Efficacy and safety of insulin analogues for the management of diabetes mellitus: a meta-analysis

Background

Although insulin analogues are commonly prescribed for the management of diabetes mellitus, there is uncertainty regarding their optimal use. We conducted meta-analyses to compare the outcomes of insulin analogues with conventional insulins in the treatment of type 1, type 2 and gestational diabetes.

Methods

We updated 2 earlier systematic reviews of the efficacy and safety of rapid-and long-acting insulin analogues. We searched electronic databases, conference proceedings and “grey literature” up to April 2007 to identify randomized controlled trials that compared insulin analogues with conventional insulins. Study populations of interest were people with type 1 and type 2 diabetes (adult and pediatric) and women with gestational diabetes.

Results

We included 68 randomized controlled trials in the analysis of rapid-acting insulin analogues and 49 in the analysis of long-acting insulin analogues. Most of the studies were of short to medium duration and of low quality. In terms of hemoglobin A_1c, we found minimal differences between rapid-acting insulin analogues and regular human insulin in adults with type 1 diabetes (weighted mean difference for insulin lispro: –0.09%, 95% confidence interval [CI] –0.16% to –0.02%; for insulin aspart: –0.13%, 95% CI –0.20% to –0.07%). We observed similar outcomes among patients with type 2 diabetes (weighted mean difference for insulin lispro: –0.03%, 95% CI –0.12% to –0.06%; for insulin aspart: –0.09%, 95% CI –0.21% to 0.04%). Differences between long-acting insulin analogues and neutral protamine Hagedorn insulin in terms of hemoglobin A_1c were marginal among adults with type 1 diabetes (weighted mean difference for insulin glargine: –0.11%, 95% CI –0.21% to –0.02%; for insulin detemir: –0.06%, 95% CI –0.13% to 0.02%) and among adults with type 2 diabetes (weighted mean difference for insulin glargine: –0.05%, 95% CI –0.13% to 0.04%; for insulin detemir: 0.13%, 95% CI 0.03% to 0.22%). Benefits in terms of reduced hypoglycemia were inconsistent. There were insufficient data to determine whether insulin analogues are better than conventional insulins in reducing long-term diabetes-related complications or death.

Interpretation

Rapid-and long-acting insulin analogues offer little benefit relative to conventional insulins in terms of glycemic control or reduced hypoglycemia. Long-term, high-quality studies are needed to determine whether insulin analogues reduce the risk of long-term complications of diabetes.Diabetes mellitus is associated with serious long-term complications and premature death.¹ Data from the Health Canada National Diabetes Surveillance System indicate that, in 2004/05, diabetes was diagnosed in about 5.5% (1.8 million) of Canadians aged 20 years and older.² Because the disease goes undetected in many cases, the true prevalence may approach 1.9 million.³Tight glycemic control, to maintain a hemoglobin A_1c concentration of 7.0% or less, is recommended for all patients with diabetes to reduce the risk of long-term complications such as cardiovascular-related death, retinopathy and nephropathy.⁴ Insulin is indicated for all patients with type 1 diabetes and for patients with type 2 diabetes if adequate glycemic control cannot be achieved through exercise, diet or oral antidiabetic therapy.⁴Conventional insulins include regular human insulin and intermediate-acting neutral protamine Hagedorn insulin. However, these agents do not replicate the pattern of basal and postprandial endogenous secretion of insulin. Insulin analogues are modified human insulins developed to address this limitation.⁵ The rapid-acting insulin analogues insulin lispro, insulin aspart and insulin glulisine are marketed in Canada as bolus insulins; the long-acting agents insulin glargine and insulin detemir are marketed as basal insulins.⁶Systematic reviews of the insulin analogues have been published previously.^7–10 However, through our comprehensive search of the literature, we did not identify any reviews of long-acting insulin analogues in the management of type 1 diabetes or gestational diabetes. In this article, we provide an up-to-date, comprehensive systematic review and meta-analysis of outcomes associated with the use of rapid-and long-acting insulin analogues in type 1 and type 2 diabetes (adult and pediatric patients) and gestational diabetes. Detailed methods and complete results are reported elsewhere.^11,12     

Breast size and risk of type 2 diabetes mellitus

Background

Elevated waist circumference and body mass index (BMI), both traditional measures of obesity, are accepted risk factors for type 2 diabetes mellitus. Girls who are obese experience earlier onset of puberty and possibly greater breast development. We sought to evaluate whether a woman''s breast size in late adolescence is associated with an increased risk of type 2 diabetes mellitus in adulthood.

Methods

In conjunction with the ongoing Nurses'' Health Study II, which began to study risk factors for breast cancer among women in 1989, we conducted a prospective cohort study involving 92 106 of the participants. We assessed the risk of type 2 diabetes mellitus in relation to self-reported bra cup sizes, categorized as ≤ A, B, C and ≥ D cups, among participants at age 20.

Results

The mean age of participants at baseline was 38.1 years. A total of 1844 new cases of type 2 diabetes mellitus arose at a mean age of 44.9 years during 886 443 person-years of follow-up. Relative to bra cup size ≤ A, the respective age-adjusted hazard ratios (and 95% confidence intervals [CIs]) were 2.30 (1.99–2.66) for B cup, 4.32 (3.71–5.04) for C cup and 4.99 (4.12–6.05) for ≥ D cup. Upon further adjustments for age at menarche, parity, physical activity, smoking status, diet, multivitamin use, family history of diabetes mellitus, BMI at age 18 and current BMI, the corresponding hazard ratios (and 95% CIs) were 1.37 (1.18–1.59) for B cup, 1.80 (1.53- 2.11) for C cup and 1.64 (1.34–2.01) for ≥ D cup. The addition of waist circumference to this model minimally changed the hazard ratios (and 95% CIs): 1.32 (1.14–1.53) for B cup, 1.71 (1.46–2.01) for C cup and 1.58 (1.29–1.94) for ≥ D cup.

Interpretation

A large bra cup size at age 20 may be a predictor of type 2 diabetes mellitus in middle-aged women. Whether this relation is independent of traditional indicators of obesity remains to be determined.Obesity is an established risk factor for type 2 diabetes mellitus.^1,2 Affected individuals show signs of insulin resistance and hyperinsulinemia, a process that may begin in childhood.^3,4 Pre-adolescent obesity is also an important predictor of age of onset of breast development in young women, and of breast size after puberty.^5,6 Premature onset of puberty is preceded by childhood insulin resistance, hyperinsulinemia and hyperandrogenemia,⁷ which may persist after puberty⁸ and continue into early adulthood.⁹Although an elevated body mass index (BMI)^10,11 and central adiposity¹² are established risk factors for insulin resistance and the onset of type 2 diabetes mellitus, little is known about the contribution of extra-abdominal adipose tissue, including breast tissue, about 60% of which is fatty tissue, to this process.^13,14 We hypothesized that a woman''s breast size in late adolescence reflects her predisposition to insulin resistance and type 2 diabetes mellitus that is both additive to, and independent of, BMI. We explored this hypothesis in conjunction with the Nurses'' Health Study II by relating bra cup size, a proxy for breast size, to the onset of type 2 diabetes mellitus.     

Oral antihyperglycemic therapy for type 2 diabetes mellitus

DIABETES MELLITUS IS A CHRONIC DISEASE that is growing in prevalence worldwide. Pharmacologic therapy is often necessary to achieve optimal glycemic control in the management of diabetes. Orally administered antihyperglycemic agents (OHAs) can be used either alone or in combination with other OHAs or insulin. The number of available OHAs has increased significantly in the last decade, which translates into more therapeutic options and complex decision-making for physicians. This review article is designed to help with these decisions. We review the mechanism of action, efficacy and side effects of the different classes of OHAs (α-glucosidase inhibitors, biguanides, insulin secretagogues, insulin sensitizers and intestinal lipase inhibitor) and discuss the current recommendations for their use.Diabetes mellitus is a chronic disease that is growing in prevalence worldwide.¹ Canadian data from the National Diabetes Surveillance Strategy demonstrate a prevalence of 4.8% among adults, with the vast majority having type 2 diabetes.²With the growing elderly Canadian population, the rising prevalence of obesity and the alarming increase in childhood and adolescent type 2 diabetes, the burden of this disease will continue to grow. Aggressive glycemic control has been demonstrated to decrease microvascular^3,4,5 and perhaps macrovascular^6,7 complications, although the latter claim remains controversial. The Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada⁸ recommends a target hemoglobin A_1c concentration of 7.0% or less for all patients with diabetes and, for those in whom it can be safely achieved, a target hemoglobin A_1c concentration in the normal range (usually ≤ 6.0%).⁸ Although nonpharmacologic therapy (e.g., diet, exercise and weight loss) remains a critical component in the treatment of diabetes, pharmacologic therapy is often necessary to achieve optimal glycemic control. Orally administered antihyperglycemic agents (OHAs) can be used either alone or in combination with other OHAs or insulin. The number of available OHAs has increased significantly in the last decade, which translates into more therapeutic options and complex decision-making. This article reviews the mechanism of action, efficacy and side effects of each OHA drug class (α-glucosidase inhibitors, biguanides, insulin secretagogues, insulin sensitizers and intestinal lipase inhibitor) and the current recommendations for their use.     

Independent associations between low-density lipoprotein cholesterol and cancer among patients with type 2 diabetes mellitus

Background

The risk association between low-density lipoprotein (LDL) cholesterol and cancer remains controversial and largely unexplored for people not receiving statin therapy.

Methods

We examined the risk association between LDL cholesterol and cancer among patients with type 2 diabetes mellitus who were free of cancer at enrolment and whose statin use was known. We considered a variety of nonlinear relationships in our analysis.

Results

During a median follow-up period of 4.90 years, cancer developed in 270 (4.4%) of 6107 patients. Among the 3800 patients who did not receive statin therapy, the risk association between LDL cholesterol and cancer was represented by a V-shaped curve. Compared with patients whose LDL cholesterol was at least 2.80 mmol/L but less than 3.80 mmol/L, the risk of cancer, death from any cause or the composite outcome of cancer or death was greater among those with an LDL cholesterol level of less than 2.80 mmol/L (hazard ratio for cancer 1.74, 95% confidence interval [CI] 1.20–2.52) and those with an LDL cholesterol level of 3.80 mmol/L or greater (hazard ratio for cancer 1.87, 95% CI 1.29–2.71). Using 3.8 mmol/L as a reference point, we found that the hazard ratio for cancer for every millimole per litre absolute change in LDL cholesterol was 1.54 (95% CI 1.19–1.99) among patients not using statins; the hazard ratio was reduced to 1.24 (1.01–1.53) for the entire sample (statin users and those not using statins). These associations persisted after adjustment for covariates and exclusion of patients with less than 2.5 years of follow-up.

Interpretation

Among patients with type 2 diabetes, the association between LDL cholesterol and cancer was V-shaped, whereby both low and high levels of LDL cholesterol were associated with elevated risk of cancer.Emerging data suggest an association between diabetes mellitus and an increased risk of cancer,¹ including breast cancer in women;² colorectal,³ pancreatic^4,5 and liver⁶ cancer in both men and women; and prostate cancer in men.⁷ Several prospective analyses, including the US National Health and Nutrition Examination Survey,⁸ have demonstrated an inverse relation between serum total cholesterol and cancer incidence and mortality in the general population, although few studies have investigated this relation among patients with type 2 diabetes mellitus. In 2004, the US National Cholesterol Education Program Adult Treatment Panel III recommended treatment targets for low-density lipoprotein (LDL) cholesterol of less than 1.81 mmol/L (less than 70 mg/dL) for patients with very high risk of coronary artery disease and less than 2.59 mmol/L (less than 100 mg/dL) for patients with high risk of coronary artery disease;⁹ these targets were intended for both diabetic and nondiabetic patients.These recommendations remain controversial. Although one recent analysis of a large cohort of patients treated with statins showed a greater risk of cancer with achievement of low LDL cholesterol,¹⁰ a more recent study reported otherwise.¹¹ Furthermore, the independent associations between LDL cholesterol level and cancer in both the general population and in patients with type 2 diabetes have not been explored. We conducted a hypothesis-generating study to explore the possible independent association between LDL cholesterol and cancer risk in Chinese patients with type 2 diabetes mellitus.     

Role of Muscle c-Jun NH2-Terminal Kinase 1 in Obesity-Induced Insulin Resistance

Obesity caused by feeding of a high-fat diet (HFD) is associated with an increased activation of c-Jun NH₂-terminal kinase 1 (JNK1). Activated JNK1 is implicated in the mechanism of obesity-induced insulin resistance and the development of metabolic syndrome and type 2 diabetes. Significantly, Jnk1^−/− mice are protected against HFD-induced obesity and insulin resistance. Here we show that an ablation of the Jnk1 gene in skeletal muscle does not influence HFD-induced obesity. However, muscle-specific JNK1-deficient (M^KO) mice exhibit improved insulin sensitivity compared with control wild-type (M^WT) mice. Thus, insulin-stimulated AKT activation is suppressed in muscle, liver, and adipose tissue of HFD-fed M^WT mice but is suppressed only in the liver and adipose tissue of M^KO mice. These data demonstrate that JNK1 in muscle contributes to peripheral insulin resistance in response to diet-induced obesity.Obesity is a major risk factor for the development of insulin resistance, hyperglycemia, and metabolic syndrome that can lead to β-cell dysfunction and type 2 diabetes (8). The prevalence of human obesity represents a serious health problem in the United States. It is therefore important that we obtain a detailed understanding of the molecular mechanism that accounts for obesity-induced insulin resistance. Recent progress has led to the identification of signal transduction pathways that may mediate the effects of obesity on insulin resistance (14, 23).c-Jun NH₂-terminal kinase 1 (JNK1) represents one signaling pathway that has been implicated in the pathogenesis of metabolic syndrome and type 2 diabetes (21). JNK1 is activated when mice are fed a high-fat diet (HFD) (7). Moreover, Jnk1^−/− mice are protected against HFD-induced insulin resistance (7). The mechanism of protection is mediated, in part, by the failure of Jnk1^−/− mice to develop HFD-induced obesity (7). However, JNK1 can regulate insulin resistance independently of obesity. Thus, mice with an adipose tissue-specific JNK1 deficiency develop normal diet-induced obesity but exhibit selective protection against HFD-induced insulin resistance in both the liver and adipose tissue (16). These data indicate that adipose tissue JNK1 plays a critical role during the development of HFD-induced insulin resistance.The liver plays a key role in the insulin-stimulated disposal of blood glucose during the postprandial state because of reduced gluconeogenesis and increased glycogen synthesis (17). However, glucose uptake by skeletal muscle also makes a major contribution to insulin-stimulated glucose disposal (17). Muscle may therefore be an important target of obesity-induced JNK1 signaling and the regulation of glucose homeostasis.The purpose of this study was to test the role of JNK1 in muscle. Our approach was to examine the effect of a muscle-specific ablation of the Jnk1 gene in mice. We found that HFD-fed control wild-type (M^WT) mice and muscle-specific JNK1-deficient (M^KO) mice became similarly obese. However, M^KO mice were selectively protected against HFD-induced insulin resistance. This analysis demonstrates that muscle JNK1 contributes to the effects of obesity on insulin resistance.     

Economic evaluation of sirolimus-eluting stents

Background

Sirolimus-eluting stents have recently been shown to reduce the risk of restenosis among patients who undergo percutaneous coronary intervention (PCI). Given that sirolimus-eluting stents cost about 4 times as much as conventional stents, and considering the volume of PCI procedures, the decision to use sirolimus-eluting stents has large economic implications.

Methods

We performed an economic evaluation comparing treatment with sirolimus-eluting and conventional stents in patients undergoing PCI and in subgroups based on age and diabetes mellitus status. The probabilities of transition between clinical states and estimates of resource use and health-related quality of life were derived from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Information on effectiveness was based on a meta-analysis of randomized controlled clinical trials (RCTs) comparing sirolimus-eluting and conventional stents.

Results

Cost per quality-adjusted life year (QALY) gained in the baseline analysis was Can$58 721. Sirolimus-eluting stents were more cost-effective in patients with diabetes and in those over 75 years of age, the costs per QALY gained being $44 135 and $40 129, respectively. The results were sensitive to plausible variations in the cost of stents, the estimate of the effectiveness of sirolimus-eluting stents and the assumption that sirolimus-eluting stents would prevent the need for cardiac catheterizations in the subsequent year when no revascularization procedure was performed to treat restenosis.

Interpretation

The use of sirolimus-eluting stents is associated with a cost per QALY that is similar to or higher than that of other accepted medical forms of therapy and is associated with a significant incremental cost. Sirolimus-eluting stents are more economically attractive for patients who are at higher risk of restenosis or at a high risk of death if a second revascularization procedure were to be required.Restenosis is a major limitation to the long-term success of percutaneous coronary intervention (PCI). It is estimated that 14% of patients who undergo PCI with stent implantation require a second intervention within a year to manage restenosis.¹ A second coronary procedure carries a significant risk of death or impairment in health-related quality of life (HRQOL).² Moreover, given that approximately 21 200 PCIs with stenting were performed in Canada in 1999, restenosis has major economic implications.³Drug-eluting stents are the most recent technologic advance in restenosis prevention. To date, 4 randomized controlled clinical trials (RCTs) have compared the efficacy of sirolimus-eluting stents (the first available drug-eluting stent) and standard uncoated stents in the treatment of de novo native coronary artery disease and published their findings: RAVEL⁴ (RAndomized study with the sirolimus-eluting VELocity balloon-expandable stent), SIRIUS⁵ (study of the SIRolImUS-eluting stent), and C-SIRIUS⁶ and E-SIRIUS,⁷ the Canadian and European arms of SIRIUS. These trials all found notable reductions in the incidence of radiographic evidence of restenosis and symptomatic restenosis with the use of sirolimus-eluting stents. However, the overall survival rate was not affected. Currently, the cost of sirolimus-eluting stents (about Can$2900 per stent) is nearly 4 times that of conventional stents.⁸ Given the volume of PCIs performed annually, decision-makers must determine their optimal use.Using a subset of the cohort in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH),⁹ we estimated clinical event rates, HRQOL and health care costs for patients undergoing PCI with implantation of a conventional stent. Combining this information with data from the 4 RCTs, we estimated the cost per quality-adjusted life-year (QALY) gained by using sirolimus-eluting stents rather than conventional stents for such patients.     

Differential Effects of Protein Kinase B/Akt Isoforms on Glucose Homeostasis and Islet Mass

Protein kinase B (PKB)/Akt is considered to be a key target downstream of insulin receptor substrate 2 (IRS2) in the regulation of β-cell mass. However, while deficiency of IRS2 in mice results in diabetes with insulin resistance and severe failure of β-cell mass and function, only loss of the PKBβ isoform leads to a mild metabolic phenotype with insulin resistance. Other isoforms were reported not to be required for metabolic regulation. To clarify the roles of the three PKB isoforms in the regulation of islet mass and glucose homeostasis, we assessed the metabolic and pancreatic phenotypes of Pkbα, Pkbβ, and Pkbγ-deficient mice. Our study uncovered a novel role for PKBα in the regulation of glucose homeostasis, whereas it confirmed that Pkbβ^−/− mice are insulin resistant with compensatory increase of islet mass. Pkbα^−/− mice displayed an opposite phenotype with improved insulin sensitivity, lower blood glucose, and higher serum glucagon concentrations. Pkbγ^−/− mice did not show metabolic abnormalities. Additionally, our signaling analyses revealed that PKBα, but not PKBβ or PKBγ, is specifically activated by overexpression of IRS2 in β-cells and is required for IRS2 action in the islets.Adaptation of pancreatic islet mass and function relative to metabolic demand maintains glucose homeostasis and may prevent the development of type 2 diabetes. β-Cell proliferation, apoptosis, growth, and function are tightly regulated by various extracellular factors and intracellular signaling pathways (23, 24, 34). In β-cells, insulin receptor substrate 2 (IRS2) controls maintenance and expansion of islet mass (29, 31, 42). In fact, IRS2-deficient mice are insulin resistant, show β-cell failure and hyperglycemia, and finally develop diabetes (26, 42). In contrast, deficiency of IRS1 only causes insulin resistance without the development of diabetes due to a compensatory increase in functional β-cell mass (1, 38). These observations indicated that IRS2, but not IRS1, is necessary for maintenance and compensatory increase of β-cell mass. Furthermore, experiments with isolated islets revealed that overexpression of IRS2, but not of IRS1, can increase β-cell proliferation and protect cells against high-glucose-induced apoptosis (29). Downstream of IRS2, phosphoinositide 3-kinase (PI3K)-protein kinase B (PKB) signaling is considered to be the critical pathway for the regulation of β-cell mass and function (12, 15, 16, 27). The serine-threonine kinase PKB, also known as Akt, is required for various cellular processes, from the regulation of cell cycle, survival, and growth to glucose and protein metabolism. In mammals, three PKB/Akt isoforms have been characterized and named PKBα/Akt1, PKBβ/Akt2, and PKBγ/Akt3. Although encoded by different genes on different chromosomes, the three isoforms display high homology at the protein level with 80 to 85% identical residues and the same structural organization (43). However, they differ in terms of tissue-specific expression. PKBα is expressed in most tissues and PKBβ is highly expressed in insulin-responsive tissues, whereas PKBγ expression is prominent in the brain and testes (17). All three isoforms are expressed in β-cells (30, 37). The roles of PKB in different tissues have been studied in transgenic-mouse models. While Pkbα^−/− and Pkbγ^−/− mice show impaired fetal growth and brain development, respectively, glucose homeostasis is unaffected in both models (9, 11, 14, 39, 46). In contrast, Pkbβ^−/− mice are insulin resistant and mildly glucose intolerant and have less adipose tissue. Depending on the strain and gender, these mice show either late loss of β-cells followed by the development of diabetes and mild growth deficiency or compensatory increase of β-cell mass without age-dependent progression into overt hyperglycemia (10, 17). These studies suggested that PKBβ is the only isoform playing a role in the regulation of energy homeostasis. On the other hand, constitutive activation of PKBα in β-cells is sufficient to increase growth and proliferation (5, 40), and in INS1 cells it prevents free fatty acid (FFA)-induced apoptosis (44). Furthermore, antagonizing total PKB activity in β-cells by ectopic expression of a kinase-dead mutant causes defects in insulin secretion (4), suggesting that in islets PKB is required mainly for normal function of the β-cells. Although these data support the notion that PKB must play a role in pancreatic β-cells, they are not in line with the stronger metabolic phenotype displayed by IRS2-deficient mice. In fact, PKBα and PKBγ appear not to be required to regulate glucose homeostasis (9, 11, 39), and in the case of Pkbβ^−/− mice, even though glucose homeostasis is impaired due to strong peripheral insulin resistance, the overall metabolic phenotype is far less severe than in Irs2^−/− mice (10), indicating that the capacity for β-cell compensation is retained in the absence of PKBβ.The aim of this study was to clarify the role of PKB in the regulation of islet mass and to define the relevance of PKB isoforms for IRS2 action in β-cells. Although it had been shown that PKBα is dispensable for the regulation of glucose homeostasis (9, 11), we found lower blood glucose concentrations in Pkbα^−/− mice. Based on this observation, we assessed in more detail the metabolic and the endocrine pancreatic phenotypes of Pkbα-, Pkbβ-, or Pkbγ-deficient mice. In addition, glucose uptake into fat cells, insulin secretion, and islet cell proliferation were investigated. Contrary to previous assumptions implying that PKBβ is the only (or at least the main) isoform playing a role in the regulation of glucose metabolism, we present evidence that both PKBα and PKBβ isoforms are required in the periphery for regulation of glucose homeostasis. While we confirmed that Pkbβ^−/− mice are insulin resistant and glucose intolerant with compensatory increase of β-cell mass, Pkbα^−/− mice showed lower blood glucose levels, were more insulin sensitive, and revealed higher serum glucagon concentrations accompanied by a mild increase in α-cell mass and proliferation. Moreover, our in vitro experiments showed that PKBα is specifically activated by IRS2 in β-cells and that its activation is required for IRS2-induced proliferation in islets.     

Insulin Regulates Adipocyte Lipolysis via an Akt-Independent Signaling Pathway

After a meal, insulin suppresses lipolysis through the activation of its downstream kinase, Akt, resulting in the inhibition of protein kinase A (PKA), the main positive effector of lipolysis. During insulin resistance, this process is ineffective, leading to a characteristic dyslipidemia and the worsening of impaired insulin action and obesity. Here, we describe a noncanonical Akt-independent, phosphoinositide-3 kinase (PI3K)-dependent pathway that regulates adipocyte lipolysis using restricted subcellular signaling. This pathway selectively alters the PKA phosphorylation of its major lipid droplet-associated substrate, perilipin. In contrast, the phosphorylation of another PKA substrate, hormone-sensitive lipase (HSL), remains Akt dependent. Furthermore, insulin regulates total PKA activity in an Akt-dependent manner. These findings indicate that localized changes in insulin action are responsible for the differential phosphorylation of PKA substrates. Thus, we identify a pathway by which insulin regulates lipolysis through the spatially compartmentalized modulation of PKA.The storage and mobilization of nutrients from specialized tissues requires the spatial organization of both signaling functions and energy stores. Nowhere is this more evident than in mammalian adipose tissue, which maintains the most efficient repository for readily available energy. Here, fuel is segregated into lipid droplets, once thought to be inert storehouses but now recognized as complex structures that represent a regulatable adaptation of a ubiquitous organelle (5, 40). The synthesis and maintenance of functional lipid droplets requires numerous proteins, not only fatty acid binding proteins and enzymes of lipid synthesis but also molecules critical to constitutive and specialized membrane protein trafficking (23).During times of nutritional need, triglycerides within the adipocyte lipid droplet are hydrolyzed into their components, fatty acids, acyl-glycerides, and, ultimately, glycerol. This process, termed lipolysis, is controlled dynamically by multiple hormonal signals that respond to the nutrient status of the organism. During fasting, catecholamines such as norepinephrine stimulate lipolysis via beta-adrenergic receptor activation, promoting adenylyl cyclase activity and the production of cyclic AMP (cAMP) (17). cAMP binds to the regulatory subunits of its major effector, protein kinase A (PKA), triggering the dissociation of these subunits and the subsequent activation of the catalytic subunits (62, 63). PKA is frequently sequestered into multiple parallel, intracellular signaling complexes, though such structures have not been studied in hormone-responsive adipocytes (68). Two targets of activated PKA important for lipolysis are hormone-sensitive lipase (HSL) and perilipin, the major lipid droplet coat protein (17). The phosphorylation of HSL on Ser 559/660 is crucial for its activation and translocation to the lipid droplet, where HSL catalyzes the hydrolysis of diglycerides to monoglycerides (26, 55). Another lipase, adipose triglyceride lipase (ATGL), carries out the initial cleavage of triglycerides to diglycerides and most likely is rate limiting for lipolysis, but it does not appear to be regulated directly via PKA phosphorylation (24, 73). Perilipin under basal conditions acts as a protective barrier against lipase activity; upon stimulation, the phosphorylation of least six PKA consensus sites triggers a conformational change in perilipin, permitting access to the lipid substrates in the droplet, the recruitment of HSL, and possibly the activation of ATGL (7, 8, 21, 41, 46, 58, 60, 61). Perilipin, therefore, possesses dual functions, both blocking lipolysis in the basal state as well as promoting lipolysis upon its phosphorylation (5, 58, 60).Following the ingestion of a meal, insulin stimulates the uptake of nutrients such as glucose into specialized tissues and also potently inhibits lipolysis in adipocytes (17). Insulin signaling in the adipocyte involves the activation of the insulin receptor tyrosine kinase, the phosphorylation of insulin receptor substrates, the activation of PI3K, and the subsequent production of specific phosphoinositides at the plasma membrane (59). These phosphoinositides then recruit Akt, via its pleckstrin homology domain, to the plasma membrane, where Akt becomes phosphorylated and activated by two upstream kinases. Akt stimulates the translocation of the glucose transporter GLUT4 to the plasma membrane, thereby promoting the uptake of glucose into the cell (2). The mechanism by which insulin inhibits lipolysis has been proposed to involve the reduction of cAMP levels and thus PKA activity. In this model, insulin signaling activates phosphodiesterase 3b (PDE3b) via the Akt-mediated phosphorylation of Ser273 (14, 32). Upon activation by Akt, PDE3b catalyzes the hydrolysis of cAMP to 5′AMP, thereby attenuating PKA activity and lipolysis. Recent studies of PDE3b knockout mice have highlighted the importance of PDE3b activity in the regulation of lipolysis but were uninformative regarding the mechanism of insulin action (12). Adipocytes isolated from these mice exhibit reduced responses to insulin with respect to lipolysis, but it is not clear whether this is due to the loss of the critical target enzyme or a normal mechanism being overwhelmed by supraphysiological concentrations of cAMP (12). Biochemical studies using dominant-inhibitory Akt have demonstrated that Akt can regulate PDE3b activity, and other studies also have suggested that Akt interacts directly with PDE3b, implying a direct connection to lipolysis regulation (1, 32). Nevertheless, the actual requirement for Akt in insulin action with regard to the lipolysis itself has not been demonstrated directly in, for example, genetic loss-of-function experiments.There now is substantial evidence implicating elevated free fatty acid levels as a consequence of inappropriate lipolysis as a major etiological factor for insulin resistance and type 2 diabetes mellitus (T2DM) (51). Conditions such as obesity and diabetes are characterized by a pathophysiological state in which these tissues become unresponsive to insulin, which contribute to the adverse long-term sequelae of diseases such as T2DM and the metabolic syndrome (4, 44). Thus, understanding in detail the mechanism by which insulin suppresses fat cell lipolysis is critical to identifying the underlying defect in resistant adipose tissue and ultimately developing effective therapeutics. In the present study, we investigated both Akt-dependent and -independent modes of insulin action toward lipolysis. We found the latter to predominate at low, physiological levels of adrenergic stimulation, acting via a pathway dependent on the preferential phosphorylation of downstream PKA substrates.     

Signal Transduction Cross Talk Mediated by Jun N-Terminal Kinase-Interacting Protein and Insulin Receptor Substrate Scaffold Protein Complexes

Scaffold proteins have been established as important mediators of signal transduction specificity. The insulin receptor substrate (IRS) proteins represent a critical group of scaffold proteins that are required for signal transduction by the insulin receptor, including the activation of phosphatidylinositol 3 kinase. The c-Jun NH₂-terminal kinase (JNK)-interacting proteins (JIPs) represent a different group of scaffold molecules that are implicated in the regulation of the JNK. These two signaling pathways are functionally linked because JNK can phosphorylate IRS1 on the negative regulatory site Ser-307. Here we demonstrate the physical association of these signaling pathways using a proteomic approach that identified insulin-regulated complexes of JIPs together with IRS scaffold proteins. Studies using mice with JIP scaffold protein defects confirm that the JIP1 and JIP2 proteins are required for normal glucose homeostasis. Together, these observations demonstrate that JIP proteins can influence insulin-stimulated signal transduction mediated by IRS proteins.The c-Jun NH₂-terminal kinase (JNK)-interacting proteins (JIPs) are implicated in the regulation of the JNK signal transduction pathway (8, 28). The JIP1 and JIP2 proteins are structurally related with similar modular domains (SH3 and PTB) and binding sites for the mixed-lineage protein kinase (MLK) group of mitogen-activated protein kinase (MAPK) kinase kinases, the MAPK kinase MKK7, and JNK (19). These JIP proteins also interact with the microtubule motor protein kinesin, several guanine nucleotide exchange factors, the phosphatase MKP7, Src-related protein kinases, and AKT to form multifunctional protein complexes (19).One potential physiological role of JIP scaffold proteins is the response to metabolic stress, insulin resistance, and diabetes. Several lines of evidence support this hypothesis. First, JIP1 is required for metabolic stress-induced activation of JNK in white adipose tissue (12). Second, MLKs that interact with JIP proteins are implicated as essential components of a signaling pathway that mediates the effects of metabolic stress on JNK activation (13). Third, studies have demonstrated that the human Jip1 gene may contribute to the development of type 2 diabetes, because a Jip1 missense mutation was found to segregate with type 2 diabetes (26). Collectively, these data suggest that JIP proteins play a role in the cellular response to metabolic stress and the regulation of insulin resistance.It is established that the insulin receptor substrate (IRS) group of scaffold proteins plays a central role in insulin signaling (27). Treatment of cells with insulin causes tyrosine phosphorylation of the insulin receptor, the recruitment of IRS proteins to the insulin receptor, and the subsequent tyrosine phosphorylation of IRS proteins on multiple residues that act as docking sites for insulin-regulated signaling molecules, including phosphatidylinositol 3 kinase (27). Negative regulation of IRS proteins is implicated as a mechanism of insulin resistance and can be mediated by multiple pathways, including IRS protein phosphorylation and degradation. Thus, the mTOR/p70^S6K (21, 22, 24) and the SOCS-1/3 (20) signaling pathways can regulate IRS protein degradation. Multisite phosphorylation on Ser/Thr residues can also regulate IRS protein function, including JNK phosphorylation of IRS1 on the inhibitory site Ser-307 that prevents recruitment of IRS1 to the activated insulin receptor (2).The IRS and JIP groups of scaffold proteins may function independently to regulate JNK-dependent and insulin-dependent signal transduction. However, functional connections between these scaffold proteins have been identified. Thus, studies using Jip1^−/− mice demonstrate that JIP1 is required for high-fat-diet-induced JNK activation in white adipose tissue, IRS1 phosphorylation on the inhibitory site Ser-307, and insulin resistance (12). These data suggest that JIP scaffold proteins function cooperatively with IRS proteins to regulate signal transduction by the insulin receptor. The purpose of this study was to examine cross talk between the JIP and IRS scaffold complexes. We demonstrate that the JIP and IRS scaffold complexes physically interact in an insulin-dependent manner and confirm that JIP proteins influence normal glucose homeostasis.     

Access to health care among status Aboriginal people with chronic kidney disease

Background

Ethnic disparities in access to health care and health outcomes are well documented. It is unclear whether similar differences exist between Aboriginal and non-Aboriginal people with chronic kidney disease in Canada. We determined whether access to care differed between status Aboriginal people (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease.

Methods

We identified 106 511 non-Aboriginal and 1182 Aboriginal patients with chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m²). We compared outcomes, including hospital admissions, that may have been preventable with appropriate outpatient care (ambulatory-care–sensitive conditions) as well as use of specialist services, including visits to nephrologists and general internists.

Results

Aboriginal people were almost twice as likely as non-Aboriginal people to be admitted to hospital for an ambulatory-care–sensitive condition (rate ratio 1.77, 95% confidence interval [CI] 1.46–2.13). Aboriginal people with severe chronic kidney disease (estimated glomerular filtration rate < 30 mL/min/1.73 m²) were 43% less likely than non-Aboriginal people with severe chronic kidney disease to visit a nephrologist (hazard ratio 0.57, 95% CI 0.39–0.83). There was no difference in the likelihood of visiting a general internist (hazard ratio 1.00, 95% CI 0.83–1.21).

Interpretation

Increased rates of hospital admissions for ambulatory-care–sensitive conditions and a reduced likelihood of nephrology visits suggest potential inequities in care among status Aboriginal people with chronic kidney disease. The extent to which this may contribute to the higher rate of kidney failure in this population requires further exploration.Ethnic disparities in access to health care are well documented;^1,2 however, the majority of studies include black and Hispanic populations in the United States. The poorer health status and increased mortality among Aboriginal populations than among non-Aboriginal populations,^3,4 particularly among those with chronic medical conditions,^5,6 raise the question as to whether there is differential access to health care and management of chronic medical conditions in this population.The prevalence of end-stage renal disease, which commonly results from chronic kidney disease, is about twice as common among Aboriginal people as it is among non-Aboriginal people.^7,8 Given that the progression of chronic kidney disease can be delayed by appropriate therapeutic interventions^9,10 and that delayed referral to specialist care is associated with increased mortality,^11,12 issues such as access to health care may be particularly important in the Aboriginal population. Although previous studies have suggested that there is decreased access to primary and specialist care in the Aboriginal population,^13–15 these studies are limited by the inclusion of patients from a single geographically isolated region,¹³ the use of survey data,¹⁴ and the inability to differentiate between different types of specialists and reasons for the visit.¹⁵In addition to physician visits, admission to hospital for ambulatory-care–sensitive conditions (conditions that, if managed effectively in an outpatient setting, do not typically result in admission to hospital) has been used as a measure of access to appropriate outpatient care.^16,17 Thus, admission to hospital for an ambulatory-care–sensitive condition reflects a potentially preventable complication resulting from inadequate access to care. Our objective was to determine whether access to health care differs between status Aboriginal (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease. We assess differences in care by 2 measures: admission to hospital for an ambulatory-care–sensitive condition related to chronic kidney disease; and receipt of nephrology care for severe chronic kidney disease as recommended by clinical practice guidelines.¹⁸     

Postdischarge thromboprophylaxis and mortality risk after hip-or knee-replacement surgery

Background

Patients undergoing hip or knee replacement are at high risk of developing a postoperative venous thromboembolism even after discharge from hospital. We sought to identify hospital and patient characteristics associated with receiving thromboprophylaxis after discharge and to compare the risk of short-term mortality among those who did or did not receive thromboprophylaxis.

Methods

We conducted a retrospective cohort study using system-wide hospital discharge summary records, physician billing information, medication reimbursement claims and demographic records. We included patients aged 65 years and older who received a hip or knee replace ment and who were discharged home after surgery.

Results

In total we included 10 744 patients. Of these, 7058 patients who received a hip replacement and 3686 who received a knee replacement. The mean age was 75.4 (standard deviation [SD] 6.8) years and 38% of patients were men. In total, 2059 (19%) patients received thomboprophylaxis at discharge. Patients discharged from university teaching hospitals were less likely than those discharged from community hospitals to received thromboprophylaxis after discharge (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80–1.00). Patients were less likely to receive thromboprophylaxis after discharge if they had a longer hospital stay (15–30 days v. 1–7 days, OR 0.69, 95% CI 0.59–0.81). Patients were more likely to receive thromboprophylaxis if they had hip (v. knee) replacement, osteoarthritis, heart failure, atrial fibrillation or hypertension, higher (v. lower) income or if they were treated at medium-volume hospitals (69–116 hip and knee replacements per year). In total, 223 patients (2%) died in the 3-month period after discharge. The risk of short-term mortality was lower among those who received thromboprophylaxis after discharge (hazard ratio [HR] 0.34, 95% CI 0.20–0.57).

Interpretation

Fewer than 1 in 5 elderly patients discharged home after a hip-or knee-replacement surgery received postdischarge thromboprophylaxis. Those prescribed these medications had a lower risk of short-term mortality. The benefits of and barriers to thromboprophylaxis therapy after discharge in this population requires further study.Venous thromboembolism is a leading cause of mortality among patients in hospital.^1,2 Major orthopedic surgery (e.g., hip or knee replacement) is associated with a high risk for postoperative venous thromboembolism.^1,3,4 Because the clinical diagnosis of venous thromboembolism is unreliable and its first manifestation may be a life-threatening pulmonary embolism,⁵ it is recommended that patients undergoing hip or knee replacement receive routine thromboprophylaxis with anticoagulant therapy after surgery unless they have contraindications to anticoagulant therapy.^1,3,5,6Thromboprophylaxis is commonly administered for the entire hospital stay, which is usually between 4 and 14 days.⁷ Expert consensus guidelines recommend that patients undergoing hip or knee replacement receive thromboprophylaxis medications for at least 10 days after surgery.⁶ These guidelines also recommend extended thromboprophylaxis for up to 28–35 days after surgery for patients undergoing hip replacement.⁶ Although there is evidence that extended thromboprophylaxis after hospital discharge is effective for reducing the risk of venous thromboembolism among patients who undergo hip replacement,⁸ the benefit among patients who undergo knee replacement has not been established.⁶ Thromboprophylaxis after discharge is likely to most benefit patients at high risk for venous thromboembolism, such as those with cancer, heart failure or major respiratory disease.^6–9 However, given that patients who undergo joint replacement are often elderly and have multiple comorbidities, the risks associated with extended thromboprophylaxis, particularly gastrointestinal bleeding and hemorrhagic strokes, may be substantial and may be relative contraindications for this therapy.¹⁰Among patients discharged home after hip-or knee-replacement surgery, we sought characterize the use of thromboprophylaxis after discharge and its consequences on risk of short-term mortality.     

Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: a cluster randomized controlled trial

Background

Sport is the leading cause of injury requiring medical attention among adolescents. We studied the effectiveness of a home-based balance-training program using a wobble board in improving static and dynamic balance and reducing sports-related injuries among healthy adolescents.

Methods

In this cluster randomized controlled trial, we randomly selected 10 of 15 high schools in Calgary to participate in the fall of 2001. We then recruited students from physical education classes and randomly assigned them, by school, to either the intervention (n = 66) or the control (n = 61) group. Students in the intervention group participated in a daily 6-week and then a weekly 6-month home-based balance-training program using a wobble board. Students at the control schools received testing only. The primary outcome measures were timed static and dynamic balance, 20-m shuttle run and vertical jump, which were measured at baseline and biweekly for 6 weeks. Self-reported injury data were collected over the 6-month follow-up period.

Results

At 6 weeks, improvements in static and dynamic balance were observed in the intervention group but not in the control group (difference in static balance 20.7 seconds, 95% confidence interval [CI] 10.8 to 30.6 seconds; difference in dynamic balance 2.3 seconds, 95% CI 0.7 to 4.0 seconds). There was evidence of a protective effect of balance training in over 6 months (relative risk of injury 0.2, 95% CI 0.05 to 0.88). The number needed to treat to avoid 1 injury over 6 months was 8 (95% CI 4 to 35).

Interpretation

Balance training using a wobble board is effective in improving static and dynamic balance and reducing sports-related injuries among healthy adolescents.Adolescents commonly participate in sports.^1,2 In a survey of adolescents in Alberta, 59% reported that they took part in sports more than 5 hours per week (unpublished data). In North America, sport is the leading cause of injury requiring medical attention and visits to an emergency department among adolescents.^3,4 In Alberta 26% of youths aged 15–19 years in a survey reported sustaining a sports-related injury requiring medical attention.⁵ The impact may be lifelong, as there is evidence that knee and ankle injuries may result in an increased risk of osteoarthritis later in life.^6,7,8 In addition, each year 8% of adolescents drop out of sports activities because of injury.⁹ The reduction in physical activity resulting from sports-related injuries could have significant long-term effects on morbidity and mortality.^10,11Proprioceptive balance training is used in rehabilitation following sports-related injuries and is becoming recognized as an important element in injury prevention in sports.^{12,13,14,15,16,17,18,19} Running, jumping or pivoting on one leg relies on a sense of joint position and muscular control for joint stability. There is evidence that static balance improves following proprioceptive balance training using a wobble board.^20,21,22,23 However, most of these studies did not examine the effect of dynamic proprioceptive balance training, which may improve postural control in athletic situations and prevent some injuries.There is evidence from randomized trials that multifaceted prevention programs, including proprioceptive balance training using a wobble board, are effective in reducing injuries to the lower extremities in specific sports.^{12,13,14,15,16,17,18,19} However, the programs in these trials were multifaceted (i.e., included warm-up, flexibility, jump training, strength training, rehabilitation and sport-specific technical components), and balance was not measured. The effectiveness of balance training alone on balance ability and prevention of injury remains unclear. Moreover, the use of these techniques in adolescents and non-elite athletes has not been studied.The objectives of our study were to determine the effectiveness of a proprioceptive home-based balance-training program in improving static and dynamic balance in adolescents and to examine the effectiveness of this training program on reducing sports-related injury among adolescents.     

Requirement of JIP1-Mediated c-Jun N-Terminal Kinase Activation for Obesity-Induced Insulin Resistance

The c-Jun NH₂-terminal kinase (JNK) interacting protein 1 (JIP1) has been proposed to act as a scaffold protein that mediates JNK activation. However, recent studies have implicated JIP1 in multiple biochemical processes. Physiological roles of JIP1 that are related to the JNK scaffold function of JIP1 are therefore unclear. To test the role of JIP1 in JNK activation, we created mice with a germ line point mutation in the Jip1 gene (Thr¹⁰³ replaced with Ala) that selectively blocks JIP1-mediated JNK activation. These mutant mice exhibit a severe defect in JNK activation caused by feeding of a high-fat diet. The loss of JIP1-mediated JNK activation protected the mutant mice against obesity-induced insulin resistance. We conclude that JIP1-mediated JNK activation plays a critical role in metabolic stress regulation of the JNK signaling pathway.Diet-induced obesity causes insulin resistance and metabolic syndrome, which can lead to β-cell dysfunction and type 2 diabetes (15). It is established that feeding mice a high-fat diet (HFD) causes activation of c-Jun NH₂-terminal kinase 1 (JNK1) (10). Moreover, Jnk1^−/− mice are protected against the effects of HFD-induced insulin resistance (10). Together, these observations indicate that JNK1 plays a critical role in the metabolic stress response. However, the mechanism that accounts for HFD-induced JNK1 activation is unclear. Recent studies have implicated the JIP1 scaffold protein in JNK1 activation caused by metabolic stress (23, 39).JIP1 can assemble a functional JNK activation module composed of a mitogen-activated protein kinase (MAPK) kinase kinase (a member of the mixed-lineage protein kinase [MLK] group), the MAPK kinase MKK7, and JNK (40, 42). This complex may be relevant to JNK activation caused by metabolic stress (23, 39). Indeed, MLK-deficient mice (14) and JIP1-deficient mice (13) exhibit defects in HFD-induced JNK activation and insulin resistance.The protection of Jip1^−/− mice against the effects of being fed an HFD may be mediated by loss of the JNK scaffold function of JIP1. However, JIP1 has also been reported to mediate other biochemical processes that would also be disrupted in Jip1^−/− mice. For example, JIP1 interacts with AKT and has been implicated in the mechanism of AKT activation (8, 17, 18, 34). Moreover, JIP1 interacts with members of the Src and Abl tyrosine kinase families (4, 16, 24), the lipid phosphatase SHIP2 (44), the MAPK phosphatase MKP7 (43), β-amyloid precursor protein (20, 31), the small GTPase regulatory proteins Ras-GRF1, p190-RhoGEF, RalGDS, and Tiam1 (2, 8, 21), ankyrin G (35), molecular chaperones (35), and the low-density-lipoprotein-related receptors LRP1, LRP2, and LRP8 (7, 37). JIP1 also interacts with other scaffold proteins, including the insulin receptor substrate proteins IRS1 and IRS2 (35). Finally, JIP1 may act as an adapter protein for kinesin-mediated (11, 12, 16, 38, 42) and dynein-mediated (35) trafficking on microtubules. The JNK scaffold properties of JIP1 therefore represent only one of the possible biochemical functions of JIP1 that are disrupted in Jip1^−/− mice.The purpose of this study was to test the role of JIP1 as a JNK scaffold protein in the response of mice to being fed an HFD. Our approach was to examine the effect of a point mutation that selectively prevents JIP1-induced JNK activation. It is established that phosphorylation of JIP1 on Thr¹⁰³ is required for JIP1-mediated JNK activation by the MLK pathway (25). Consequently, the phosphorylation-defective Thr103Ala JIP1 protein does not activate JNK (25). Here we describe the analysis of mice with a point mutation in the Jip1 gene that replaces the JIP1 phosphorylation site Thr¹⁰³ with Ala. We show that this mutation suppresses HFD-induced JNK activation and insulin resistance. These data demonstrate that JNK activation mediated by the JIP1 scaffold complex contributes to the response of mice to an HFD.     

Effects of rising tuition fees on medical school class composition and financial outlook

Background

Since 1997, tuition has more than doubled at Ontario medical schools but has remained relatively stable in other Canadian provinces. We sought to determine whether the increasing tuition fees in Ontario affected the demographic characteristics and financial outlook of medical students in that province as compared with those of medical students in the rest of Canada.

Methods

As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, we compared the respondents from Ontario schools with those from the other schools (control group). Respondents were asked about their age, sex, self-reported family income (as a direct indicator of socioeconomic status), the first 3 digits of their postal code at graduation from high school (as an indirect indicator of socioeconomic status), and importance of financial considerations in choosing a specialty and location of practice. We used logistic regression models to see if temporal changes (1997 v. 2000) among Ontario medical students differed from those among medical students elsewhere in Canada apart from Quebec.

Results

Responses were obtained from 2994 (68.5%) of 4368 medical students. Across the medical schools, there was an increase in self-reported family income between 1997 and 2000 (p = 0.03). In Ontario, the proportion of respondents with a family income of less than $40 000 declined from 22.6% to 15.0%. However, compared with the control respondents, the overall rise in family income among Ontario students was not statistically significant. First-year Ontario students reported higher levels of expected debt at graduation than did graduating students (median $80 000 v. $57 000) (p < 0.001), and the proportion of students expecting to graduate with debt of at least $100 000 more than doubled. Neither of these differences was observed in the control group. First-year Ontario students were also more likely than fourth-year Ontario students to report that their financial situation was “very” or “extremely” stressful and to cite financial considerations as having a major influence on specialty choice or practice location. These differences were not observed in the control group.

Interpretation

At Canadian medical schools, there are fewer students from low-income families in general. However, Ontario medical students report a large increase in expected debt on graduation, an increased consideration of finances in deciding what or where to practise, and increasing financial stress, factors that are not observed among students in other provinces.Since 1997 all 5 Ontario medical schools have increased tuition fees dramatically. At the University of Toronto, for example, tuition nearly tripled in 3 years, from $4844 in 1997/98 to $14 000 in 2000/01. Tuition fees at other Canadian medical schools have been relatively stable (Fig. 1).Open in a separate windowFig. 1: Medical school tuition and ancillary fees in Ontario and elsewhere in Canada (Quebec excepted), 1997–2000. Source: Canadian Medical Education Statistics.²¹The effects of increasing tuition have not been examined systematically in Canada; however, concern has been expressed that accessibility is being compromised.^1,2,3 A small number of studies in the United States have investigated the effects of increasing tuition;^4,5 several US commentators have also argued that high tuition may restrict access to medical education for those from low-income families, underrepresented minority groups and rural areas.^6,7 Moreover, recent editorials have emphasized the advantages of a diverse, representative medical student body.^8,9,10 Aside from issues of accessibility, medical student diversity may also be beneficial for pragmatic reasons. Students from underrepresented groups are more likely to treat ethnic minorities,^11,12 practise in rural communities^13,14 and work in socioeconomically depressed areas.^15,16,17We studied the effects of increases in tuition fees on the demographic characteristics and attitudes of medical students by comparing students in Ontario, where tuition fees increased rapidly, with students from a control group of Canadian medical schools in provinces that did not experience a rapid increase. Our main hypotheses were that the increases in fees would be associated with increases in family income and expected debt at graduation. We also hypothesized that students in Ontario who enrolled after the increase would feel more financial stress than control students and be more likely to feel that financial considerations would affect their choice of specialty or practice location.