Genlisea is an ideal candidate model organism for the understanding of genome reduction as the genus includes species with both relatively large (∼1700 Mbp) and ultrasmall (∼61 Mbp) genomes. This comparative, phylogeny-based analysis of genome sizes and karyotypes in Genlisea provides essential data for selection of suitable species for comparative whole-genome analyses, as well as for further studies on both the molecular and cytogenetic basis of genome reduction in plants.

Coaxial Nanotube Battery inside Single Nanopore

We report here a nanobattery comprised of nanotubular electrodes and electrolyte confined within an anodic aluminum oxide (AAO) nanopore. To construct confined electrically insulating electrolyte space in batteries with aligned nanoelectrodes, we have used atomic layer deposition (ALD) to synthesize nanotubular, heterogeneous coaxial electrodes at both ends of AAO nanopores. The nanoelectrodes include Ru nanotube current collectors with V2O5storage material on top of the Ru to form a symmetric full storage cell, with anode and cathode separated by an electrolyte region. The V2O5 is prelithiated at one end to serve as anode while pristine V2O5 at the other end serves as cathode, so that the battery can be asymmetrically cycling between 0.2V and 1.8V. Capacity retention at high power (relative to 1C values 178mAh/g) is 95% at 5C and 46% at 150C. At 5C rate (12 min charge-discharge cycle), 81.3% capacity remains after 1000 cycles. The importance of incorporating integrated current collectors is demonstrated by the rate performance of V2O5 cathode with Ru nanotube current collector as compared to a Au planar current collector. While both show similar capacity at low rate (1C), at high rates (150C) that demand fast electron transport the V2O5/Ru nanotube (78mAh/g) exhibits almost twice the capacity of the V2O5/planar Au (42mAh/g). This nanopore battery poses an extreme case of highly confined organic electrolyte environments in ultrasmall batteries. These promising results demonstrate the importance of integrating current collectors with storage nanoelectrodes, the benefit of electrolyte-accessible surface area of the nanotubular electrodes, and the cycling robustness of the nanostructures. At the same time, they provide a valuable data source for fundamental modeling to understand and quantify a science of “nanoionics” – a mesoscale phenomenon resulting from dense packing of ion storage nanostructures.

Three of 7 hemoglobin A1c point-of-care instruments do not meet generally accepted analytical performance criteria.

In 2009, we investigated the conformance of 8 hemoglobin A(1c) (Hb A(1c)) point-of-care (POC) instruments. Since then, instruments have improved and new devices are available on the market. In this second study, we evaluated the performance of DCA Vantage, Afinion, InnovaStar, Quo-Lab, Quo-Test, Cobas B101, and B-analyst Hb A(1c) POC instruments. Clinical and Laboratory Standards Institute protocols EP-5 and EP-9 were applied to investigate imprecision, accuracy, and bias. We assessed bias using the mean of 3 certified secondary reference measurement procedures (SRMPs). Assay conformance with the National Glycohemoglobin Standardization Program (NGSP) certification criteria was also evaluated. Interference of common Hb variants was investigated for methods that could work with hemolysed material. The total CVs for all instruments, except for the DCA Vantage at a high Hb A(1c) value, were ≤3.1% in SI units and ≤2.1% in Diabetes Control and Complications Trial (DCCT) units. Afinion, DCA Vantage, B-analyst, and Cobas B101 instruments passed the NGSP criteria with 2 different reagent lot numbers. Quo-Test, Quo-Lab, and InnovaStar instruments had a negative bias compared to the mean of the 3 SRMPs and failed NGSP criteria. Most of the common Hb variants did not interfere with the investigated instruments, except Hb AE for the Cobas B101. Afinion, DCA Vantage, Cobas B101, and B-analyst instruments met the generally accepted performance criteria for Hb A(1c). Quo-Test, Quo-Lab, and InnovaStar met the criteria for precision but not for bias. Proficiency testing should be mandated for users of Hb A1c POC assays to ensure quality.

Transposable elements and genome size variations in plants.

Although the number of protein-coding genes is not highly variable between plant taxa, the DNA content in their genomes is highly variable, by as much as 2,056-fold from a 1C amount of 0.0648 pg to 132.5 pg. The mean 1C-value in plants is 2.4 pg, and genome size expansion/contraction is lineage-specific in plant taxonomy. Transposable element fractions in plant genomes are also variable, as low as ~3% in small genomes and as high as ~85% in large genomes, indicating that genome size is a linear function of transposable element content. Of the 2 classes of transposable elements, the dynamics of class 1 long terminal repeat (LTR) retrotransposons is a major contributor to the 1C value differences among plants. The activity of LTR retrotransposons is under the control of epigenetic suppressing mechanisms. Also, genome-purging mechanisms have been adopted to counter-balance the genome size amplification. With a wealth of information on whole-genome sequences in plant genomes, it was revealed that several genome-purging mechanisms have been employed, depending on plant taxa. Two genera, Lilium and Fritillaria, are known to have large genomes in angiosperms. There were twice times of concerted genome size evolutions in the family Liliaceae during the divergence of the current genera in Liliaceae. In addition to the LTR retrotransposons, non-LTR retrotransposons and satellite DNAs contributed to the huge genomes in the two genera by possible failure of genome counter-balancing mechanisms.

The Impact of Diabetes Nurse Case Management on Hemoglobin A1c (HgbA1c) and Self-Efficacy of Patients with Type 2 Diabetes: A Systematic Review

Purpose: The aim of this systematic review is to present current knowledge on diabetes nurse case management and assess its effects on Hemoglobin (HgbA 1c ) and patient self-efficacy. Methods: An electronic search was conducted for the period of 1998 to 2013 using databases of the scientific literature in Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo using a range of keywords and a variety of combinations of Medical Subject Headings (MeSH) terms. Information gathered was evaluated for relevance. Results: Eleven studies that met the inclusion criteria were used in this systematic review. In several studies considered in this review, diabetes nurse case management had positive effects on patient’s HgbA 1c . It reduced HgbA 1c andimproved HgbA 1c values compared to standard care. Moreover, in several studies diabetes case management improved type 2 diabetes patients’ self-efficacy. Conclusion: Diabetes nurse case management is necessary for countries with increasing prevalence of diabetes 2 such as Saudi Arabia and the states of the Co-operation Council for the Arab States of the Gulf as it will help improve the quality of care provided to patients and improve their clients’ health outcomes. Overall this study provides evidence that case management has positive effects on type 2 diabetic patients’ HgbA1c and self-efficacy.

Development of Flow Cytometric Protocol for Nuclear DNA Content Estimation and Determination of Chromosome Number in Pongamia pinnata L., a Valuable Biodiesel Plant

The potentiality of Pongamia pinnata L. as a sustainable source of feedstock for the biodiesel industry is dependent on an extensive knowledge of the genome structure of the plant. Flow cytometry, with propidium iodide (PI) as the DNA stain, was used to estimate the nuclear DNA content of P. pinnata, with respect to Zea mays 'CE-777' as standard. The internal and pseudo-internal standardization was followed on account of the inhibitory effect of secondary compounds on PI intercalation. The antioxidants (PVP-40 and β-mercaptoethanol) were added to the nuclear isolation buffer for the reduction of inhibitory effect of P. pinnata cytosol. Nuclear DNA content estimation was done for P. pinnata leaves from different altitudes (37-117 m height from sea level) of Assam. Flow cytometry analysis indicated that the nuclear DNA content of P. pinnata is 2.66 pg with predicted 1C value of 1,300 Mb using Z. mays as standard. Coefficient of variation in flow cytometric analysis was within the limit of 5 % indicating that the results were reliable. Somatic chromosome numbers were counted from root-tip cells and was found to be 2n = 22 corresponding to the diploid level (x = 11). A decreasing trend in the nuclear DNA content was observed for the species of different altitudes.

Investigation of fracture properties of California asphalt mixtures using semicircular bending and beam fatigue tests

Fatigue cracking is a primary distress in asphalt concrete (AC) due to repetitive stresses and strains caused by both traffic loading and environmental factors. The fatigue resistance of AC is investigated by a number of fatigue tests. The main objective of this study is to investigate the use of the semi-circular bending (SCB) test as a quality assurance/quality control (QA/QC) measure for field construction. The comparison of fracture properties of seven AC mixtures from the SCB and beam fatigue test (BFT) is conducted. The J c and K 1c values for the seven mixtures were determined. The BFT was performed on the same mixtures and the initial stiffness, N f and plateau value (PV) were determined. The coefficient of variation (CV) ranged from 0% to 38% for J c and from 0% to 35% for K 1c. The CV ranged from 10% to 93% for the initial stiffness, 2% to 83% for N f and 8% to 167% for PV. The SCB J c and BFT N f and PV indicated lower fracture properties for PG64-10RAP (LIME), AN-HMA and WMA-ADVERA mixtures than other mixtures. The BFT N f and PV achieved similar ranking for all mixtures. There is good correlation between N f and PV with J c, and not a good correlation between the initial stiffness with J c, N f and PV. This has indicated that the initial stiffness is not a good representative for fracture properties of AC while J c, N f and PV are better indicators. The results of this study indicate that the SCB test has a great potential as a QA/QC test of fracture properties of asphalt mixtures.

Direct healthcare costs and clinical outcomes after insulin initiation in patients with type 2 diabetes mellitus in Spain: 24-month follow-up data from the INSTIGATE study

Abstract Background and objective The INSTIGATE study assessed healthcare costs and clinical outcomes in patients with type 2 diabetes mellitus starting insulin therapy in Spain over a 24-month follow up period. Material and methods This was an observational, non-interventional, prospective, multicenter study. Costs incurred in the previous 6 months were assessed at each visit. Results A total of 172 patients with a mean body mass index of 29.6 kg/m 2 , a mean [standard deviation] duration of diabetes of 10.9 [7.0] years and a hemoglobin A 1c value of 9.2% [1.5%] were followed up for at least 12 and up to 24 months. Direct costs were assessed from the perspective of the Spanish healthcare system. Long/intermediate-acting insulin alone was started in 116 patients (67.4%). After 6, 12, and 24 months of insulin treatment, mean [SD] intraindividual changes from baseline in hemoglobin A 1c were −1.9% [1.65%], −1.6 [1.73%], and −1.5% [1.76%] respectively. Mean (median) total diabetes-related healthcare costs per patient increased from €659 (€527) to €1.085 (€694) 6 months after insulin initiation, decreased to €646 (€531) after 12 months, and increased again after 24 months to €667 (€539). Insulin/oral antidiabetics, primary/specialized care, and blood glucose monitoring accounted for 41%, 26%, and 19% of total cost at 24 months respectively. Conclusions Clinical parameters of these patients with type 2 diabetes mellitus improved following insulin initiation. After a temporary increase, direct healthcare costs of diabetes care returned to baseline values at the end of the follow-up period.

A risk‐adjusted economic evaluation of alternative models of involvement of practice nurses in management of type 2 diabetes

To determine the cost-effectiveness of alternative models of practice nurse involvement in the management of type 2 diabetes within the primary care setting. Linked routinely collected clinical data and resource use (general practitioner visits, hospital services and pharmaceuticals) were used to undertake a risk-adjusted cost-effectiveness analysis of alternative models of care for the management of diabetes patients. These models were based on the reported level of involvement of practice nurses in the provision of clinical-based activities. Potential confounders were controlled for by using propensity score-weighted regression analyses. The impact of alternative models of care on outcomes and costs was measured and incremental cost-effectiveness estimated. The uncertainty around the estimates of cost-effectiveness was illustrated through bootstrapping. Although the difference in total cost between two models of care was not statistically significant, the high-level model was associated with better outcomes (larger mean reductions in HbA(1c)). The upper 95% confidence intervals showed that the incremental cost per 1% decrease in HbA(1c) is only $454, and per one additional patient to achieve an HbA(1c) value of less than 53 mmol/mol (7.0%) is $323. Further analyses showed little uncertainty surrounding the decision to adopt the high-level model. The results provide a strong indication that the high-level model is a cost-effective way of managing diabetes patients. Our findings highlight the need for effective incentives to encourage general practices to better integrate practice nurses in the provision of clinical services.

Pharmacist management of patients with diabetes mellitus enrolled in a rural free clinic

The impact of pharmacist management of patients with diabetes mellitus enrolled in a rural free clinic was evaluated. Data from 95 patients continuously enrolled in a new pharmacist service were analyzed over 24 months. Patients were at least 18 years old, qualified for free care on the basis of income or insurance status, and had a diagnosis of type 2 diabetes mellitus upon clinic entry. Under a collaborative agreement, pharmacists educated patients on diabetes, counseled patients on lifestyle modifications, assessed appropriateness of drug therapy, and managed drug therapy for diabetes and associated comorbid conditions. Clinical impact was measured by changes from baseline glycosylated hemoglobin (HbA(1c)) levels, blood pressure, and lipid levels over a 24-month period. Using published cost estimates, the economic impact of the clinic was calculated based on expected savings for each patient who had a decrease of ≥1% in HbA(1c) value. Significant reductions from baseline in HbA1c values (p < 0.0001), systolic blood pressure (p = 0.0011), diastolic blood pressure (p = 0.0015), low-density-lipoprotein cholesterol (p < 0.0001), and triglyceride levels (p = 0.0001) were achieved in clinic patients. Based on an expected savings of $1,118 per patient who had a decrease of >1% in HbA(1c) value (n = 67), the pharmacist service was estimated to provide a savings of $74,906 per year. Pharmacist management of patients with type 2 diabetes significantly influenced clinical and economic outcomes in an uninsured population living in a rural area with few health care resources.

Update Typ-1-Diabetes

Type 1a diabetes develops from a chronic autoimmune process leading to absolute insulin deficiency and proneness to ketosis. Prospective studies have clearly shown that intensive insulin therapy (ICT) results in improved quality of life and reduced development of diabetes-associated microvascular and macrovascular complications. The gold standard of therapy in type 1 diabetes is insulin injection with a basal bolus insulin regimen, in which patient daily routine and wishes are considered. The treatment goals should be determined on an individualized basis together with the patient. An HbA(1c) value < 7.0% is considered to be well controlled while values ≤ 6.5% indicate an excellent blood glucose control, as long as there are no episodes of severe hypoglycemia. As many adult patients with type 1 diabetes develop additional cardiovascular risk factors dyslipidemia and hypertension should also be considered and treated according to current treatment guidelines. A multimodal treatment may be the best way to preserve quality of life in patients with type 1 diabetes.

Screening for depression and diabetes‐related distress in a diabetes outpatient clinic

To investigate: (1) the willingness of patients with diabetes to participate in a screening programme; (2) the extent to which patients with diabetes who screen positive endorse need for psychosocial care; (3) the rate of referral to psychosocial care during screening vs. usual care. Four hundred and ninety-nine patients with diabetes were invited to complete the Center for Epidemiologic Studies Depression and the Problem Areas in Diabetes questionnaires. Patients screening positive on either instrument were invited for an interview. One year after screening was withdrawn, rates of referral to psychosocial care were assessed from physician reports of patient referrals. In total, 349/499 (70%) patients with diabetes completed the questionnaire. Patients who did not take up the screening were younger, smoked more often and had higher HbA(1c) values. 'No-shows' for clinical appointments accounted for 74% of non-participation. Of the 104 (30% of 349) patients screening positive, 45 accepted an invitation for an interview. Finally, 36/104 (35%) would like a referral for psychological care. Seven per cent of patients were referred to psychological care during screening compared with 1% when screening was withdrawn. Results raise questions as to whether screening is the most efficient way to identify patients with psychological problems. Many patients did not take up the screening, especially those with low adherence to diabetes care in general. Furthermore, few patients screening positive wanted to be referred. Screening should be evaluated in the context of consideration of alternative ways to identify at-risk patients, including providing resources to deal with patients with already known adjustment and adherence problems.

Insulin Detemir

Insulin detemir (Levemir®) is a long-acting insulin analogue indicated for use as basal insulin therapy in patients with type 1 or 2 diabetes mellitus. The protracted action of insulin detemir is explained by increased self-association and reversible binding to albumin, which slows its systemic absorption from the injection site. In glucose-clamp studies, less within-patient variability in glucose-lowering effect was seen with insulin detemir than with neutral protamine Hagedorn (NPH) insulin or insulin glargine in patients with type 1 or 2 diabetes. The beneficial effect of insulin detemir on glycaemic control was shown in numerous randomized, open-label, multicentre trials, including when used as basal-bolus therapy in patients with type 1 or 2 diabetes and as basal therapy in addition to oral antidiabetic drugs in insulin-naive patients with type 2 diabetes. In terms of glycosylated haemoglobin (HbA(1c)).[primary endpoint in most trials], insulin detemir was generally at least as effective as NPH insulin, insulin glargine or insulin lispro protamine suspension in patients with type 1 or 2 diabetes, and at least as effective as biphasic insulin aspart in patients with type 2 diabetes. Less within-patient variability in blood glucose was also generally seen with insulin detemir than with NPH insulin in patients with type 1 or 2 diabetes. Significantly less weight gain was generally seen with insulin detemir than with NPH insulin in patients with type 1 diabetes or with insulin detemir than with NPH insulin, insulin glargine, insulin lispro protamine suspension or biphasic insulin aspart (in one study) in patients with type 2 diabetes (i.e. insulin detemir generally had a weight-sparing effect). The addition of insulin detemir to liraglutide plus metformin improved glycaemic control in insulin-naive patients with type 2 diabetes and inadequate glycaemic control, although a significantly greater reduction in bodyweight was seen in patients receiving liraglutide plus metformin than in those receiving add-on therapy with insulin detemir. Results of two trials in patients aged 2-16 or 6-17 years (and a subgroup analysis in children aged 2-5 years) indicate that a basal-bolus insulin regimen incorporating insulin detemir appears to be a suitable option for use in paediatric patients with type 1 diabetes. Less within-patient variation in self-measured fasting plasma glucose was seen with insulin detemir than with NPH insulin in one of the studies. Insulin detemir was noninferior to NPH insulin in pregnant women with type 1 diabetes in terms of the HbA(1c) value achieved at 36 gestational weeks. In addition, maternal and neonatal outcomes with insulin detemir were similar to those seen with NPH insulin. Subcutaneous insulin detemir was generally well tolerated in the treatment of patients with type 1 or 2 diabetes, including in paediatric patients and pregnant women with type 1 diabetes. The majority of adverse events, including serious adverse events, reported in insulin detemir recipients were not considered to be related to the study drug. Insulin detemir was generally associated with a significantly lower risk of nocturnal hypoglycaemia than NPH insulin in patients with type 1 or 2 diabetes, particularly nocturnal minor hypoglycaemia. In conclusion, insulin detemir is a useful option for use as basal insulin therapy in patients with type 1 or 2 diabetes.