Detection of impaired glucose tolerance and undiagnosed type 2 diabetes in UK South Asians: an effective screening strategy

AIM

We tested a stepwise, community-based screening strategy for glucose intolerance in South Asians using a health questionnaire in conjunction with body mass index (BMI). Anthropometric measurements (waist and hip circumference, sagittal diameter and percentage body fat) were then conducted in a hospital setting followed by an oral glucose tolerance test (OGTT) to identify subjects at the highest risk and analyse the factors predicting that risk.

METHODS

A health questionnaire was administered to 435 subjects in a community setting and BMI was measured. Subjects were graded by a risk score based on the health questionnaire as high, medium and low. Subjects with high and medium risk scores and a representative sample of those with low scores had anthropometric measurements in hospital followed by an OGTT. In total, 205 (47%) of the subjects had an OGTT performed.

RESULTS

In total, 48.7% of the subjects tested with an OGTT had evidence of glucose dysregulation: 20% had diabetes and 28.7% had impaired glucose tolerance (IGT). Logistic regression model explained 49.1% of the total variability. The significant predictors of diabetes and IGT were Blood Glucose Monitoring Strips (BMI), random blood glucose (BM), sibling with diabetes and presence of diagnosed hypertension or ischaemic disease. Most of these predictors along with other heredity diabetes factors create a composite score, with high predictability, as the receiver operating curve analysis shows.

CONCLUSION

We describe a simple, stepwise strategy in a community setting, based on a health questionnaire and anthropometric measurements, to explain about 50% of cases with IGT and diabetes and diagnose about 50% of cases from the population screened. We have also identified factors that predict the risk.

Physical assessment: implications for nurse educators and nursing practice

AIM

In New Zealand, the physical assessment of a patient has traditionally been the domain of the medical profession. As a country implementing advanced practice roles, with an expectation that both nurse practitioners and registered nurses will use physical assessment skills, the relevancy of physical assessment for each scope of practice has currency. The aim of this literature review was to discover what could be learnt from the experiences of Western countries that already incorporate physical assessment skills into nurses' health assessment.

FINDINGS

Nurses in the USA, and more recently Canada and Australia, readily incorporate physical assessment skills into their nursing practice as a component of health assessment. The international literature identified that any change to the nurse's role in health assessment, to include physical assessment skills, requires strategies that involve the regulatory, educational and practice components of nursing.

CONCLUSION

Nurses and other health professionals must perceive that this role expansion will improve health outcomes for the diverse populations accessing health care. Teaching physical assessment skills within a holistic health model will enable nurses to contribute a more comprehensive health assessment to the planning and monitoring of people's health care.

Cost-effectiveness of screening with contrast enhanced magnetic resonance imaging vs X-ray mammography of women at a high familial risk of breast cancer

Contrast enhanced magnetic resonance imaging (CE MRI) is the most sensitive tool for screening women who are at high familial risk of breast cancer. Our aim in this study was to assess the cost-effectiveness of X-ray mammography (XRM), CE MRI or both strategies combined. In total, 649 women were enrolled in the MARIBS study and screened with both CE MRI and mammography resulting in 1881 screens and 1–7 individual annual screening events. Women aged 35–49 years at high risk of breast cancer, either because they have a strong family history of breast cancer or are tested carriers of a BRCA1, BRCA2 or TP53 mutation or are at a 50% risk of having inherited such a mutation, were recruited from 22 centres and offered annual MRI and XRM for between 2 and 7 years. Information on the number and type of further investigations was collected and specifically calculated unit costs were used to calculate the incremental cost per cancer detected. The numbers of cancer detected was 13 for mammography, 27 for CE MRI and 33 for mammography and CE MRI combined. In the subgroup of BRCA1 (BRCA2) mutation carriers or of women having a first degree relative with a mutation in BRCA1 (BRCA2) corresponding numbers were 3 (6), 12 (7) and 12 (11), respectively. For all women, the incremental cost per cancer detected with CE MRI and mammography combined was £28 284 compared to mammography. When only BRCA1 or the BRCA2 groups were considered, this cost would be reduced to £11 731 (CE MRI vs mammography) and £15 302 (CE MRI and mammography vs mammography). Results were most sensitive to the unit cost estimate for a CE MRI screening test. Contrast-enhanced MRI might be a cost-effective screening modality for women at high risk, particularly for the BRCA1 and BRCA2 subgroups. Further work is needed to assess the impact of screening on mortality and health-related quality of life.

Distal adenomatous polyps are rare in patients with inflammatory bowel disease

OBJECTIVE

There is an increased risk of colorectal cancer in patients with inflammatory bowel disease (IBD). The aim of this study was to compare the prevalence of left sided adenomas in patients with IBD aged 55-64 years with a local age matched control population.

METHOD

A review of clinical notes. The prevalence of adenomas in patients with IBD attending for either sigmoidoscopy or colonoscopy was compared with local age matched controls that participated in the national screening trial for colorectal cancer with flexible sigmoidoscopy.

RESULTS

Of 106 patients (61 male, 45 female, mean age of 59 years), 80 suffered from ulcerative colitis, 20 from Crohn's disease, and six from indeterminate colitis. All patients had undergone at least one flexible sigmoidoscopy and 75 had a colonoscopy. Distal adenomas were found in three patients with ulcerative colitis compared with 67 of 749 controls (2.8% v 8.9%, chi(2) = 4.6, p = 0.03).

CONCLUSIONS

The results suggest that distal adenomatous polyps are rare in patients aged 55-64 years with IBD compared with a control population. This supports the hypothesis that lesions other than polyps are important for the development of colorectal cancer in patients with IBD.

Serial analysis of gene expression (SAGE) of host-plant resistance to the cassava mosaic disease (CMD)

Cassava mosaic disease (CMD) is a viral disease of the important tropical staple crop cassava (Manihot esculenta) and preferred management involves use of host-plant resistance. The best available resistance is controlled by a single dominant gene. Serial analysis of gene expression (SAGE) was used to analyze the gene expression pattern in a bulk of 40 each of CMD resistant and susceptible genotypes drawn from a gene mapping progeny. Messenger RNA used for the SAGE analysis came from plants that were exposed to heavy disease pressure over a period of 2 years in the field. A total of 12,786 tags were studied, divided into 5733 and 7053 tags from the resistant and susceptible genotypes, respectively. Tag annotation was by PCR amplification using the tag sequence as sense primer and 4000 cassava ESTs generated from the bulk of CMD resistant genotypes. Annotation of more than 30 differentially expressed tags revealed several genes expressed during systemic acquired resistance (SAR) in plants and other genes involved in cell-to-cell and cytoplasm-to-nucleus virus trafficking. Differential expression of the most abundantly expressed tag, corresponding to a beta-tubulin gene, was confirmed by Northern Analysis. RFLP analysis of the tags in the parents and bulks of the CMD mapping progeny revealed only one tag, a WRKY transcription factor, associated with the region bearing the dominant CMD gene.

Evaluation of a multiprofessional community stroke team: a randomized controlled trial

OBJECTIVES

There is inconclusive evidence of the effectiveness of stroke rehabilitation by a community stroke team. The aim was to evaluate a specialist multiprofessional team in a community setting.

DESIGN

Randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Stroke patients and their informal carers who were referred to receive rehabilitation from a community stroke team.

OUTCOME MEASURES

Barthel Index, Extended Activities of Daily Living Scale (EADL), General Health Questionnaire (GHQ-12) by patient and carer, Carer Strain Index (CSI), Euroquol, knowledge of stroke and satisfaction with services six months after recruitment.

RESULTS

There were no significant differences between patients who received rehabilitation from community stroke team (n = 189) and those who received routine care (n = 232) in their independence in activities of daily living, mood, quality of life or knowledge of stroke. The patients in the community stroke team group were significantly more satisfied with the emotional support they had received (p < 0.01). There were no significant differences between the groups in satisfaction with practical help or overall satisfaction. Carers of patients in the community stroke team were under significantly less strain than carers in the routine care group (p < 0.04). Carers of patients in the community stroke team group were significantly more satisfied with their knowledge of stroke (p < 0.01) and were more satisfied overall (p < 0.01).

CONCLUSIONS

The patients treated by the community stroke team were more satisfied with the emotional support they received and had equivalent outcomes in terms of independence in activities of daily living and mood. Their carers were under less strain and were more satisfied with their knowledge of stroke recovery, the emotional support they received and overall satisfaction with services. The results support the provision of rehabilitation by a community-based specialist multiprofessional team.

Entonox analgesia for prostatic biopsy

We performed a prospective randomised double-blind study to evaluate the efficacy of Entonox (nitrous oxide) as an analgesic for trans-rectal ultrasound (TRUS) and prostate biopsy. A total of 50 patients breathed either Entonox or air during sextant prostatic biopsies all of which were performed by the same surgeon. The degree of pain experienced was recorded on a 100 mm visual analogue pain scale. A total of 17 further patients were excluded from the study because they wished to drive home after TRUS. Most patients breathing air experienced moderate pain (median pain score 34), whereas those breathing Entonox experienced minimal pain (median pain score 11). Two patients who used Entonox and one breathing air experienced severe pain. We conclude that patients undergoing prostate biopsy without analgesia experience moderate pain and this can be reduced significantly by using Entonox.

Ocular palsy following Le Fort 1 osteotomy: a case report

A 33-year-old female patient developed an ipsilateral sixth nerve palsy and partial third nerve palsy following a Le Fort 1 osteotomy. Complete resolution occurred at 10 weeks. The likely mechanism of injury secondary to pterygo-maxillary dysjunction is highlighted, with description of the relevant anatomy. Previous cases of ocular motility complications following Le Fort 1 osteotomy are discussed. We recommend that significant care be taken in osteotome placement in the pterygo-maxillary fissure, particularly in those prone to unpredicted fractures such as older patients, or where the anatomy is congenitally abnormal or altered by previous surgery.

Penetration of herbicides to groundwater in an unconfined chalk aquifer following normal soil applications

The persistence and penetration of the herbicides isoproturon and chlorotoluron in an unconfined chalk aquifer has been monitored over a 4-year period through soil sampling, shallow coring and groundwater monitoring. Chlorotoluron was applied on plots as a marker compound, having never been used previously on that, or surrounding fields. The fieldsite had a 5 degree slope with soil depths of 0.5 to 1.5 m and a water table between 20 and 5 m from the soil surface. Where the water table was deepest (9-20 m below surface (mbs)) little or no positive herbicide detections were made. However, where the water table was at only 4-5 mbs, a regular pesticide signal of around 0.1 microg/l for isoproturon and chlorotoluron could be distinguished. Over the winter recharge period automatic borehole samplers revealed a series of short-lived peaks of isoproturon and chlorotoluron reaching up to 0.8 microg/l. This is consistent with a preferential flow mechanism operating at this particular part of the field. Such peaks were occurring over 2 years after the last application of these compounds. Shallow coring failed to uncover any significant pesticide pulse moving through the deep unsaturated zone matrix at the fieldsite.

Genetic testing and insurance: opportunities and challenges for society

The increased availability of genetic tests poses new challenges to society. Here, we address the wider implications of genetic testing, with an emphasis on the markets for insurance. It also considers issues such as confidentiality, patient autonomy and fear of discrimination and the doctor-patient relationship.

Small scale water recycling systems--risk assessment and modelling

This paper aims to use quantitative risk analysis, risk modelling and simulation modelling tools to assess the performance of a proprietary single house grey water recycling system. A preliminary Hazard and Operability study (HAZOP) identified the main hazards, both health related and economic, associated with installing the recycling system in a domestic environment. The health related consequences of system failure were associated with the presence of increased concentrations of micro-organisms at the point of use, due to failure of the disinfection system and/or the pump. The risk model was used to assess the increase in the probability of infection for a particular genus of micro-organism, Salmonella spp, during disinfection failure. The increase in the number of cases of infection above a base rate rose from 0.001% during normal operation, to 4% for a recycling system with no disinfection. The simulation model was used to examine the possible effects of pump failure. The model indicated that the anaerobic COD release rate in the system storage tank increases over time and dissolved oxygen decreases during this failure mode. These conditions are likely to result in odour problems.