Does self monitoring of blood glucose as opposed to urinalysis provide additional benefit in patients newly diagnosed with type 2 diabetes receiving structured education? The DESMOND SMBG randomised controlled trial protocol

BackgroundThe benefit of self-monitoring of blood glucose (SMBG) in people with type 2 diabetes on diet or oral agents other than sulphonylureas remains uncertain. Trials of interventions incorporating education about self-monitoring of blood glucose have reported mixed results. A recent systematic review concluded that SMBG was not cost-effective. However, what was unclear was whether a cheaper method of self-monitoring (such as urine glucose monitoring) could produce comparable benefit and patient acceptability for less cost.Methods/DesignThe DESMOND SMBG trial is comparing two monitoring strategies (blood glucose monitoring and urine testing) over 18 months when incorporated into a comprehensive self-management structured education programme. It is a multi-site cluster randomised controlled trial, conducted across 8 sites (7 primary care trusts) in England, UK involving individuals with newly diagnosed Type 2 diabetes.The trial has 80% power to demonstrate equivalence in mean HbA1c (the primary end-point) at 18 months of within ± 0.5% assuming 20% drop out and 20% non-consent. Secondary end-points include blood pressure, lipids, body weight and psychosocial measures as well as a qualitative sub-study.Practices were randomised to one of two arms: participants attend a DESMOND programme incorporating a module on self-monitoring of either urine or blood glucose. The programme is delivered by accredited educators who received specific training about equipoise. Biomedical data are collected and psychosocial scales completed at baseline, and 6, 12, and 18 months post programme. Qualitative research with participants and educators will explore views and experiences of the trial and preferences for methods of monitoring.DiscussionThe DESMOND SMBG trial is designed to provide evidence to inform the debate about the value of self-monitoring of blood glucose in people with newly diagnosed type 2 diabetes. Strengths include a setting in primary care, a cluster design, a health economic analysis, a comparison of different methods of monitoring while controlling for other components of training within the context of a quality assured structured education programme and a qualitative sub-study

Vortices, Instantons and Branes

The purpose of this paper is to describe a relationship between the moduli space of vortices and the moduli space of instantons. We study charge k vortices in U(N) Yang-Mills-Higgs theories and show that the moduli space is isomorphic to a special Lagrangian submanifold of the moduli space of k instantons in non-commutative U(N) Yang-Mills theories. This submanifold is the fixed point set of a U(1) action on the instanton moduli space which rotates the instantons in a plane. To derive this relationship, we present a D-brane construction in which the dynamics of vortices is described by the Higgs branch of a U(k) gauge theory with 4 supercharges which is a truncation of the familiar ADHM gauge theory. We further describe a moduli space construction for semi-local vortices, lumps in the CP(N) and Grassmannian sigma-models, and vortices on the non-commutative plane. We argue that this relationship between vortices and instantons underlies many of the quantitative similarities shared by quantum field theories in two and four dimensions.Comment: 32 Pages, 4 Figure

Influence of fire prevention management strategies on the diversity of butterfly fauna in the eastern Pyrenees

Fire prevention management is becoming a necessity in many Mediterranean locations to regulate fire of natural or human origin. However, very few studies have determined the real effects of the strategies adopted on local fauna. Butterflies are sensitive to local changes and they can thus serve as indicators of environmental changes. Three different types of fire prevention management approaches in three different localities in the Eastern Pyrenees (France) were performed and the butterfly community composition was investigated. We show that of the 80 species of butterflies observed, 36 % can be considered as biological markers. An original objective treatment of data using hierarchical distance analysis combined with a neural network analysis (Self-Organizing Maps) was applied in this study. Our conclusions are that the overall number of species is maintained independently of the fire prevention type but that some important changes are observed among butterfly communities, with a clear reduction of the numbers of endemic/specialized species in favour of generalist ones for the two most drastic fire prevention management approaches studied here. The influence of such approaches is discussed on the basis of the conservation of Mediterranean species of Lepidoptera

Impact of Financial Considerations on Willingness to Take Sacubitril/Valsartan for Heart Failure

Background Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out‐of‐pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. Methods and Results To evaluate the impact of out‐of‐pocket costs and a novel cost‐priming intervention on willingness to take sacubitril/valsartan for heart failure with reduced ejection fraction, participants with self‐reported heart disease were surveyed using the online Ipsos Knowledge Panel. Participants were presented with a modified decision aid for sacubitril/valsartan and then, in a 3×2 factorial design, randomly assigned to 1 of 3 cost conditions ($10,$50, or $100/month) and to a control group or cost‐priming intervention, defined by being asked questions about their financial situation before learning about the benefits of sacubitril/valsartan. Of the 1013 participants included in the analysis, 85$10, 62% at $50, and 33$100 (P<0.0001). In a multivariable logistic regression model, participants were more likely to take sacubitril/valsartan at $10 versus$100 (odds ratio [OR], 14.3 [95% CI, 9.4–21.8]) and $50 compared with$100 (OR, 3.6 [95% CI, 2.5–5.1]). Overall, participants in the cost‐primed group were more willing to take sacubitril/valsartan than those not primed to consider their financial situation (63% versus 56%, P=0.04). There was no statistically significant interaction between cost conditions and cost priming. Perceived benefit of sacubitril/valsartan over angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers decreased as cost increased but did not vary by cost priming. Conclusions Commonly encountered out‐of‐pocket costs of sacubitril/valsartan may impact individuals’ willingness to take the medication even when recommended by their physicians. Priming individuals to consider personal finances before learning about the drug increased willingness to take sacubitril/valsartan