International challenges without borders: a descriptive study of family physicians' educational needs in the field of diabetes.

BACKGROUND: The optimal care of persons with diabetes by general practitioners and family physicians (GP/FP) is complex and requires multiple competencies. This is a fairly unrecognized key challenge in the healthcare systems. In some cases, local and national Continuous Professional Development (CPD) initiatives target these challenges; however there have been few international initiatives, possibly because challenges emerging from different studies have not been linked across national boundaries. In this context, the authors have compiled data about gaps and/or barriers inherent to GP/FP care of persons with type 2 diabetes from Austria, Canada, Germany and the United Kingdom. METHODS: Secondary analyzes of pre-existing studies were conducted to identify challenges in the care of patients with type 2 diabetes as faced by GPs/FPs. Two sources of data were reviewed: unpublished research data from collaborating organizations and articles from a literature search (in English and German). Articles retrieved were scanned by the research team for relevance to the study objectives and to extract existing gaps and barriers. The identified challenges were then categorized along three major axes: (1) phase of the continuum of care {from screening to management}; (2) learning domain {knowledge, skills, attitudes, behavior, context}; and (3) by country/region. Compilation and categorization were performed by qualitative researchers and discrepancies were resolved through discussion until concordance was achieved. RESULTS AND DISCUSSION: Thirteen challenges faced by GPs/FPs in the care for patients with type 2 diabetes were common in at least 3 of the 4 targeted countries/regions. These issues were found across the entire continuum of care and included: pathophysiology of diabetes, diagnostic criteria, treatment targets assessment, drugs' modes of action, decision-making in therapies, treatment guidelines, insulin therapy, adherence, management of complications, lifestyle changes, team integration, bureaucracy and third-party payers. The issues reported were not restricted to the physicians' knowledge, but also related to their skills, attitudes, behaviours and context. CONCLUSIONS: This study revealed challenges faced by GPs/FPs when caring for patients with diabetes, which were similar across international and health system borders. Common issues might be addressed more efficiently through international educational designs, adapted to each country's healthcare system, helping develop and maintain physicians' competencies.

MicroRNAs: Loquacious speaks out.

In Drosophila, Dicer-2 requires the double-stranded RNA binding protein R2D2, to mediate the assembly of short interfering RNAs into the RNA-induced silencing complex. New data show that Dicer-1 also requires a double-stranded RNA binding protein called Loquacious for efficient microRNA-mediated gene silencing.

Dose adjustment of metformin and dipeptidyl-peptidase IV inhibitors in diabetic patients with renal dysfunction.

OBJECTIVES: This analysis of real-world data aimed to (a) determine the proportion of Type II diabetes (T2DM) patients treated with metformin or dipeptidyl peptidase-4 inhibitors (DPP-4i) that require dose adjustment or therapy discontinuation due to chronic kidney disease (CKD), and (b) to assess the time required to dose adjustment from the time of worsening of CKD. METHODS: In this retrospective study, two study populations were defined in a large healthcare organization. In the cross-sectional analysis, the distribution of CKD stages and the appropriate dosage of metformin and DPP-4i in 2013 was examined according to renal function among T2DM patients. In the longitudinal analysis, a cohort was defined to assess the time elapsed from first indication worsening of CKD to dose adjustment, among patients treated with those medications during years 2006-2013. RESULTS: Among patients treated with metformin or DPP-4i, one third of patients with CKD failed to adjust the dosage or to discontinue metformin or DPP-4i as indicated. Median time for dose adjustment or discontinuation was significantly longer for DPP-4i than for metformin (9.8 compared to 16.8 months for metformin and DPP-4i, respectively; p-value <.001). CONCLUSIONS: This real-world data analysis showed that adjustment of dose or discontinuation of metformin or DPP-4i in patients with worsening CKD occurred less often in DPP-4i users than metformin users and took a longer time.

In vitro analysis of microRNA processing using recombinant Dicer and cytoplasmic extracts of HeLa cells.

MicroRNAs (miRNAs) constitute a novel class of short, non-coding RNAs that play crucial roles as silencers of gene expression during biological processes such as development, growth control, cell death, and differentiation. To ensure correct function, the expression of miRNAs must be tightly regulated, a process that is believed to take place at the promoter level. Regulation of the miRNA processing cascade has only recently been shown to play an important role as well and we envision the discovery of additional factors affecting or modulating miRNA processing and ultimately miRNA expression. The biochemical analysis of such factors requires a robust assay to monitor miRNA processing. Here, we discuss protocols and techniques that were used to investigate how the expression of brain-specific miRNA miR-138 is controlled at the level of precursor-miRNA (pre-miRNA) processing.

Post-transcriptional regulation of microRNA expression.

microRNAs (miRNAs) are endogenous, noncoding approximately 22-nucleotide RNA molecules that have recently emerged as fundamental, post-transcriptional regulators of cognate target gene expression. Many mammalian miRNAs are expressed in a tissue-specific manner, a phenomenon that has so far been attributed to transcriptional regulation. We here show by Northern blots and in situ hybridization experiments that the expression of mammalian miRNAs can be regulated at the post-transcriptional level. In particular, miR-138 is spatially restricted to distinct cell types, while its precursor, pre-miR-138-2, is ubiquitously expressed throughout all tissues analyzed. Furthermore, pre-miR-138-2 is exported from the nucleus to the cytoplasm, suggesting that cleavage of this pre-miRNA by Dicer is restricted to certain tissues and cell types. Thus, differential processing of pre-miRNAs might be an alternative mechanism to control miRNA function.

Cleavage of the siRNA passenger strand during RISC assembly in human cells.

A crucial step in the RNA interference (RNAi) pathway involves the assembly of RISC, the RNA-induced silencing complex. RISC initially recognizes a double-stranded short interfering RNA (siRNA), but only one strand is finally retained in the functional ribonucleoprotein complex. The non-incorporated strand, or 'passenger' strand, is removed during the assembly process and most probably degraded thereafter. In this report, we show that the passenger strand is cleaved during the course of RISC assembly following the same rules established for the siRNA-guided cleavage of a target RNA. Chemical modifications impairing the cleavage of the passenger strand also impair the cleavage of a target RNA in vitro as well as the silencing of a reporter gene in vivo, suggesting that passenger strand removal is facilitated by its cleavage during RISC assembly. Interestingly, target RNA cleavage can be rescued if an otherwise non-cleavable passenger strand shows a nick at the scissile phosphodiester bond, which further indicates that the cleavage event per se is not essential.