Navicular stress fractures: outcomes of surgical and conservative management

OBJECTIVE

To compare the long term outcomes of the two treatment options for navicular stress fractures: non-weightbearing cast immobilisation and surgical fixation.

DESIGN

Retrospective case study.

PARTICIPANTS

Subjects aged 18 years and older who had been treated for a navicular stress fracture more than two years previously.

MAIN OUTCOME MEASURES

Questionnaire based analogue pain score and function score; tenderness on palpation; abnormality detected on computed tomography (CT).

RESULTS

In all, 32 fractures in 26 subjects were investigated. No significant differences were found between surgical and conservative management for current pain (p = 0.984), current function (p = 0.170), or abnormality on CT (p = 0.173). However, surgically treated patients more often remained tender over the "N spot" (p = 0.005), even after returning to competition for two years or more.

CONCLUSIONS

Surgical fixation of navicular stress fractures appears to be as effective as conservative management over the longer term. However, there remains a small but measurable degree of pain and loss of function over this period. The value of using "N spot" tenderness as the sole clinical predictor of treatment success requires further investigation, as some patients remained tender despite successful completion of treatment and return to competition.

CT-guided obturator nerve block via the posterior approach

OBJECTIVE

To describe the technique of obturator nerve block under CT guidance via the posterior approach, and to evaluate the efficacy of the procedure in the short-term and mid-term relief of chronic hip pain.

DESIGN AND PATIENTS

Consecutive patients referred for obturator nerve block were prospectively enrolled in this study. Under CT-guidance, via a posterior approach through the pelvis, local anaesthetic and steroid were infiltrated around the obturator nerve using a 22G spinal needle. Fifty-one patients (19 male, 32 female), mean age 54 years, with hip pain refractory to conventional therapy underwent the procedure. Visual Analogue Scale pain scores were recorded before the procedure and at 30 minutes, 24 hours, 1 week and 3 months thereafter.

RESULTS

Pain scores within 30 minutes showed a decrease from a mean +/- SD score of 8.41+/-1.22 pre-procedure to 2.86+/-2.1, p<0.001. At 24 hours, the mean pain score was 2.06+/-1.76, a decrease of 76% from pre-procedural score, p<0.001. Sustained pain relief at 1 week and 3 months was attained in 92% (mean pain score 2.41+/-2.2, p<0.001) and 82% (mean pain score 3.80+/-2.94, p<0.001) of cases respectively. Follow-up data was complete for all 51 patients. No serious side-effects were reported.

CONCLUSIONS

In patients with hip pain refractory to conventional pain control measures, CT-guided obturator nerve block can provide relief from pain in the short to medium term. The posterior approach offers safe, reliable and effective access to the nerve, in a procedure which is well-tolerated by the patient.

Symptoms of non-gonococcal urethritis in heterosexual men: a case control study

OBJECTIVE

To determine microbial and behavioural factors contributing to non-gonococcal urethral symptoms in men.

METHODS

Case-control study of heterosexual men with non-gonococcal urethral symptoms (cases) and without urethral symptoms (controls) attending Melbourne Sexual Health Centre, Australia. Sexual behaviour and condom use were measured by questionnaire. First stream urine was tested for potential pathogens: Chlamydia trachomatis (ligase chain reaction), Mycoplasma genitalium (polymerase chain reaction, PCR), Ureaplasma urealyticum (culture and PCR), and Streptococcus spp, Gardnerella vaginalis, and Haemophilus species (culture). Urethral smears from cases were examined for polymorphonuclear leucocytes.

RESULTS

80 cases and 79 controls were recruited over 4 months in 2002-3. 49 cases (61%) had urethritis by microscopic criteria, 17 (21%) had Chlamydia trachomatis (adjusted odds ratio (OR) 27 (95% confidence interval (CI): 3.4 to 222)), five (6%) had Mycoplasma genitalium (OR 6.1 (95% CI: 0.6 to 61)), and 11 (14%) had Gardnerella vaginalis (OR 9.0 (95% CI: 1.6 to 52)). Other organisms were not significantly associated with urethral symptoms. The presence of urethritis on urethral smear did not predict the presence of Chlamydia trachomatis (OR 1.7 (95% CI: 0.5 to 5.4)). Urethral symptoms were significantly associated with unprotected vaginal sex with more than one casual partner (OR 9.3 (95% CI: 1.3 to 65)) and unprotected anal sex with a regular partner in the past month (OR 3.5 (95% CI: 1.0 to 13)).

CONCLUSION

Gardnerella vaginalis and unprotected anal sex may cause symptoms of non-gonococcal urethritis. Microscopy of the urethral smear to diagnose urethritis in this population does not help to identify which men with urethral symptoms require treatment for chlamydia.

Bioaccumulation of 51Cr, 63Ni and 14C in Baltic Sea benthos

The Baltic Sea is a species-poor, semi-enclosed, brackish sea, whose sediments contain a wide range of contaminants, including sediment-associated metals and radionuclides. In this study, we have examined and compared bioaccumulation kinetics and assimilation efficiencies of sediment-associated (51)Cr, (63)Ni and (14)C in three key benthic invertebrates (the deposit-feeding Monoporeia affinis, the facultative deposit-feeding Macoma baltica, and the omnivorous Halicryptus spinulosus). Our results demonstrate that (i) all radionuclides were accumulated, (ii) the different radionuclides were accumulated to various extents, (iii) small changes in organic carbon concentration can influence the accumulation, and (iv) the degree of accumulation differed only slightly between species. These processes, together with sediment resuspension and bioturbation, may remobilise trace metals from the sediment to the water and to higher trophic levels, and therefore should be taken into account in exposure models and ERAs.

Familial dementia caused by polymerization of mutant neuroserpin

Aberrant protein processing with tissue deposition is associated with many common neurodegenerative disorders; however, the complex interplay of genetic and environmental factors has made it difficult to decipher the sequence of events linking protein aggregation with clinical disease. Substantial progress has been made toward understanding the pathophysiology of prototypical conformational diseases and protein polymerization in the superfamily of serine proteinase inhibitors (serpins). Here we describe a new disease, familial encephalopathy with neuroserpin inclusion bodies, characterized clinically as an autosomal dominantly inherited dementia, histologically by unique neuronal inclusion bodies and biochemically by polymers of the neuron-specific serpin, neuroserpin. We report the cosegregation of point mutations in the neuroserpin gene (PI12) with the disease in two families. The significance of one mutation, S49P, is evident from its homology to a previously described serpin mutations, whereas that of the other, S52R, is predicted by modelling of the serpin template. Our findings provide a molecular mechanism for a familial dementia and imply that inhibitors of protein polymerization may be effective therapies for this disorder and perhaps for other more common neurodegenerative diseases.

Chemotyping of yeast mutants using robotics

By now, the EUROFAN programme for the functional analysis of genes from the yeast genome has attained its cruising speed. Indeed, several hundreds of yeast mutants with no phenotype as tested by growth on standard media and no significant sequence similarity to proteins of known function are available through the efforts of various laboratories. Based on the methodology initiated during the pilot project on yeast chromosome III (Yeast 13, 1547-1562, 1997) we adapted it to High Throughput Screening (HTS), using robotics. The first 100 different gene deletions from EUROSCARF, constructed in an FY1679 strain background, were run against a collection of about 300 inhibitors. Many of these inhibitors have not been reported until now to interfere in vivo with growth of Saccharomyces cerevisiae. In the present paper we provide a list of novel growth conditions and a compilation of 49 yeast deletants (from chromosomes II, IV, VII, X, XIV, XV) corresponding to 58% of the analysed genes, with at least one clear and stringent phenotype. The majority of these deletants are sensitive to one or two compounds (monotropic phenotype) while a distinct subclass of deletants displays a hyper-pleiotropic phenotype with sensitivities to a dozen or more compounds. Therefore, chemotyping of unknown genes with a large spectrum of drugs opens new vistas for a more in-depth functional analysis and a more precise definition of molecular targets.

Lay carers' satisfaction with community palliative care: results of a postal survey. South Tyneside MAAG Palliative Care Study Group

This paper reports the substantive findings of a study that examined the feasibility of using postal questionnaires to assess the satisfaction of lay caregivers with the care received in the community by those dying of cancer. The focus of the analysis was the quality of information provided by health professionals, health services used in the final year of the dying person's life and the lay carer's views about the quality of these services. The study was a retrospective survey of lay carers identified from death certificates over a 9-month period. Of the 355 people contacted, 156 completed the questionnaires, a 44% response rate. The results of the survey indicate that information provision was deemed unsatisfactory by a large proportion of respondents, and that dissatisfaction with care received from hospital, the district nursing service and the general practitioner was common. Levels of satisfaction with care were clearly related to a range of service factors. Our survey also highlighted clear differences in the perceived quality of specialist and generic services for those dying of cancer. A comparison of the findings from this postal study with those reported in earlier retrospective interview surveys of lay carers suggests that the use of the postal questionnaire is a valid and cost-effective approach for assessing quality of care. The data provide baseline information against which improvements in the quality of care can be measured.

Feasibility of using postal questionnaires to examine carer satisfaction with palliative care: a methodological assessment. South Tyneside MAAG Palliative Care Study Group

This paper reports on the methodological findings from a project which examined the feasibility of using a postal questionnaire to assess lay carer satisfaction with palliative care. The focus of this paper is the process of questionnaire development and its psychometric evaluation. The questionnaire was derived from an interview schedule used in previous national surveys of care for the dying, and was refined through qualitative work with recently bereaved lay carers. It was then tested in a postal survey of 355 lay carers identified from death registration certificates. Overall response rates were low, but significantly enhanced by the use of a single reminder sent 3 weeks after the initial mailshot. The analysis indicated that in the majority of cases the person targeted to receive the questionnaire was the most appropriate informant. Psychometric evaluation of the questionnaire against five criteria was encouraging, with low item nonresponse and ineligible response, and some evidence of discriminatory power, reliability, and face and content validity. Postal approaches appear to represent an acceptable means of assessing user satisfaction with palliative care, compared with more resource-intensive methods.

Obturator neuropathy: a cause of exercise-related groin pain

Obturator neuropathy is a cause of exercise-related groin pain, particularly in those who play sports that involve much running, twisting and turning, and kicking. Symptoms include pain that begins insidiously at the adductor origin on the pubic bone and worsens with exercise. Diagnostic measures include reproduction of pain by stretching the pectineus muscle after exercise, electromyography, and a local anesthetic block of the obturator nerve. Surgery allows most patients to resume previous levels of activity.

Managing common stress fractures: let risk level guide treatment

The repetitive stresses of sports and exercise can produce an array of stress fractures. Most are uncomplicated, but some, such as femoral neck fractures, carry a higher risk of nonunion or complete fracture. The diagnosis is primarily clinical, but imaging with plain radiographs, scintigraphy, CT, or MRI may provide confirmation if necessary. Treatment of uncomplicated fractures centers on rest and reversing training errors or equipment problems. Management of high-risk fractures is more aggressive. Depending on imaging results, most of these require either surgery or several weeks of non-weight bearing immobilization and rehabilitation.

CD44 and CD44v6 downregulation in clinical prostatic carcinoma: relation to Gleason grade and cytoarchitecture

BACKGROUND

Altered expression of CD44 has been implicated in tumor progression and metastasis in multiple neoplasms.

METHODS

CD44 expression in archival tissues of prostate carcinoma was examined by immunohistochemistry with monoclonal antibodies against core CD44 and the RNA splice variant CD44v6 (v6).

RESULTS

Core CD44 expression was reduced in the majority of primary neoplastic foci (n = 94) and loss of expression correlated with increasing Gleason grade. Staining for v6 was absent in most carcinomas and metastases. Expression of core CD44 in pelvic lymph node (n = 27) and bone metastases (n = 21) was significantly reduced. In addition, CD44 expression correlated with cytoarchitecture. Tall columnar tumor cells typically stained positively, yet more rounded cells forming cribiform structures or nests showed reduced expression. All cases of high-grade prostatic intraepithelial neoplasia were positive for core CD44 yet, there was decreased expression in cribiform and micropapillary variants.

CONCLUSIONS

The majority of clinically relevant human prostatic carcinomas and metastases downregulate expression of CD44. Additional studies to determine whether CD44 cell surface expression relates to clinical outcome independent of other established clinicopathologic risk factors are warranted.

Obturator nerve entrapment

PURPOSE

To describe a case of obturator nerve entrapment, a previously unreported cause of chronic groin pain in athletes.

CASE SUMMARY

A 23-year-old man, an elite Australian rules footballer, presented with a 2-year history of groin pain. Conservative treatment was unsuccessful. Examination postexercise revealed adductor weakness and medial thigh paraesthesia. Diagnosis of obturator nerve entrapment was confirmed by EMG and nerve block. Surgical neurolysis was performed. The patient returned to sport and has remained symptom free.

DISCUSSION

Although intrapelvic obturator nerve entrapment has been reported following surgical trauma, no cases of sport-related entrapment have been described.

RELEVANCE

Obturator nerve entrapment should be considered as a potential cause of chronic groin pain in athletes.

Obturator nerve entrapment. A cause of groin pain in athletes

Chronic groin pain in athletes is often difficult to diagnose and treat. There are many anatomic structures in the inguinal and groin region that have the potential to cause pain. We report 32 cases of a previously undescribed condition in athletes of "obturator neuropathy," a fascial entrapment of the obturator nerve where it enters the thigh. This condition represents a type of groin pain in athletes that is treatable by surgical means. There is a characteristic clinical pattern of exercise-induced medial thigh pain commencing in the region of the adductor muscle origin and radiating distally along the medial thigh. Needle electromyography demonstrates denervation of the adductor muscles. Surgical neurolysis treatment provides the definitive cure of this problem, with athletes returning to competition within several weeks of treatment. The surgical findings are entrapment of the obturator nerve by a thick fascia overlying the short adductor muscle. The role of conservative treatment in the management of this condition is unknown at present.

Discriminant validity of the TSC-40 in an outpatient setting

This study examines the discriminant validity of the Trauma Symptom Checklist (TSC-40) in a clinical sample. The TSC-40 was developed as a research instrument for assessing the impact of a history of sexual victimization. Previous validity studies used nonclinical samples of women (Elliott & Briere, 1992; Gold, Milan, Myall, & Johnson, 1994). In the present study, the TSC-40 was administered to 103 men and 79 women requesting services at two outpatient clinics. Information about sexual victimization was collected from the client during intake and from the therapist after the client had received 6 months of therapy. A history of CSA was associated both with high symptom levels across symptom dimensions, and, specifically, with elevation on the trauma subscale of the TSC-40. The findings support the view that, in a clinical setting, CSA is associated both with generalized distress and with PTSD symptoms.

Stress fractures: a review of 180 cases

OBJECTIVE

To review the cases of stress fracture seen over a 2-year period at a sports medicine clinic.

DESIGN

One hundred and eighty cases diagnosed as stress fractures on the basis of clinical picture and radiological evidence were reviewed. The following features of each stress fracture were noted: age, sex, site, sport/activity.

SETTING

A sports medicine centre in Melbourne, Australia.

PATIENTS

The average age was 21.8 years. Seventy eight of these stress fractures were seen in women, 102 in men.

RESULTS

The most common sites of stress fractures were the metatarsal bones (n = 42), tibia (n = 36), fibula (n = 30), tarsal navicular (n = 26) and pars interarticularis (n = 17). The most common sport was track (n = 54). Other common sports activities were jogging/distance running (n = 35), dance (n = 32) and Australian football (n = 14). The distribution of sites of stress fractures varied from sport to sport. Among the track athletes (n = 54), navicular (n = 19), tibia (n = 14) and metatarsal (n = 9) were the most common stress fracture sites. The distance runners (n = 35) predominantly sustained tibia (n = 15), and fibula (n = 8) stress fractures, while metatarsal stress fractures (n = 18) were the most common among dancers. The distribution of sports varied with the site of the stress fracture. In the metatarsal stress fractures (n = 42), dance was the most common activity. Distance running (n = 15) and track (n = 14) were the most common sports in the group to have sustained tibia stress fractures (n = 36). Track athletes (n = 14) were particularly prevalent in the navicular stress fracture group (n = 26).

CONCLUSION

The distribution of sites of stress fractures in this study shows some differences from previously published studies.

Policy priorities in diabetes care: a Delphi study

OBJECTIVES

To produce policy priorities for improving care of diabetes based on the findings of original research into patient and professional opinions of diabetes care in South Tyneside. To judge the feasibility of implementing these priorities as policy.

DESIGN

A two round Delphi survey with a panel of 28 ¿experts.¿ In the first round each respondent produced a list of recommendations based on the findings of a report of patients' and professionals' opinions of diabetes care. 20 respondents produced a total of 180 recommendations, reviewed by a monitoring panel to produce a summary list of 28 recommendations. In the second round respondents rated each recommendation on two 5 point Likert scales.

SETTING

Mainly Tyneside but also other parts of England.

SUBJECTS

28 healthcare professionals, including patients and patients' representatives.

MAIN MEASURES

Voting by experts on how important each recommendation was to improving diabetes care service, and how likely the recommendation was to be implemented in the next five years.

RESULTS

There was a high degree of consensus among respondents about recommendations considered important and likely to be implemented--namely, those concerned with improving communications between doctors in hospital and in general practice, and improving communications with patients. Respondents were more pessimistic about the prospects of implementing the recommendations than about their importance. Respondents thought that standards were important for improving care, and half would stop payments to general practice diabetic clinics that did not keep to district standards for diabetes care. For two recommendations a mismatch occurred between the importance of the recommendations and likelihood of implementation. This may reflect the practical problems of implementing recommendations. 18 of the 22 respondents thought that the study was useful in generating recommendations.

CONCLUSIONS

The Delphi technique is a useful method for determining priorities for diabetes care and in assessing the feasibility of implementing recommendations.

Stress fracture of the body of the talus in athletes demonstrated with computer tomography

PURPOSE

This article describes a series of four previously unreported stress fractures of the body of the talus.

CASE SUMMARY

The four patients presented with ankle pain of gradual onset for periods of three weeks to 12 months. Radioisotope scans in all four patients showed identical pictures of markedly increased uptake in the region of the body of the talus. Computed tomographic scan images were also similar showing a distinct fracture line through the posterolateral aspect of the body of the talus extending into the subtalar joint. All four patients were treated differently ranging from rest to surgery, but no treatment appears totally successful.

DISCUSSION

A single case of stress fracture of the neck of talus has previously been reported in a runner, but no previous cases of stress fracture of the body of the talus have been reported. The mechanism may be that in the presence of excessive subtalar pronation and plantar-flexion, the lateral process of the calcaneus impinges on the concave posterolateral corner of the talus. No treatment appeared totally successful but the authors would recommend a six week period of non-weight-bearing rest.

RELEVANCE

The diagnosis of stress fracture of the body of the talus should be considered in the athlete who presents with gradual onset of ankle pain.

Manipulative physiotherapy for spinal problems in primary care: outcomes of care

Outcome measures for physiotherapy in a primary health care setting should be evaluated before physiotherapy becomes widely available in general practice. The aim of this study was to assess changes in outcome measures in patients with spinal problems treated with bed rest, advice and analgesia ('traditional' treatment) and with manual/manipulative physiotherapy ('active' treatment). A retrospective analysis was carried out of computerized records of patients treated in primary care with manual and manipulative physiotherapy for spinal problems and a group with a similar age/sex/diagnosis profile who were given traditional treatment. Outcome measures in the 12 months following the initial diagnosis were: referrals, recurrences, casualty attendances, X-rays and number of prescribed analgesic and non-steroidal anti-inflammatory agents (NSAIDs). In the active group, there were 231 lumbar and 154 cervical patients, and 82 and 75, respectively, in the traditional group. There was a significant decrease in the recurrence rate [odds ratio (OR) = 0.56, 95% confidence interval (CI) 0.37-0.84] and in the numbers attending casualty (OR = 0.19, 95% CI 0.04-0.76) for 'active' compared with 'traditional' patients. For patients with cervical problems, there was a significant decrease in the active group of NSAIDs prescribed (P < 0.05). Certain outcomes of spinal problems are improved by the provision of manipulative physiotherapy in general practice.

Glycated haemoglobin levels in patients with diabetes in one general practice over a 10-year period

The aim of the study was to evaluate the level of control, as reflected by HbA1c, in patients with diabetes attending one general practice over a 10-year period. The study was based in one general practice in South Tyneside, UK and consisted of an analysis of HbA1c values of all patients with diabetes attending the practice between 1983 and 1992. HbA1c levels were analysed and are presented as multiples of the standard deviation above the mean. In the practice 256 patients with non-insulin-dependent diabetes mellitus (NIDDM) and 76 with insulin-dependent diabetes mellitus (IDDM), attended for a total of 1596 doctor/patient contacts in the diabetic clinic over 10 years. The prevalence of diabetes was 1.9%. Over the course of the clinic, in any one year, 25% of patients with NIDDM and 55% with IDDM had levels of HbA1c above those thought to be associated with increased risk of microvascular complications. Significant reduction in glycated haemoglobin (HbA1c) occurred in the first year after diagnosis (p < 0.01) and after changing treatment from diet alone to diet and oral hypoglycaemic agents (p < 0.001). We conclude that a large proportion of patients within this population had levels of glycaemic control that put them 'at increased risk'.

A midwifery team for high-risk pregnancies

A midwifery group practice approach has been developed for the care of high-risk mothers at the Chelsea & Westminster Hospital. The team of six midwives working with the professor of obstetrics, the consultant obstetrician and a physician cares for a caseload of 200 high-risk women a year. Midwives are able to acquire and maintain the skills necessary to care for high-risk mothers. Audit of the scheme is essential and will be complemented by a satisfaction survey completed by clients, midwives and doctors.

An approach to manageable datasets in diabetes care. British Diabetic Association

A proposal is made to help the implementation of the British Diabetic Association dataset for diabetes care in those sites of care where information technology has yet to be established, or is in need of modification. A stepped approach is suggested and priorities identified.

Conformational properties of four peptides corresponding to alpha-helical regions of Rhodospirillum cytochrome c2 and bovine calcium binding protein

Four peptides corresponding to alpha-helical regions delimited by residues 63-73 and 97-112 of cytochrome c2 (Rhodospirillum) and residues 24-36 and 45-55 of bovine calcium binding protein are predicted to be alpha-helical by a recently developed method [Rooman, M., Kocher, J.P., & Wodak, S.J. (1991) J. Mol. Biol. 221, 961-979], synthesized by solid phase methods, and purified by HPLC, and their solution conformations are determined by NMR and CD. The observed conformational properties of these peptides in solution confirmed prediction results: in water/TFE (60/40, v/v) at room temperature, these peptides adopt an alpha-helical conformation, as shown by an extended pattern of strong, sequential dNN(i,i + 1) NOE cross-peaks, d alpha N(i,i + 1) NOEs of reduced intensity, several medium-range [d alpha N(i,i + 3), d alpha N(i,i + 4), d alpha beta-(i,i + 3)] NOE connectivities, small 3JH alpha N values, and more upfield alpha-proton chemical shifts. CD studies at different TFE concentrations and at room temperature provide further evidence of the propensity of these peptides to adopt an alpha-helical conformation in solution, as determined by the ellipticity values at 222 nm, and by deconvolution of the CD spectra. According to the method used, helicities in the range 34-50% and 55-75% are found for the 63-73 and 97-112 fragments of cytochrome c2, respectively, and in the range 53-80% and 42-65% for the fragments 24-36 and 45-55 of calcium binding protein in water/TFE (60/40, v/v) at 298 K. In addition, the experiments and predictions agree for those residues that are more flexible. Finally, the relevance of our results for the protein folding pathways is discussed.

The nominal group technique: a research tool for general practice?

Qualitative methods are increasingly recognized as valuable, yet practitioners face difficult decisions in their choice of method and the process of analysis. The nominal group technique combines quantitative and qualitative data collection in a group setting, and avoids problems of group dynamics associated with other group methods such as brainstorming, Delphi and focus groups. Idea generation and problem solving are combined in a structured group process, which encourages and enhances the participation of group members. The stages involved in conducting a nominal group are described, and practical problems of its use in a health care setting are discussed with reference to a study of the priorities of care of diabetic patients, carers and health professionals. Some potential applications of the technique in audit and exploratory research are also outlined.

Diabetes care: who are the experts?

OBJECTIVES

To identify issues that patients and professionals consider important in diabetes care and differences in their priorities for care and to determine patients' and professionals' judgements of the relative importance of their chosen priorities.

DESIGN

Structured group interviews using the nominal group technique.

SETTING

Five district health authorities on Tyneside.

SUBJECTS

Five nominal groups: expert (seven), non-expert (seven) health care professionals; insulin dependent (four), non-insulin dependent patients (eight); and carers of diabetic patients (eight).

MAIN MEASURES

Items important in diabetes care to each nominal group (themes of care), ranked into a series of "top 10" items for each group, and allocated a score according to relative importance to individual members; scores were standardised by individual weighting and group weighting for comparison within and between groups.

RESULTS

Patients and professionals agreed that information given to patients, interaction between professionals and patients, patient autonomy, and access were important for good diabetes care, but the importance assigned to each differed. Thus the professionals emphasised empathy and aspects of good communication and patients the desire to know enough to live a "normal" life. Differences were also found within the patient groups; these related to changes in patients' needs at specific points in the development of their illness and in their orientations to care.

CONCLUSION

Patients differ from professionals in their orientation to diabetes care, and they can, and should, be involved in setting priorities for care. Since these priorities are dynamic further work is needed to explore the nature of patient satisfaction with diabetes care.

Posthepatic rate of appearance of insulin: measurement and validation in the nonsteady state

To assess the accuracy with which insulin appearance rates in the peripheral circulation can be measured out of steady state, seven conscious dogs were simultaneously infused with somatostatin and insulin at known variable rates. Tritiated insulin was infused concurrently at a constant rate. Insulin rates of appearance were estimated continuously on the basis of a two-compartment model for systemic insulin kinetics. The calculations were performed assuming that insulin kinetics were linear (tracer data not used) and nonlinear or time varying (tracer data used to assess the variation). The average error in areas under the curve was -3.5 +/- 2.5 and 27.0 +/- 14.2% when nonlinear or linear kinetics were assumed. The maximal errors when linearity was assumed was 39.9 +/- 11.3% and decreased to 16.3 +/- 2.6% when the tracer data was used to account for changes in the fractional removal rate of insulin. The accuracy of the linear estimates improved as the fractional removal rate remained closer to constant. These data suggest that a priori assumptions should not be made on the linearity of the insulin system in a given experimental situation.

Work-load and outcomes of diabetes care in general practice

The effect of starting a general practice diabetes clinic on practice work-load and intermediate outcome measures was studied retrospectively using patient records. The 35 diabetic patients included had been diagnosed greater than 4 years before the diabetes clinic started and were followed for 6 years in the clinic, together with a group of age- and sex-matched controls. There was a significant rise in the consultation rates of the diabetic patients, due to an increase in diabetes-related consultations, from 3.9 consultations yr-1 to 6.7 consultations yr-1 (p less than 0.001). There was a fall in HbA1c level of 0.22 (99% CI 0.13, 0.32) %Hb yr-1 over the 6 years and in body mass index of 0.37 (99% CI 0.22, 0.52) kg m-2 yr-1, suggesting an improvement in diabetes management.

Can general practitioners assess diabetic control? Can anybody do any better?

A prospective study assessing the ability of various health professionals to estimate the control of diabetic patients from the accepted measures made for diabetes care was carried out. Patients were stratified into four categories according to the estimated HbA1c, and 45-60% were accurately assigned by the professionals. Patients were also divided into two broader groups according to their need to have changes in treatment made. None of the professionals could assign patients with Type 1 diabetes into these two groups with an accuracy of greater than 71%. With Type 2 diabetic patients accuracy improved up to 98% and there was little difference between the professionals. The current HbA1c was accurately predicted into two broad groups by the previous HbA1c alone in 89% of cases of Type 2 diabetes. These findings have implications for the routine care of diabetic patients and the education of health care professionals.

Use of secondary prophylaxis against myocardial infarction in the north of England

OBJECTIVE

To record the use of secondary prophylactic drugs in patients discharged from hospital having had a myocardial infarction.

DESIGN

Prospective postal questionnaire survey of a random one in two sample of general practitioners in the region.

SETTING

The nine family practitioner committee areas within the Northern Regional Health Authority.

PATIENTS

Patients who had had a myocardial infarction and were discharged to their general practitioner.

MAIN OUTCOME MEASURE

Whether beta blockers or aspirin, or both, were given on discharge.

RESULTS

Of 267 patients, 158 (59%) were treated suboptimally in that they did not receive a secondary prophylactic drug to which they had no contraindication. For most patients this entailed underuse of one drug, but 17 (6%) of patients received no treatment. beta Blockers were 2.5 times less likely to be used than aspirin. Treatment was not associated with the age or sex of the patient, risk of further infarction, or hospital of discharge.

CONCLUSIONS

Secondary prophylaxis after myocardial infarction is practised haphazardly. It should be offered to all patients who can tolerate it, after a trial period to assess any side effects of the drugs if necessary.

Terminal deletions of the long arm of chromosome 7: five new cases

Twenty-two cases of terminal deletions of the long arm of chromosome 7 have been reported. We present 5 new cases, 3 of which were ascertained due to fetal holoprosencephaly, one due to anencephaly, and one due to multiple structural defects in a 15-year-old boy. The presence of holoprosencephaly in 3 of the 5 cases reported herein and in 2 previously reported cases suggests that this manifestation may be commonly observed in individuals with deletion 7q.

A study of childhood scalds

A retrospective review of admissions to the Wessex Regional Burn Centre was made to determine the incidence and causes of childhood scalds during the periods 1960-65 and 1979-84. No reduction in numbers injured or significant change in causes were observed. Children aged 1-2 years old are still the most prone to scalding injury.

Use of nude mouse xenografts as preclinical screens. Characterization of xenograft-derived melanoma cell lines

Cell lines derived from human melanoma xenografts were characterized for surface markers, karyotype abnormalities, and in vitro drug sensitivity. Xenografts were established using metastatic explants from untreated patients and passaged in nude mice. Cell lines were readily established from melanoma xenografts, and formed colonies when plated in semisolid media. The lines expressed human melanoma-associated and other surface antigens, human lactate dehydrogenase (LDH) isoenzymes, and contained only human chromosomes. They failed to express murine histocompatibility determinants and were negative for murine viruses by mouse antibody production assay. Karyotypes showed abnormalities of chromosomes 3, 6, and 7 similar to other melanomas. In vitro chemosensitivity profiles were compared using cell line and xenograft colony-forming assays. Values were similar for the original xenografts and their cell lines. Xenograft-derived human melanoma lines resemble other melanoma cell lines and primary melanomas with respect to surface antigens and karyotype abnormalities, and are appropriate models for studying in vitro drug sensitivity. When used as a model for transition from solid tumor to cell line, these studies suggest cell lines closely mirror in vitro chemosensitivities of parent tumor cells. However, occasional, unpredictable changes in sensitivity to some drugs occurs during this transition.