A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: World-wide healthcare systems are faced with an epidemic of type 2 diabetes. In the United Kingdom, clinical care is primarily provided by general practitioners (GPs) rather than hospital specialists. Intermediate care clinics for diabetes (ICCD) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors. This study aims to (1) compare patients with type 2 diabetes registered with practices that have access to an ICCD service with those that have access only to usual hospital care; (2) assess the cost-effectiveness of the intervention; and (3) explore the views and experiences of patients, health professionals and other stakeholders. METHODS: This two-arm cluster randomized controlled trial (with integral economic evaluation and qualitative study) is set in general practices in three UK Primary Care Trusts. Practices are randomized to one of two groups with patients referred to either an ICCD (intervention) or to hospital care (control).Intervention group: GP practices in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist. Patients are reviewed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice.orControl group: Standard GP care, with referral to secondary care as required, but no access to ICCD.Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control. The primary outcome is the proportion of participants reaching three risk factor targets: HbA1c (<=7.0%); blood pressure (<140/80); and cholesterol (<4 mmol/l), at the end of the 18-month intervention period. The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD) and stroke assessed by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. Other secondary outcomes include body mass index and waist circumference, use of medication, reported smoking, emotional adjustment, patient satisfaction and views on continuity, costs and health related quality of life. We aimed to randomize 50 practices and recruit 2,555 patients. DISCUSSION: Forty-nine practices have been randomized, 1,997 patients have been recruited to the trial, and 20 patients have been recruited to the qualitative study. Results will be available late 2012.Trial registration[ClinicalTrials.gov: Identifier NCT00945204].     

Engineering of protease variants exhibiting altered substrate specificity

By using an improved genetic screening system, variants of the HAV 3CP protease which exhibit altered P2 specificity were obtained. We randomly mutated the His145, Lys146, Lys147, and Leu155 residues that constitute the S2 pocket of 3CP and then isolated variants that preferred substrates with Gln over the original Thr at the P2 position using a yeast-based screening method. One of the isolated variants cleaved the Gln-containing peptide substrate more efficiently in vitro, proving the efficiency of our method in isolating engineered proteases with desired substrate selectivity.     

Biotransformation of β-keto nitriles to chiral (<Emphasis Type="Italic">S</Emphasis>)-β-amino acids using nitrilase and ω-transaminase

Objective

To enzymatically synthesize enantiomerically pure β-amino acids from β-keto nitriles using nitrilase and ω-transaminase.

Results

An enzyme cascade system was designed where in β-keto nitriles are initially hydrolyzed to β-keto acids using nitrilase from Bradyrhizobium japonicum and subsequently β-keto acids were converted to β-amino acids using ω-transaminases. Five different ω-transaminases were tested for this cascade reaction, To enhance the yields of β-amino acids, the concentrations of nitrilase and amino donor were optimized. Using this enzymatic reaction, enantiomerically pure (S)-β-amino acids (ee > 99%) were generated. As nitrilase is the bottleneck in this reaction, molecular docking analysis was carried out to depict the poor affinity of nitrilase towards β-keto acids.

Conclusions

A novel enzymatic route to generate enantiomerically pure aromatic (S)-β-amino acids from β-keto nitriles is demonstrated for the first time.

     

A novel process for the production of high-purity galactooligosaccharides (GOS) using consortium of microbes

Galactooligosaccharides (GOS) are nondigestible dietary fibers which have a beneficial effect on human health by promoting the growth of probiotic bacteria in the gut. In addition, other health benefits have been reported from oligosaccharides consumption such as stimulation of intestinal mobility, colon cancer prevention, mineral absorption as well as protection against certain pathogenic bacterial infections. The goal of this research was to develop an efficient biotransformation system using a consortium of microbes for the production of ≥85% pure GOS and reusing the cell biomass in repeated cycles of biotransformation. Production of GOS by lactose transgalactosylation using whole cells of Sporobolomyces singularis MTCC 5491 as a source of β-galactosidase and monosaccharides utilization by yeast isolate (NUTIDY007) were studied. For increasing the purity of GOS, growth and bioconversion parameters on the transgalactosylation by the whole cells were investigated. Further, continuous production of GOS was studied in a reactor with microfiltration membrane system. A maximum GOS purity of 42% was achieved using single culture of S. singularis. Under optimized conditions, single culture of S. singularis produced a maximum of 56% pure GOS. Addition of second culture to the reaction mixture for utilization of glucose significantly increased the GOS purity from 56% to ≥85%. The product consisted of tri- to penta-galactooligosaccharides. Trisaccharides were the main component of the reaction mixture. A maximum productivity of 10.9?g/L/hr was obtained under the optimum conditions.     

Low frequency of precore mutants in anti-hepatitis B e antigen positive subjects with chronic hepatitis B virus infection in Chennai, Southern India

The natural course of chronic hepatitis B (CH-B) virus infection is reportedly variable, and the long-term outcomes in hepatitis B e antigen (HBeAg)-negative chronic hepatitis B infection are distinct from HBeAg-positive chronic hepatitis. However, the molecular virological factors that contribute to the progression of liver disease in the south Indian setting remain largely unclear. We prospectively studied 679 consecutive patients for HBsAg, HBeAg, anti-HBeAg, and HBV DNA by qualitative PCR. Randomly selected samples were subjected to bidirectional sequencing to reveal core/precore variants. Of the total 679 chronic HBV cases investigated, 23% (154/679) were replicative HBV carriers. Furthermore, amongst the 560 HBV DNA samples analyzed, 26% (146/560) were viremic. Among the 154 HBeAg positive cases, HBV DNA was positive in 118 cases (77%), significantly (p<0.001) higher than the anti-HBe positive (7%) (28/406) cases. Significant increase in liver disease (p<0.01) with ALT enzyme elevation (p<0.001) was observed in both HBe and anti-HBe viremic cases. Interestingly, low frequencies of mutations were seen in the precore region of the HBV strains studied. HBV precore and core promoter variants were less often detected in subjects with "e" negative chronic HBV infection and, therefore, may not have a prognostic role in determining liver disease sequelae in this part of tropical India.     

Effects of thermal discharge from a nuclear power plant on culturable bacteria at a tropical coastal location in India

I.

Field studies were carried out 1 year to understand the distribution of culturable bacteria in the coastal waters in relation to the thermal discharge.     

Isolation and characterization of <Emphasis Type="Italic">Pseudoalteromonas ruthenica</Emphasis> (SBT033), an EPS-producing biofilm bacterium from the seawater intake point of a tropical power station

Biofilm formation in bacteria is closely linked with production of exopolysaccharides (EPS). This study examined the quantitative variations in EPS production and biofilm-forming ability among bacteria isolated from the seawater intake point of a power station located on the east coast of India. Of the 233 isolates obtained from the intake site, 71 bacterial isolates displayed different colony morphological characteristics. Thirteen isolates that produced wide and thick mucoid colonies were further tested for their ability to attach and form biofilms by microtitre plate assay and confocal microscopy. EPS production among the selected bacterial isolates ranged from 826 to 1838 μg ml⁻¹. Strain SBT033, which produced the maximum amount of EPS also displayed the maximum biofilm-forming ability among the 13 isolates. This strain was selected for further characterization using biochemical and molecular methods. The pale orange-pigmented isolate was a Gram negative, aerobic, short rod-shaped and grew well only in the presence of 2% NaCl. On the basis of phenotypic characteristics the isolate SBT033 is shown to belong to the genus Pseudoalteromonas. Analysis of 16S rRNA of the isolate revealed 99% homology with Pseudoalteromonas ruthenica.     

Bioelectricity production from wastewater treatment in dual chambered microbial fuel cell (MFC) using selectively enriched mixed microflora: Effect of catholyte

The performance of aerated and ferricyanide catholytes on the bioelectricity production was evaluated in dual chambered microbial fuel cell (MFC) (mediatroless anode; graphite electrodes) employing selectively enriched H(2) producing mixed consortia as anodic inoculum. Two MFCs with aerated catholyte (MFC(AC)) and ferricyanide catholyte (MFC(FC)) were operated separately to elucidate the difference in power generation potential and carbon removal efficiency under similar operating conditions [ambient pressure; room temperature (28+/-2 degrees C); acidophilic microenvironment (pH 6)]. The experimental data demonstrated the feasibility of in situ bioelectricity generation along with wastewater treatment. Effective power generation and substrate removal efficiency was documented in the fuel cell operated with ferricyanide catholyte (586 mV; 2.37 mA; 0.559 kg COD/m(3) day) than aerated catholyte (572 mV; 1.68 mA; 0.464 kg COD/m(3) day). Maximum power yield (0.635 W/kg COD(R) and 0.440 W/kg COD(R)) and current density (222.59 mA/m(2) and 190.28 mA/m(2)) was observed at 100 Omega resistor with ferricyanide and aerated catholytes, respectively. The study documented both wastewater treatment and electricity production through direct conversion of H(2) in a single system.     

Biodegradation of phenol and m-cresol in a batch and fed batch operated internal loop airlift bioreactor by indigenous mixed microbial culture predominantly Pseudomonas sp

An internal loop airlift reactor (ILALR) is developed and studied for biodegradation of phenol/m-cresol as single and dual substrate systems under batch and fed batch operation using an indigenous mixed microbial strain, predominantly Pseudomonas sp. The results showed that the culture could degrade phenol/m-cresol completely at a maximum concentration of 600mgl(-1) and 400mgl(-1), respectively. Batch ILALR study has revealed that phenol has been preferentially degraded by the microbial culture rather than m-cresol probably owing to the toxic effect of the later. Sum kinetic model evaluated the interaction between the phenol/m-cresol in dual substrate system, which resulted in a high coefficient of determination (R(2)) value >0.98). The fed batch results showed that the strain was able to degrade phenol/m-cresol with maximum individual concentrations 600mgl(-1) each in 26h and 37h, respectively. Moreover for fed batch operation, degradation rates increased with increase in feed concentration without any lag in the degradation profile.