Increasing diabetes testing adherence with incentives in rural Northwestern Ontario.

Introduction: The health outcomes of rural Canadians have been described as poor and can in some part be related to diabetes mellitus. Despite the high mortality and morbidity rates associated with the disease, compliance with management remains low. Research has shown that a small financial incentive used to modify patient behaviour, can improve outcomes in cardiac disease and exercise adherence. This study aims to evaluate if a small financial incentive awarded to rural Northwestern Ontario patients with diabetes who complete an haemoglobin A1c (HbA1c) test, would result in greater compliance in test completion. Methods: Patients were recruited through two Northern rural clinics. Participants were divided into two groups: Group A received a financial incentive, whereas Group B received a letter of reminder. HbA1c tests were recorded every 6 months for 2 years and compliance was analysed using a t-test and Chi-square. Results: One hundred and forty-six participants were recruited with 30 lost to follow-up. Overall, the incentive group completed a statistically significantly higher number of HbA1c tests compared to those in the control group. In addition, it was noted that there was an increase in test adherence for participants that received reminder letters, although not an initially expected outcome of the study. Conclusion: The results suggest that either a financial incentive or a reminder directed towards rural Canadians could have a benefit in promoting health behaviours to subsequent medical management of diabetes mellitus.

Résumé Introduction: Les résultats en matière de santé des Canadiennes et Canadiens vivant en milieu rural ont été décrits comme médiocres et peuvent en partie être liés au diabète sucré. Malgré les taux élevés de mortalité et de morbidité associés à cette maladie, l'observance du traitement reste faible. La recherche a montré qu'un petit incitatif financier utilisé pour modifier le comportement du patient, peut améliorer les résultats dans les maladies cardiaques et l'adhésion à l'exercice. Cette étude vise à évaluer si une petite incitation financière accordée aux patients diabétiques des régions rurales du nord-ouest de l'Ontario qui effectuent un test HbA1c, entraînerait une plus grande conformité dans l'exécution du test. Méthodes: Les patients ont été recrutés dans deux cliniques rurales du nord. Les participants ont été divisés en deux groupes: Le groupe A a reçu une incitation financière, tandis que le groupe B a reçu une lettre de rappel. Les tests HbA1c ont été enregistrés tous les 6 mois pendant 2 ans et la conformité a été analysée à l'aide d'un test t et d'un chi carré. Résultats: 146 participants ont été recrutés, dont 30 ont été perdus lors du suivi. Dans l'ensemble, le groupe incitatif a réalisé un nombre statistiquement significatif de tests d'HbA1c par rapport aux participants du groupe témoin. De plus, une augmentation de l'adhésion aux tests a été remarquée pour les participants qui ont reçu des lettres de rappel, bien que ce ne soit pas un résultat initial attendu de l'étude. Conclusion: Les résultats suggèrent que soit une incitation financière, soit un rappel destiné aux Canadiennes et Canadiens des zones rurales pourrait avoir un avantage dans la promotion des comportements de santé pour la gestion médicale ultérieure du diabète sucré. Mots-clés: Gestion du diabète sucré, incitation financière, médecine rurale, test HbA1c.

Novel fibrogenic pathways are activated in response to endothelial apoptosis: implications in the pathophysiology of systemic sclerosis.

Apoptosis of endothelial cells (EC) is appreciated as a primary pathogenic event in systemic sclerosis. Yet, how apoptosis of EC leads to fibrosis remains to be determined. We report that apoptosis of EC triggers the release of novel fibrogenic mediators. Medium conditioned by apoptotic EC (SSC) was found to inhibit apoptosis of fibroblasts, whereas medium conditioned by EC in which apoptosis was blocked (with either pan-caspase inhibition or Bcl-x(L) overexpression) did not. PI3K was activated in fibroblasts exposed to SSC. This was associated with downstream repression of Bim-EL and long-term up-regulation of Bcl-x(L) protein levels. RNA interference for Bim-EL in fibroblasts blocked apoptosis. SSC also induced PI3K-dependent myofibroblast differentiation with expression of alpha-smooth muscle actin, formation of stress fibers, and production of collagen I. A C-terminal fragment of the domain V of perlecan was identified as one of the fibrogenic mediators present in SSC. A synthetic peptide containing an EGF motif present on the perlecan fragment and chondroitin 4-sulfate, a glycosaminoglycan anchored on the domain V of perlecan, induced PI3K-dependent resistance to apoptosis in fibroblasts and myofibroblast differentiation. Human fibroblasts derived from sclerodermic skin lesions were more sensitive to the antiapoptotic activities of the synthetic peptide and chondroitin 4-sulfate than fibroblasts derived from normal controls. Hence, we propose that a chronic increase in endothelial apoptosis and/or increased sensitivity of fibroblasts to mediators produced by apoptotic EC could form the basis of a fibrotic response characterized by sustained induction of an antiapoptotic phenotype in fibroblasts and persistent myofibroblast differentiation.