Therapeutic inertia amongst general practitioners with interest in diabetes.

INTRODUCTION: As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. METHODS: In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. RESULTS: Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. CONCLUSION: Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.

Metabolic Effects Associated with ICS in Patients with COPD and Comorbid Type 2 Diabetes: A Historical Matched Cohort Study.

BACKGROUND: Management guidelines for chronic obstructive pulmonary disease (COPD) recommend that inhaled corticosteroids (ICS) are prescribed to patients with the most severe symptoms. However, these guidelines have not been widely implemented by physicians, leading to widespread use of ICS in patients with mild-to-moderate COPD. Of particular concern is the potential risk of worsening diabetic control associated with ICS use. Here we investigate whether ICS therapy in patients with COPD and comorbid type 2 diabetes mellitus (T2DM) has a negative impact on diabetic control, and whether these negative effects are dose-dependent. METHODS AND FINDINGS: This was a historical matched cohort study utilising primary care medical record data from two large UK databases. We selected patients aged ≥40 years with COPD and T2DM, prescribed ICS (n = 1360) or non-ICS therapy (n = 2642) between 2008 and 2012. The primary endpoint was change in HbA1c between the baseline and outcome periods. After 1:1 matching, each cohort consisted of 682 patients. Over the 12-18-month outcome period, patients prescribed ICS had significantly greater increases in HbA1c values compared with those prescribed non-ICS therapies; adjusted difference 0.16% (95% confidence interval [CI]: 0.05-0.27%) in all COPD patients, and 0.25% (95% CI: 0.10-0.40%) in mild-to-moderate COPD patients. Patients in the ICS cohort also had significantly more diabetes-related general practice visits per year and received more frequent glucose strip prescriptions, compared with those prescribed non-ICS therapies. Patients prescribed higher cumulative doses of ICS (>250 mg) had greater odds of increased HbA1c and/or receiving additional antidiabetic medication, and increased odds of being above the Quality and Outcomes Framework (QOF) target for HbA1c levels, compared with those prescribed lower cumulative doses (≤125 mg). CONCLUSION: For patients with COPD and comorbid T2DM, ICS therapy may have a negative impact on diabetes control. Patients prescribed higher cumulative doses of ICS may be at greater risk of diabetes progression. TRIAL REGISTRATION: ENCePP ENCEPP/SDPP/6804.

Resource use and outcomes associated with initiation of injectable therapies for patients with type 2 diabetes mellitus.

INTRODUCTION: Management of type 2 diabetes mellitus (T2DM) often requires intervention with oral and injectable therapies. Across National Health Service (NHS) England, injectable therapies may be initiated in secondary, intermediate or primary care. We wished to understand resource utilization, pathways of care, clinical outcomes, and experience of patients with T2DM initiated on injectable therapies. METHOD: We conducted three service evaluations of initiation of injectable therapies (glucagon-like peptide-1 receptor agonists (GLP-1 RAs) or basal insulin) for T2DM in primary, secondary and intermediate care. Evaluations included retrospective review of medical records and service administration; prospective evaluation of NHS staff time on each episode of patient contact during a 3-month initiation period; patient-experience survey for those attending for initiation. Data from each evaluation were analysed separately and results stratified by therapy type. RESULTS: A total of 133 patients were included across all settings; 54 were basal-insulin initiations. After initiation, the mean HbA1c level fell for both types of therapies, and weight increased for patients on basal insulin yet fell for patients on GLP-1 RA. The mean cost of staff time per patient per initiation was: £43.81 for GLP-1 RA in primary care; £243.49 for GLP-1 RA and £473.63 for basal insulin in intermediate care; £518.99 for GLP-1 RA and £571.11 for basal insulin in secondary care. Patient-reported questionnaires were completed by 20 patients, suggesting that patients found it easy to speak to the diabetes team, had opportunities to discuss concerns, and felt that these concerns were addressed adequately. CONCLUSION: All three services achieved a reduction in HbA1c level after initiation. Patterns of weight gain with basal insulin and weight loss with GLP-1 RA were as expected. Primary care was less resource-intensive and costly, and was driven by lower staff costs and fewer clinic visits.

Fused-core, sub-2 microm packings, and monolithic HPLC columns: a comparative evaluation.

Three different HPLC column technologies (i.e., monolith, fused-core particles, and sub-2 microm particles) were evaluated, comparing van Deemter plots, speed of analysis, back pressure, and mobile phase consumption. Very high linear velocities (approximately 12 mm/s) were achieved with the monolithic column using modest pressure (110 bar) at the expense of high mobile phase consumption. The minimum plate height of the monolith was similar to that of a 3 microm-particle packed column (i.e., h = 8 microm), operated at optimal linear velocities; the monolithic column showed substantially lower mass transfer dependence, however. The 2.7 microm fused-core packing material yielded efficiencies closer to the sub-2 microm material than to the 3 microm-particle packed column and could be operated at high flow rates. The fused-core column was able to achieve linear velocities similar to those attained on the sub-2 microm column, staying below 620 bar instead of almost near 1030 bar required by the sub-2 microm material. The lack of pH stability of the monolithic column prevented its use to separate basic compounds (i.e., tricyclic antidepressants) at high pH. Best separation of these components at high pH was achieved using the column packed with 1.7 microm hybrid material.

Injection valve for ultrahigh-pressure liquid chromatography.

The increased interest in HPLC at elevated pressures, beyond the conventional 6000 psi (400 bar), has created a demand for injection systems capable of withstanding pressures beyond the 20,000 psi (1380 bar). To achieve high-resolution separations, an appropriate length of columns packed with sub 2-microm packing materials, a 30,000-40,000 psi (2070-2760 bar) pressure range is desirable. A new air-actuated needle valve injection system rated to withstand pressures of up to 40,000 psi (2760 bar) has been evaluated. Under isocratic chromatographic conditions, injecting 200 nL and operated at approximately 20,000 psi (1380 bar), the system showed a peak area reproducibility of approximately 2.5% RSD, contrasting the 5% RSD of a pressured-balanced injection system operated under similar conditions. Programmed for partial loop injections using injection times of 300-700 ms (injection volumes in the range of 1-2.5 microL) and operated at pressures close to 30,000 psi (2070 bar), the reproducibility in peak area for the amounts injected was approximately 1.5% RSD or lower, while an injection time of 100 ms resulted in a reproducibility of 3-4% RSD. The new injection system did not show any significant carryover, and after thousands of injections, the system has not shown sign of wear, loss of pressure during injection, or loss in chromatographic performance.

Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren.

BACKGROUND: Pathways, a multisite school-based study aimed at promoting healthful eating and increasing physical activity, was a randomized field trial including 1704 American Indian third to fifth grade students from 41 schools (21 intervention, 20 controls) in seven American Indian communities. METHODS: The intervention schools received four integrated components: a classroom curriculum, food service, physical activity, and family modules. The curriculum and family components were based on Social Learning Theory, American Indian concepts, and results from formative research. Process evaluation data were collected from teachers (n=235), students (n=585), and families. Knowledge, Attitudes, and Behavior Questionnaire data were collected from 1150 students including both intervention and controls. RESULTS: There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years, based on the results of repeating the third and fourth grade test items in the fifth grade. Family members participated in Family Events and take-home activities, with fewer participating each year. CONCLUSION: A culturally appropriate school intervention can promote positive changes in knowledge, cultural identity, and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service.