Blood glucose self-monitoring in type 2 diabetes: a randomised controlled trial

OBJECTIVES: To determine whether self-monitoring of blood glucose (SMBG), either alone or with additional instruction in incorporating the results into self-care, is more effective than usual care in improving glycaemic control in non-insulin-treated diabetes. DESIGN: An open, parallel group randomised controlled trial. SETTING: 24 general practices in Oxfordshire and 24 in South Yorkshire, UK. PARTICIPANTS: Patients with non-insulin-treated type 2 diabetes, aged > or = 25 years and with glycosylated haemoglobin (HbA1c) > or = 6.2%. INTERVENTIONS: A total of 453 patients were individually randomised to one of: (1) standardised usual care with 3-monthly HbA1c (control, n = 152); (2) blood glucose self-testing with patient training focused on clinician interpretation of results in addition to usual care (less intensive self-monitoring, n = 150); (3) SMBG with additional training of patients in interpretation and application of the results to enhance motivation and maintain adherence to a healthy lifestyle (more intensive self-monitoring, n = 151). MAIN OUTCOME MEASURES: The primary outcome was HBA1c at 12 months, and an intention-to-treat analysis, including all patients, was undertaken. Blood pressure, lipids, episodes of hypoglycaemia and quality of life, measured with the EuroQol 5 dimensions (EQ-5D), were secondary measures. An economic analysis was also carried out, and questionnaires were used to measure well-being, beliefs about use of SMBG and self-reports of medication taking, dietary and physical activities, and health-care resource use. RESULTS: The differences in 12-month HbA1c between the three groups (adjusted for baseline HbA1c) were not statistically significant (p = 0.12). The difference in unadjusted mean change in HbA1c from baseline to 12 months between the control and less intensive self-monitoring groups was -0.14% [95% confidence interval (CI) -0.35 to 0.07] and between the control and more intensive self-monitoring groups was -0.17% (95% CI -0.37 to 0.03). There was no evidence of a significantly different impact of self-monitoring on glycaemic control when comparing subgroups of patients defined by duration of diabetes, therapy, diabetes-related complications and EQ-5D score. The economic analysis suggested that SMBG resulted in extra health-care costs and was unlikely to be cost-effective if used routinely. There appeared to be an initial negative impact of SMBG on quality of life measured on the EQ-5D, and the potential additional lifetime gains in quality-adjusted life-years, resulting from the lower levels of risk factors achieved at the end of trial follow-up, were outweighed by these initial impacts for both SMBG groups compared with control. Some patients felt that SMBG was helpful, and there was evidence that those using more intensive self-monitoring perceived diabetes as having more serious consequences. Patients using SMBG were often not clear about the relationship between their behaviour and the test results. CONCLUSIONS: While the data do not exclude the possibility of a clinically important benefit for specific subgroups of patients in initiating good glycaemic control, SMBG by non-insulin-treated patients, with or without instruction in incorporating findings into self-care, did not lead to a significant improvement in glycaemic control compared with usual care monitored by HbA1c levels. There was no convincing evidence to support a recommendation for routine self-monitoring of all patients and no evidence of improved glycaemic control in predefined subgroups of patients

Fatty acid metabolism in marine fish: Low activity of fatty acyl Δ5 desaturation in gilthead sea bream ( Sparus aurata ) cells

Marine fish are known to have an absolute dietary requirement for C20 and C22 highly unsaturated fatty acids. Previous studies using cultured cell lines indicated that underlying this requirement in marine fish was either a deficiency in fatty acyl Δ5 desaturase or C18-20 elongase activity. Recently, Ghioni et al. (Biochim. Biophys. Acta, 1437, 170-181, 1999) presented evidence that in turbot cells there was low activity of C18-20 elongase whereas Δ5 desaturase had high activity. In the present study, the fatty acid desaturase/elongase pathway was investigated in a cell line (SAF-1) from another carnivorous marine fish, sea bream. The metabolic conversions of a range of radiolabelled polyunsaturated fatty acids that comprised the direct substrates for Δ6 desaturase ([1-14C]18:2n-6 and [1-14C]18:3n-3), C18-20 elongase ([U-14C]18:4n-3), Δ5 desaturase ([1-14C]20:3n-6 and [U-14C]20:4n-3) and C20-22 elongase ([1-14C]20:4n-6 and [1-14C]20:5n-3) were utilized. The results showed that fatty acyl Δ6 desaturase in SAF-1 cells was highly active and there was substantial C18-20 elongase and C20-22 elongase activities. A deficiency in the desaturation/elongation pathway was clearly identified at the level of the fatty acyl Δ5 desaturase which was very low, particularly with 20:4n-3 as substrate. In comparison, the apparent activities of Δ6 desaturase, C18-20 elongase and C20-22 elongase were approximately 94-fold, 27-fold and 16-fold greater than that for Δ5 desaturase towards their respective n-3 polyunsaturated fatty acid substrates. The evidence obtained in the SAF-1 cell line is consistent with the dietary requirement for C20 and C22 highly unsaturated fatty acids in the marine fish, the sea bream, being primarily due to a deficiency in fatty acid Δ5 desaturase activity

Non-Equilibrium Bose-Einstein Condensates, Dynamical Scaling and Symmetric Evolution in large N Phi^4 theory

We analyze the non-equilibrium dynamics of the O(N) Phi^4 model in the large N limit and for states of large energy density. The dynamics is dramatically different when the energy density is above the top of the tree level potential V_0 than when it is below it.When the energy density is below V_0, we find that non-perturbative particle production through spinodal instabilities provides a dynamical mechanism for the Maxwell construction. The asymptotic values of the order parameter only depend on the initial energy density and all values between the minima of the tree level potential are available, the asymptotic dynamical `effective potential' is flat between the minima. When the energy density is larger than V_0, the evolution samples ergodically the broken symmetry states, as a consequence of non-perturbative particle production via parametric amplification. Furthermore, we examine the quantum dynamics of phase ordering into the broken symmetry phase and find novel scaling behavior of the correlation function. There is a crossover in the dynamical correlation length at a time scale t_s \sim \ln(1/lambda). For t < t_s the dynamical correlation length \xi(t) \propto \sqrt{t} and the evolution is dominated by spinodal instabilities, whereas for t>t_s the evolution is non-linear and dominated by the onset of non-equilibrium Bose-Einstein condensation of long-wavelength Goldstone bosons.In this regime a true scaling solution emerges with a non- perturbative anomalous scaling length dimension z=1/2 and a dynamical correlation length \xi(t) \propto (t-t_s). The equal time correlation function in this scaling regime vanishes for r>2(t-t_s) by causality. For t > t_s the equal time correlation function falls of as 1/r. A semiclassical but stochastic description emerges for time scales t > t_s.Comment: Minor improvements, to appear in Phys. Rev. D. Latex file, 48 pages, 12 .ps figure

Stochastic Acceleration by Turbulence

The subject of this paper is stochastic acceleration by plasma turbulence, a process akin to the original model proposed by Fermi. We review the relative merits of different acceleration models, in particular the so called first order Fermi acceleration by shocks and second order Fermi by stochastic processes, and point out that plasma waves or turbulence play an important role in all mechanisms of acceleration. Thus, stochastic acceleration by turbulence is active in most situations. We also show that it is the most efficient mechanism of acceleration of relatively cool non relativistic thermal background plasma particles. In addition, it can preferentially accelerate electrons relative to protons as is needed in many astrophysical radiating sources, where usually there are no indications of presence of shocks. We also point out that a hybrid acceleration mechanism consisting of initial acceleration by turbulence of background particles followed by a second stage acceleration by a shock has many attractive features. It is demonstrated that the above scenarios can account for many signatures of the accelerated electrons, protons and other ions, in particular $^3$He and $^4$He, seen directly as Solar Energetic Particles and through the radiation they produce in solar flares.Comment: 29 pages 7 figures for proceedings of ISSI-Bern workshop on Particle Acceleration 201

Evaluating data capture methods for the establishment of diagnostic reference levels in CT scanning

Objective Concerns about the radiation dose associated with CT scanning have led to a call for establishment of diagnostic reference levels. Self-complete surveys have been used extensively to gather this information, however, departmental Radiological Information System\u27s/Picture Archive Communication Systems (RIS/PACS) also hold this information. We compared dosimetry derived from survey with that using RIS/PACSs. Methods Technical data were collected from a large metropolitan tertiary hospital in WA using both data collection methods for a range of adult CT scanning examinations. Radiation dose was calculated from both datasets and the results evaluated for several indexes of inter-rater agreement. Results Radiation dose calculated using self-report survey data differed both systematically and proportionally from that calculated using RIS/PACS data. Differences were not consistent across CT examination type and thus not amenable to simple correction. The disparity was greater and more variable for organ dose than effective dose due to reliance of survey data on “generic” anatomical start and stop limits compared with actual data available on RIS/PACS. Conclusions The bias observed in our study indicates that care should be taken when interpreting the results of studies measuring radiation dose using self-complete surveys. The availability of electronic databases that include information required for the evaluation and monitoring of CT radiation dose provides the opportunity to capture better quality data in a cost-effective manner. We recommend that national and local databases are established that routinely capture these data so as to facilitate the development and monitoring of radiation dose associated with CT scanning