Chronic kidney disease and diabetes in the national health service: a cross-sectional survey of the U.K. national diabetes audit

AIMS

We investigated the prevalence of chronic kidney disease and attainment of therapeutic targets for HbA1c and blood pressure in a large U.K.-based diabetes population.

METHODS

The U.K. National Diabetes Audit provided data from 1 January 2007 to 31 March 2008. Inclusion criteria were a documented urinary albumin:creatinine ratio and serum creatinine. Patients were stratified according to chronic kidney disease stage and albuminuria status. Chronic kidney disease was defined as an estimated glomerular filtration rate < 60 ml min(-1) 1.73 m(-2) , albuminuria or both. The proportions of patients achieving nationally defined glycaemic and systolic blood pressure targets were determined.

RESULTS

The cohort comprised 1,423,669 patients, of whom 868,616 (61%) met inclusion criteria. Of the patients analysed, 92.2% had Type 2 diabetes. A higher proportion of people with Type 2 diabetes (42.3%) had renal dysfunction compared with those with Type 1 diabetes (32.4%). Achievement of systolic blood pressure and HbA1c targets was poor. Among people with Type 1 diabetes, 67.8% failed to achieve an HbA1c < 58 mmol/mol (7.5%). Of all people with diabetes, 37.8% failed to achieve a systolic blood pressure < 140 mmHg. Blood pressure control was poor in advanced chronic kidney disease. For example, mean (standard deviation) systolic blood pressure rose from 128.6 (15.4) mmHg among people with Type 1 diabetes and normal renal function to 141.0 (23.6) mmHg in those with chronic kidney disease stage 5 and macroalbuminuria.

CONCLUSIONS

The high prevalence of chronic kidney disease and poor attainment of treatment targets highlights a large subset of the diabetes population at increased risk of cardiovascular mortality or progressive kidney disease.

Excess mortality during hospital stays among patients with recorded diabetes compared with those without diabetes

AIM

To assess the additional mortality during hospital admissions among patients with recorded diabetes and identify the extent of variation in English provider trusts.

METHODS

Inpatient admissions to all English hospitals between April 2010 and March 2012 were extracted from Hospital Episode Statistics. Binary logistic regression was used to standardize for age, sex, deprivation, method and reason for admission, co-morbidities and type of trust. Trust level standardized mortality ratios for inpatients with recorded diabetes were compared with those without recorded diabetes and with published measures of hospital mortality.

RESULTS

Of the 10 169 003 hospital admissions analysed, 11.2% had recorded diabetes, but 21.5% of inpatient deaths occurred in this group. After adjustment for case mix, hospital admissions in patients with recorded diabetes had a 6.4% greater risk of dying (2052 more deaths over 2 years) than would be expected compared with similar patients without recorded diabetes. The additional risk of death was significantly greater in smaller trusts. The highest additional risk of death was found in hospital admissions of younger female patients admitted electively. At provider trust level, 37.4% of variation in adjusted mortality in patients with recorded diabetes was explained by the mortality in those without recorded diabetes.

CONCLUSION

A diagnosis of diabetes has an adverse impact on hospital mortality that cannot be explained by usual case-mix adjustments, and the additional risk of dying is greatest among hospital admissions that would normally have a low risk of death. This implies that diabetes may override the usual risk factors for hospital mortality.

Obesity and kidney disease in type 1 and 2 diabetes: an analysis of the National Diabetes Audit

BACKGROUND

Obesity is increasingly prevalent in many countries. Obesity is a major risk factor for the development of type 2 diabetes but its relationship with diabetic kidney disease (DKD) remains unclear. Some studies have suggested that the metabolic syndrome (including obesity) may be associated with DKD in type 1 diabetes.

AIM

To investigate the association between obesity and DKD.

DESIGN

Retrospective cross-sectional study.

METHODS

National Diabetes Audit data were available for the 2007-08 cycle. Type 1 and 2 diabetes patients with both a valid serum creatinine and urinary albumin:creatinine ratio were included. DKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2), albuminuria or both. Logistic regression was used to analyse associations of obesity (body mass index ≥30 kg/m(2)) and other variables including year of birth, year of diagnosis, ethnicity and stage of kidney disease.

RESULTS

A total of 58 791 type 1 and 733 769 type 2 diabetes patients were included in the analysis. After adjustment, when compared with type 1 diabetes patients with normal renal function those with DKD were up to twice as likely to be obese. Type 2 DKD patients were also more likely to be obese. For example, type 2 diabetes patients with an eGFR <15 ml/min/1.73 m(2) and normoalbuminuria, microalbuminuria or macroalbuminuria were all more likely to be obese; odds ratios (95% CI) 1.65 (1.3-2.1), 1.56 (1.28-1.92) and 1.27 (1.05-1.54), respectively.

CONCLUSION

This study has highlighted a strong association between obesity and kidney disease in type 1 diabetes and confirmed their association in type 2 diabetes.

Potential role of preoperative conventional MRI including diffusion measurements in assessing epidermal growth factor receptor gene amplification status in patients with glioblastoma

BACKGROUND AND PURPOSE

Epidermal growth factor receptor amplification is a common molecular event in glioblastomas. The purpose of this study was to examine the potential usefulness of morphologic and diffusion MR imaging signs in the prediction of epidermal growth factor receptor gene amplification status in patients with glioblastoma.

MATERIALS AND METHODS

We analyzed pretreatment MR imaging scans from 147 consecutive patients with newly diagnosed glioblastoma and correlated MR imaging features with tumor epidermal growth factor receptor amplification status. The following morphologic tumor MR imaging features were qualitatively assessed: 1) border sharpness, 2) cystic/necrotic change, 3) hemorrhage, 4) T2-isointense signal, 5) restricted water diffusion, 6) nodular enhancement, 7) subependymal enhancement, and 8) multifocal discontinuous enhancement. A total of 142 patients had DWI available for quantitative analysis. ADC maps were calculated, and the ADCmean, ADCmin, ADCmax, ADCROI, and ADCratio were measured.

RESULTS

Epidermal growth factor receptor amplification was present in 60 patients (40.8%) and absent in 87 patients (59.2%). Restricted water diffusion correlated with epidermal growth factor receptor amplification (P = .04), whereas the other 7 morphologic MR imaging signs did not (P > .12). Quantitative DWI analysis found that all ADC measurements correlated with epidermal growth factor receptor amplification, with the highest correlations found with ADCROI (P = .0003) and ADCmean (P = .0007).

CONCLUSIONS

Our results suggest a role for diffusion MR imaging in the determination of epidermal growth factor receptor amplification status in glioblastoma. Additional work is necessary to confirm these results and isolate new imaging biomarkers capable of noninvasively characterizing the molecular status of these tumors.

Variation in the recorded incidence of amputation of the lower limb in England

AIMS/HYPOTHESIS

The study aimed to explore the variation in recorded incidence of lower limb amputation in England.

METHODS

The incidences of amputations in adults with and without diabetes were determined from hospital episode statistics over 3 years to 31 March 2010 and compared between the 151 Primary Care Trusts (PCTs) in England.

RESULTS

There were 34,109 amputations, including 16,693 (48.9%) in people with diabetes. The incidence was 2.51 per 1,000 person-years in people with diabetes and 0.11 per 1,000 person-years in people without (relative diabetes risk 23.3). Incidence varied eightfold across PCTs in people both with diabetes (range 0.64-5.25 per 1,000 person-years) and without (0.03-0.24 per 1,000 person-years). Amputations in people with diabetes varied tenfold--both major (range 0.22-2.20 per 1,000 person-years) and minor (range 0.30-3.25 per 1,000 person-years). The incidences of minor and major amputations were positively correlated both in those with (r = 0.537, p < 0.0005) and without (r = 0.611, p < 0.0005) diabetes. Incidences of amputations were also correlated between people with and without diabetes (total amputations r = 0.433, p < 0.0005; major amputations r = 0.528, p < 0.0005). There was a negative correlation between the incidence of amputation and estimated prevalence of ethnic Asians. No association was found between the PCT incidence of either total amputations and general population prevalence of social deprivation (r = -0.138, p = 0.092) or smoking (r = 0.137, p = 0.096).

CONCLUSIONS/INTERPRETATION

Variation in amputation incidence occurs across England. Because of the similarity in amputation variation between people with and without diabetes the variation may reflect generic differences in local healthcare delivery, although racial factors may also contribute.

Somatotopic organization of motor pathways in the internal capsule: a probabilistic diffusion tractography study

BACKGROUND AND PURPOSE

The location of the motor pathways in the PLIC remains controversial. In the current study, we trace the fibers from the tongue, face, hand, and foot motor cortices by using probabilistic diffusion tractography and define their somatotopic organization in the PLIC.

MATERIALS AND METHODS

Twenty subjects were retrospectively studied. Fiber tracts were separately calculated between ROIs in the cerebral peduncle and in the 4 different motor regions in the precentral gyrus. Probabilistic connectivity maps were generated, and the voxel with the highest probability was designated as the position of the motor pathway. The PI and LI were defined as the relative anteroposterior and mediolateral locations of the motor pathways.

RESULTS

Tongue pathways were located anteromedial to face in 16 hemispheres (40%), with P < .05 for the PI and LI. Face pathways were located anteromedial to hand in 25 hemispheres (62.5%) with P < .05 for PI and LI. Hand pathways were anteromedial to foot in 14 hemispheres (35%) and anterior in 11 hemispheres (27.5%), with P < .05 for PI but P > .13 for LI. Group analysis showed that the somatotopic arrangement of the bilateral hemispheres was symmetric.

CONCLUSIONS

Probabilistic tractography demonstrated the anteroposterior alignment of the motor pathways along the long axis in the PLIC. Probabilistic tractography successfully tracked the motor pathways of the tongue, face, hand, and foot from the precentral gyrus through their intersection with the larger superior longitudinal fasciculus to the PLIC in all cases, overcoming limitations of standard (nonprobabilistic) tractography methods.

Analysis of circulating angiogenic biomarkers from patients in two phase III trials in lung cancer of chemotherapy alone or chemotherapy and thalidomide

BACKGROUND

Thalidomide has potent anti-inflammatory and anti-angiogenic properties. It was evaluated in combination with chemotherapy in two randomised placebo-controlled trials in patients with small cell lung cancer (SCLC, n=724) and advanced non-small cell lung cancer (NSCLC, n=722). Neither study demonstrated an improvement in overall survival with the addition of thalidomide to chemotherapy. This study investigated circulating angiogenic biomarkers in a subset of these patients.

METHODS

Serial plasma samples were collected in a cohort of patients enrolled in these two trials (n=95). Vascular endothelial growth factor (VEGF), soluble truncated form of VEGF receptor-2 (sVEGFR-2), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), basic fibroblast growth factor (bFGF) and soluble intercellular adhesion molecule-1 (sICAM-1) levels were measured by enzyme-linked immunosorbent assays. Results were correlated with patient clinical data including stage, response rate and progression-free survival (PFS).

RESULTS

Baseline biomarker levels were not significantly different between SCLC and NSCLC. For pooled treatment groups, limited stage SCLC was associated with lower baseline VEGF (P=0.046), sICAM-1 (P=0.008) and IL-8 (P=0.070) than extensive stage disease. Low baseline IL-8 was associated with a significantly improved PFS in both SCLC and NSCLC (P=0.028), and a greater reduction in IL-8 was associated with a significantly improved tumour response (P=0.035). Baseline angiogenic factor levels, however, did not predict response to thalidomide.

CONCLUSION

Circulating angiogenic biomarkers did not identify patients who benefited from thalidomide treatment.

Potential utility of conventional MRI signs in diagnosing pseudoprogression in glioblastoma

OBJECTIVE

To examine the potential utility of conventional MRI signs in differentiating pseudoprogression (PsP) from early progression (EP).

METHODS

This retrospective study reviewed initial postradiotherapy MRI scans of 321 patients with glioblastoma undergoing chemotherapy and radiotherapy. A total of 93 patients were found to have new or increased enhancing mass lesions, raising the possibility of PsP. Final diagnosis of PsP or EP was established upon review of surgical specimens from a second resection or by clinical and radiologic follow-up. A total of 11 MRI signs potentially helpful in the differentiation between PsP and EP were examined on the initial post-RT MRI and were correlated with the final diagnosis through χ(2) or Fisher exact test.

RESULTS

Sixty-three (67.7%) of the 93 patients had EP, of which 22 (34.9%) were diagnosed by pathology. Thirty patients (32.3%) had PsP; 6 (16.7% of the 30) were diagnosed by pathology. Subependymal enhancement was predictive for EP (p = 0.001) with 38.1% sensitivity, 93.3% specificity, and 41.8% negative predictive value. The other 10 signs had no predictive value (p = 0.06-1.0).

CONCLUSIONS

Conventional MRI signs have limited utility in diagnosing PsP in patients with recently treated glioblastomas and worsening enhancing lesions. We did not find a sign with a high negative predictive value for PsP that would have been the most useful for the clinical physician. When present, subependymal spread of the enhancing lesion is a useful MRI marker in identifying EP rather than PsP.

Isolated diffusion restriction precedes the development of enhancing tumor in a subset of patients with glioblastoma

BACKGROUND AND PURPOSE

Most response criteria for patients with glioblastoma rely on increases in the contrast enhancing abnormality to determine tumor progression. Our aim was to determine retrospectively in patients with glioblastoma whether diffusion restriction can predict the development of new enhancing mass lesions.

MATERIALS AND METHODS

We reviewed the brain MR imaging scans (including DWI and ADC maps) of 208 patients with glioblastoma. Patients with restricted diffusion in or adjacent to the tumor were identified, with further analysis only performed on those patients with low-ADC lesions without enhancement. These patients were followed to determine if new concordant enhancement developed at the site of the low-ADC lesion. A Wilcoxon signed rank test, competing risk analysis, and Kaplan-Meier curves were used to compare the mean drop in ADC values, assess enhancement-free survival, and determine overall survival, respectively.

RESULTS

In 67 of the 208 patients (32.2%), visibly detectable restricted diffusion was seen during treatment. The study cohort was formed by the 27 patients with low-ADC lesions and no corresponding enhancement. Twenty-three (85.2%) patients developed gadolinium-enhancing tumor at the site of restricted diffusion a median of 3.0 months later (95% CI, 2.6-4.1 months). The mean decrease in ADC was 22.9% from baseline (P < .001). The 3-month enhancement-free survival probability was 0.481 (95% CI, 0.288-0.675). The 12-month overall survival probability was 0.521 (95% CI, 0.345-0.788). Restricted diffusion predicted enhancement regardless of antiangiogenic therapy with bevacizumab.

CONCLUSIONS

In a subset of patients with glioblastoma, development of a new focus of restricted diffusion during treatment may precede the development of new enhancing tumor.

Fabrication of Planar and Cross-Sectional TEM Specimens Using a Focused Ion Beam

A new technique using a focused ion beam has been developed for the fabrication of transmission electron microscopy specimens in pre-selected regions. The method has been proven in the fabrication of both cross-sectional and planar specimens, with no induced artefacts. The lateral accuracy achievable in the selection of an area for cross-sectional analysis is better than one micrometre. The technique has been applied to a number of silicon and III-V based integrated circuits, and is expected to be suitable for many other materials and structures.

Structure-Property Relationships in the Toughening of Poly(Methyl Methacrylate) by Sub-Micron Size, Multiple-Layer Particles

Rubber-toughened poly(methyl methacrylate) materials have been prepared by blending poly(methyl methacrylate) with specially-synthesised, refractive index matched particles containing two, three and four radially-alternating rubbery and glassy layers. The paper describes the effects upon mechanical properties of (i) two-, three- and four-layer particle structure and (ii) particle diameter and glassy core size for three-layer particles.

Sphenoid masses in children: radiologic differential diagnosis with pathologic correlation

Childhood central skull base masses are rare, often difficult to diagnose, and have overlapping imaging findings. In this review, we provide an overview of the epidemiology, clinical findings, and management of pediatric sphenoid bone and sphenoid sinus masses with an emphasis on imaging findings that may help to differentiate lesions. Radiologic-pathologic correlation is provided. Finally, an imaging-based algorithm is presented as a guide to help radiologists narrow their differential diagnoses. Some of the entities discussed are virtually unique to the pediatric population; others occur rarely in this age group but should be considered in the appropriate clinical setting. Entities included in the discussion are grouped into 2 categories: those that cause nonaggressive osseous remodeling and those that are more commonly associated with aggressive bone changes. Mucocele, aneurysmal bone cyst, giant cell lesions, meningioma, and fibrous dysplasia tend to remodel bone, while entities such as chordoma, craniopharyngioma, rhabdomyosarcoma, sinonasal carcinoma, and neuroblastoma may cause more aggressive local bone changes.

Fishing for gaps in science: a bibliographic analysis of Brazilian freshwater ichthyology from 1986 to 2005

To investigate Brazilian freshwater ichthyology, from 1986 to 2005, a bibliometric analysis was conducted using abstracts downloaded from The Web of Science database searching for the keywords 'fish', 'pisces', 'teleostei' and the address field having the word 'Brazil'. The results of this study showed that Brazilian freshwater ichthyology publications have been increasing during the study period. This process is a consequence of a series of investments that the Brazilian Government has made. Furthermore, data analyses identified scientific areas where there was a lack of scientific knowledge (e.g. studies of species threatened with extinction and certain hydrologic basins). Research institutions from the north-east and northern region of Brazil had the lowest participation in scientific productivity, which was a reflection of their regions poorer economic situation. This study showed that scientific productivity in Brazilian ichthyology was a direct reflection of state investment in research. Furthermore, data in this study follow expected statistical probabilities, for example, fishes from the most diverse families were the most studied. Thus, the study shows that great progress has been made by Brazilian ichthyologists in the last 20 years; however, due to the mega diversity of fishes in Brazil, much remains to be done if many species are to become known to science and to be saved from extinction. This it seems will depend on continued and further investment by Brazilian Government funding agencies, as Brazilian ichthyologists have demonstrated their capacity to generate high quality information about their study species.