Increased prevalence of non-alcoholic fatty liver disease in European women with a history of gestational diabetes

AIMS/HYPOTHESIS

Non-alcoholic fatty liver disease (NAFLD) is common in type 2 diabetes but it is unknown whether NAFLD is prevalent in European women at risk of type 2 diabetes. We studied the prevalence of, and risk factors for, NAFLD in European women with previous gestational diabetes (GDM) at high risk of type 2 diabetes.

METHODS

A total of 110 women with previous GDM and 113 without previous GDM, with non-diabetic glucose tolerance were recruited retrospectively from antenatal databases. Participants underwent liver ultrasound scan examination, anthropometry and blood sampling for liver function tests and to determine levels of fasting lipids, NEFA and insulin and glucose concentrations in order to derive insulin sensitivity and insulin secretion indices (HOMA%S and HOMA%B, respectively).

RESULTS

There was no significant difference in BMI in women with previous GDM compared with those without previous GDM (28.9 ± 0.6 vs. 27.9 ± 0.6 kg/m(2), respectively; p = 0.12). Women with previous GDM had higher fasting and 2 h glucose concentrations following a 75 g OGTT ([mean ± SEM] fasting glucose 5.3 ± 0.1 vs. 5.1 ± 0.1 mmol/l, p = 0.02; 2 h glucose 6.8 ± 0.2 vs. 5.8 ± 0.3 mmol/l, p = 0.02), dyslipidaemia (LDL-cholesterol 3.3 ± 0.1 vs. 2.8 ± 0.1 mmol/l; HDL-cholesterol [median {interquartile range}] 1.3 [1.2-1.6] vs. 1.8 [1.5-1.9] mmol/l; triacylglycerol 1.3 [0.9-1.6] vs. 1.0 [0.7-1.7] mmol/l, all p ≤ 0.03), higher insulin secretion and lower insulin sensitivity. NAFLD prevalence was greater in women with previous GDM compared with those without previous GDM: 38% (95% CI 28-47%) vs. 17% (95% CI 10-24%), p = 0.001. In multiple logistic regression analysis, lower insulin sensitivity and raised serum alanine transaminase concentrations were associated with NAFLD.

CONCLUSIONS/INTERPRETATION

NAFLD is prevalent in European women with previous GDM. Impaired insulin sensitivity and increased liver transaminase activity are closely associated with NAFLD in these women.

Cancer survival in Lampang, Thailand, 1990-2000

The Lampang cancer registry was established in 1995, with retrospective data collection since 1988. Cancer registration is currently done by passive methods. The registry is contributing data on survival for 40 cancer sites or types registered during 1990-2000. Follow-up has been carried out by passive and active methods with median follow-up ranging from 1-74 months for different cancers. The proportion having a histologically verified diagnosis for various cancers ranged between 30-100%; death certificate only (DCO) cases comprised 0-33%; 67-100% of total registered cases were included for survival analysis. Complete follow-up at five years ranged from 96-100% for different cancers. The 5-year age-standardized relative survival rate was the highest for skin non-melanoma (85%) followed by lip (81%), thyroid (74%), corpus uteri (71%) and penis (71%). The 5-year relative survival by age group showed a fluctuating trend. An overwhelmingly high proportion of cases were diagnosed with a regional spread of disease, ranging from 35-68% for different cancers, and survival was decreasing with increasing extent of disease for most cancers studied.

Studies on Fabrication and Characterization of Nanoclay Reinforced Nylon-6 composites: Enhancement of Heat distortion Temperature

<p>Organically modified nanoclay (cation exchange capacity of 135 to 145 meq/100 g) was used as nanophase reinforcement for fabrication of nylon-6 nanocomposites. The thickness of clay platelets varied form 1.2 nm to 1.3 nm with 3.485 nm as d-spacing. Nylon 6/nanoclay composites were fabricated with loading of 2.5, 5.0 and 10 wt.% nanoclay via direct melt compounding technique using conventional twinscrew extruder. Processing temperature profile from hopper to header was 230-240-245-260 °C and screw speed was maintained at 180 rpm. The nylon 6/clay nanocomposites were characterized for thermal and mechanical properties. The structural properties were characterized by Differential Scanning Calorimeter (DSC) and X-ray diffraction analysis. The tensile fracture morphology was analyzed by using Scanning Electron Microscope (SEM). DSC nonisothermal curves show an increase in the crystallization temperature with increasing degree of crystallinity. The crystallization rate of the nanoclay reinforced nylon 6 composites was found to be significantly faster than that for the pristine nylon 6 and suggests that the layered silicates act as nucleating centers. XRD result shows that addition of nanoclay by this technique favors the formation of γ-crystalline phase in nylon 6/nanoclay composites. Due to this, there is substantial enhancement in the tensile strength and Izod impact strength. A variation from 700 to 971 Kg/cm² for tensile strength and from 3.0 to 3.4 Kg.cm/cm of notch for Izod impact strength. The detailed results are presented.</p>

Detection of lip, alveolar ridge and hard palate abnormalities using two-dimensional ultrasound enhanced with the three-dimensional reverse-face view

OBJECTIVE

The aim of this study was to assess conventional two-dimensional (2D) ultrasound enhanced with a three-dimensional (3D) ultrasound technique, the 'reverse-face' view (3D-RF) in prenatal evaluation of the involvement of the lips, alveolar ridge and secondary palate in suspected isolated orofacial clefting.

METHODS

One hundred and twenty-four cases of suspected orofacial clefting diagnosed by a routine 2D ultrasound scan were referred for specialist ultrasound at 20-34 weeks' gestation for a detailed assessment of the lips and palate using both 2D and 3D ultrasound. For the 3D examination the lips and alveolar ridges were examined both in profile and in the frontal plane. The palate was then assessed in the reverse coronal view by rotating the face through 180° on the vertical axis to produce the 3D-RF view. Antenatal diagnoses were compared with postnatal findings. Left and right lip and alveolar ridge defects were counted separately according to the Kernohan 'striped Y' classification.

RESULTS

Of 124 patients, 110 had isolated facial clefts and were available for follow-up; in 10, 3D-RF views were not successfully obtained, leaving 100 cases for assessment. The sensitivity of the 2D enhanced with 3D-RF technique for the diagnosis of cleft of the lip was 116/122 (95%), false-positive rate (FPR) 7.7%; for alveolar ridge was 87/103 (84.5%), FPR 7.2%; and for hard palate was 61/68 (89.7%), FPR 15.6%.

CONCLUSION

The data reported represent the largest series of orofacial abnormalities diagnosed by 2D ultrasound and enhanced with 3D imaging to refine the detection of clefts of the hard palate. The technique is feasible in 90% of patients in whom almost 90% have a correct classification of clefts of the lip, alveolar ridge and palate.

Hepatic vein transit times of a microbubble agent in assessing response to antiviral treatment in patients with chronic hepatitis C

Microbubble measurement of hepatic vein transit times (HVTT) may have the potential to assess severity of hepatitis C virus (HCV)-related liver disease, where there is a shorter HVTT with more severe disease. We investigated the utility of this test as a marker of response to antiviral treatment. Thirty-seven patients with biopsy-proven HCV-related disease undergoing antiviral treatment were studied. All had baseline scans and then repeat scans 6 months after the end of treatment. HVTT using Levovist were obtained from the right and middle hepatic veins, and the shorter time was used for analysis. The aspartate aminotransferase to platelet ratio index (APRI) scores were calculated retrospectively. There were seven patients with mild hepatitis, 23 with moderate/severe hepatitis and seven with cirrhosis. The mean baseline HVTT in responders ± SE increased from 27.3 ± 2.29 s to 33.5 ± 2.8 s posttreatment (P = 0.01). In the 10 nonresponders, the HVTT remained the same; 43.3 ± 9 s baseline compared to 44 ± 7.8 s posttreatment (P = 0.84). This trend was also seen with the APRI score where in responders, the mean score decreased from 1.1 ± 0.2 to 0.74 ± 1 (P = 0.03) and in nonresponders, the score remained unchanged; 0.88 ± 0.2 compared to 0.84 ± 0.2 (P = 0.31). HVTT measurement lengthened, while APRI scores decreased in patients who responded to antiviral treatment while both remained the same, shortened (HVTT) or increased (APRI), respectively, in patients who were nonresponders. These results are encouraging and indicate that these tests could be potentially used as markers of response to treatment and could obviate the need for serial biopsies in antiviral future treatment studies.

Optimal combinations of ultrasound-based and serum markers of disease severity in patients with chronic hepatitis C

Combinations of noninvasive markers may improve discrimination of chronic liver disease severity. The aims of this study were to compare four validated serum and ultrasound-based markers of hepatic disease severity head-to-head with liver biopsy and to assess optimal combinations with consideration of cost. A total of 67 patients with biopsy-proven chronic hepatitis C underwent all four techniques on the same visit [aspartate aminotransferase (AST) to platelet ratio index (APRI); Enhanced Liver Fibrosis (ELF) panel; transient elastography (TE) and ultrasound microbubble hepatic transit times (HTT)]. Markers were combined according to increasing financial cost and ordinal regression used to determine contributions. APRI, ELF, TE and HTT predicted cirrhosis with diagnostic accuracy of 86%, 91%, 90% and 83% respectively. ELF and TE were the most reliable tests with an intra-class correlation of 0.94 each. Either ELF or TE significantly enhanced the prediction of fibrosis stage when combined with APRI, but when combined together, did not improve the model further. Addition of third or fourth markers did not significantly improve prediction of fibrosis. Combination of APRI with either ELF or TE effectively predicts fibrosis stage, but combinations of three or more tests lead to redundancy of information and increased cost.

Unilateral vocal cord paralysis associated with subdural haemorrhage in a newborn infant

A term infant developed stridor, hoarse cry and respiratory distress after forceps-assisted delivery. Oral feeding resulted in aspiration. Flexible laryngoscopy showed a right-sided vocal cord paralysis (VCP). A magnetic resonance image (MRI) of the brain revealed an ovoid lesion in the posterior fossa impinging on the brainstem, which was considered to represent a subdural haematoma. Clinical signs of vocal cord palsy and the associated MRI changes resolved spontaneously by 6 weeks of age. Vocal cord palsy is a common cause of stridor in newborn infants, although in many cases it is considered idiopathic. This is the first report of vocal cord palsy associated with subdural haemorrhage after instrumental delivery, and may represent an important and previously unappreciated cause of VCP. This case highlights the importance of magnetic resonance brain imaging in those infants with VCP in whom the aetiology is uncertain.

Normal coronary angiography and primary percutaneous coronary intervention for ST elevation myocardial infarction: a literature review and audit findings

It is becoming increasingly common to offer primary percutaneous coronary intervention as first line treatment for ST elevation myocardial infarction (STEMI). In a subset of patients presenting with suspected STEMI, coronary arteries appear normal at coronary angiography. In this article, the current literature of this group of patients is reviewed. The incidence of 'normal' angiography, the clinical and electrocardiographic features of this group of patients and the alternative diagnoses for presentation are discussed. This article reviews the factors leading to such presentation, the clinical characteristics of such patients and the implications, clinical and economic.

Regeneration of tendo Achillis

A child with traumatic laceration of the tendo Achillis developed secondary infection after primary repair. This resulted in the loss of 5 cm of the distal part of the tendon and overlying soft tissue. The patient was treated with a free skin flap to cover the wound and to control the infection leaving reconstruction for a second-stage procedure. However, when he was assessed two years after the skin-flap, delayed reconstruction proved to be unnecessary since he had regained normal ankle function spontaneously and could demonstrate equal function in both tendons.

Low-dose azathioprine or mercaptopurine in combination with allopurinol can bypass many adverse drug reactions in patients with inflammatory bowel disease

BACKGROUND

The thiopurine drugs, azathioprine and mercaptopurine (MP), are established treatments for IBD. However, therapeutic failure caused by adverse drug reactions occurs frequently.

AIM

To study combination of allopurinol with reduced-dose thiopurine in an attempt to avoid adverse drug reactions in the treatment of IBD.

METHODS

Patients with drug reactions to full-dose thiopurines were recruited for combination therapy in two IBD centres in this retrospective study. Dosing was guided by measuring thiopurine methyltransferase (for UK patients) or thioguanine nucleotides and methyl-6MP (Australian patients). Response was monitored by clinical activity indices.

RESULTS

Of 41 patients, 25 had non-hepatic and 16 had hepatitic reactions. Clinical remission was achieved in 32 patients (78%) with a median follow-up of 41 weeks (range 0.5-400). Patients who did not respond to combination therapy tended to fail early with the same adverse reaction. The relative risk of having an adverse reaction with methyl-6MP in the top interquartile range was 2.7 (1.3-28) times that with methyl-6MP in the lower three quartiles (95% confidence interval).

CONCLUSION

The combined experience from our centres is the largest reported experience of this combination therapy strategy in IBD, and the first to provide evidence for benefit in thiopurine and allopurinol co-therapy to avoid non-hepatitic adverse drug reactions.

Medication errors in community pharmacy: an investigation into the types and potential causes

Objectives

To establish the nature of medication errors occurring within community pharmacy and analyse common error patterns. To identify factors which influence the occurrence of medication errors and near misses, with the intention of designing systems or strategies to reduce the occurrence of these events.

Setting

Fifteen community pharmacies situated within Brighton and Hove City Primary Care Trust, East Sussex, between January and March 2004.

Method

A self-reporting form was designed, piloted and administered to pharmacists, which gathered information on the detection of an error or near miss in the dispensing process.

Key findings

One-hundred and thirteen near misses and thirty-two medication errors were reported. The majority of near misses were detected by the pharmacist at the final check, and the majority of medication errors were detected by the patient or patient's representative. Selection errors were most common, with similar drug names and packaging cited as the main contributory factors. ‘Business’ was frequently cited as the circumstance surrounding the error.

Conclusion

This study demonstrates that pharmacists do have an important part to play and the positive impact of community pharmacists in preventing, detecting and correcting errors and thus preventing harm to patients in the primary care setting. However, medication errors do occur, and therefore a multifactorial approach by manufacturers, marketing and packaging personnel, in addition to input from pharmacists, may be an effective permanent solution in reducing the errors made.