Diabetic ketoacidosis at the onset of type 1 diabetes is associated with future HbA1c levels

AIMS/HYPOTHESIS

We investigated the long-term impact of diabetic ketoacidosis (DKA) at onset on metabolic regulation and residual beta cell function in a Danish population with type 1 diabetes.

METHODS

The study is based on data from DanDiabKids, a Danish national diabetes register for children. The register provides clinical and biochemical data on patients with type 1 diabetes diagnosed in 1996-2009 and then followed-up until 1 January 2012. Repeated-measurement models were used as statistical methods.

RESULTS

The study population comprised 2,964 children <18 years. The prevalence of DKA at diagnosis was 17.9%. Of the total subjects, 8.3% had mild, 7.9% had moderate and 1.7% had severe DKA. DKA (moderate and severe) was associated with increased HbA1c (%) levels (0.24; 95% CI 0.11, 0.36; p = 0.0003) and increased insulin dose-adjusted HbA1c (IDAA1c, 0.51; 95% CI 0.31, 0.70; p < 0.0001) during follow-up, after adjustment for covariates. Children without a family history of diabetes were more likely to present with DKA (19.2% vs 8.8%, p < 0.0001); however, these children had a lower HbA1c (%) level over time (-0.35; 95% CI -0.46, -0.24; p < 0.0001). Continuous subcutaneous insulin infusion (CSII) was associated with a long-term reduction in HbA1c, changing the effect of DKA, after adjustment for covariates (p < 0.0001).

CONCLUSIONS/INTERPRETATION

DKA at diagnosis was associated with poor long-term metabolic regulation and residual beta cell function as assessed by HbA1c and IDAA1c, respectively; however, CSII treatment was associated with improvement in glycaemic regulation and residual beta cell function, changing the effect of DKA at onset in our population.

Establishing a cell line from Atlantic cod as a novel tool for in vitro studies

The present work describes the generation of a cell line from newly hatched Atlantic cod (Gadus morhua) larvae (ACL cells). Primary cultures were initiated by explant outgrowth from partially minced tissues and subcultured cells were exposed to UV radiation. After a substantial period of growth lag, cells started to proliferate and different growth conditions were tested to establish the cell line. At present, the ACL cell line has been subcultured for more than 100 passages. ACL cells had a polygonal shape and the morphology appeared homogenous with epithelial-like cells. Cell growth was dependent on the presence of foetal bovine serum and cells proliferated in a wide temperature range with optimal growth at 15 °C. By exposure to a viral dsRNA mimic (poly I:C) the cells expressed high levels of a repertoire of genes comprising both inflammatory mediators and interferon stimulated genes. Infection studies with two different viruses showed that infectious pancreatic necrosis virus (IPNV) propagated efficiently, and induced low level expression of genes of both pathways before the cells rapidly died. No productive infection was obtained with nervous necrosis virus (NNV), but a transient increase in the viral RNA level, followed by a high increase in expression of selected ISGs, suggests that the virus enters the cells but is unable to complete its replication cycle. To our knowledge, ACL cells are at the moment the only existing cell line from Atlantic cod. Our results demonstrate that ACL cells can be a useful research tool for further exploration of host-pathogen interactions and it is believed that this cell line will serve as a valuable tool also for studies within other research areas.

Predictors of adverse outcomes on an acute geriatric rehabilitation ward

BACKGROUND

multidisciplinary rehabilitation is of proven benefit in the management of older inpatients. However, the identification of patients who will do well with rehabilitation currently lacks a strong evidence base.

OBJECTIVES

the aims of this study were to compare the importance of chronological age, gender, co-morbidities and frailty in the prediction of adverse outcomes for patients admitted to an acute geriatric rehabilitation ward.

DESIGN

prospective observational cohort study.

SUBJECTS AND SETTING

two hundred and sixty-five patients admitted consecutively to an acute geriatric rehabilitation ward at a tertiary care teaching hospital.

METHODS

frailty status was measured by an index of accumulated deficits, giving a potential score from 0 (no deficits) to 1.0 (all 40 deficits present). Patients were stratified into three outcomes: good (discharged to original residence within 28 days), intermediate (discharged to original residence but longer hospital stay) and poor (newly institutionalised or died).

RESULTS

patients were old (82.6 ± 8.6 years) and frail (mean frailty index (FI) 0.34 ± 0.09). Frailty status correlated significantly with length of stay and was a predictor of poor functional gain. The odds ratio of intermediate and poor outcome relative to a good outcome was 4.95 (95% CI = 3.21, 7.59; P < 0.001) per unit increase in FI. Chronological age, gender and co-morbidity showed no significant association with outcomes.

CONCLUSION

frailty is associated with adverse rehabilitation outcomes. The FI may have clinical utility, augmenting clinical judgement in the management of older inpatients.

Small Lead and Indium Inclusions in Aluminium

Ion implantation of lead or indium into aluminium results in spontaneous phase separation and formation of lead or indium precipitates. The precipitates grow in topotactical alignment with the matrix, giving TEM images characterized by moiré fringes. The size and density of the precipitates increase with increasing fluence until coalescence begins to occur. Implantations at elevated temperatures lead to formation of larger precipitates with well developed facets. This is particularly significant for implantations above the bulk melting point of the implanted species. Melting and solidification have been followed by in-situ TEM heating and cooling experiments. Superheating up to ∼ 50 K above the bulk melting point has been observed, and the largest inclusions melt first. Melting is associated with only partial loss of facetting of the largest inclusions. Initial growth of the inclusions occurs by trapping of atoms retained in supersaturated solution. Further growth occurs by coalescence of neighbouring inclusions in the liquid phase. Solidification is accompanied by a strong undercooling ∼ 30 K below the bulk melting point, where the smallest inclusions solidify first. Solidification is characterized by spontaneous restoration of the facets and the topotactical alignment.

Lead inclusions in aluminium

Ion implantation at room temperature of lead into aluminium leads to spontaneous phase separation and formation of lead precipitates growing topotactically with the matrix. Unlike the highly pressurised (∼ 1–5 GPa) solid inclusions formed after noble gas implantations, the pressure in the lead precipitates is found to be less than 0.12 GPa.

Recently we have observed the intriguing result that the lead inclusions in aluminium exhibit both superheating and supercooling [1]. In this paper we review and elaborate on these results. Small implantation-induced lead precipitates embedded in an aluminium matrix were studied by X-ray diffraction. The (111) Bragg peak originating from the lead crystals was followed during several temperature cycles, from room temperature to 678 K. The melting temperature for bulk lead is 601 K. In the first heating cycle we found a superheating of the lead precipitates of 67 K before melting occurred. During subsequent cooling a supercooling of 21 K below the solidification point of bulk lead was observed. In the subsequent heating cycles this hysteresis at the melting transition was reproducible. The full width of the hysteresis loop slowly decreased to 62 K, while the mean size of the inclusions gradually increased from 14.5 nm to 27 nm. The phenomena of superheating and supercooling are thus most pronounced for the small crystallites. The persistence of the hysteresis loop over successive heating cycles demonstrate that its cause is intrinsic in nature, and it is believed that the superheating originates from the lack of free surfaces of the lead inclusions.

Nanoscale Sn Inclusions in Al – Structure and Melting-Solidification Properties

Al-Sn surface alloys with 2-3 at.% Sn have been made by ion implantation of Sn in Al. The microstructure of the alloys consists of dense distributions of nanoscale Sn inclusions embedded in the Al matrix. For implantations carried out at 425 K the inclusions have sizes in the range from about 2 to 15 nm. The structure of the inclusions is tetragonal - the white Sn structure – with lattice parameters of a = 0.583 nm and c = 0.318 nm respectively, i.e. identical to the lattice parameters of bulk Sn. The inclusions grow in preferred alignment with the matrix and the most commonly observed orientation relationships is given by (100)Sn ||(111)Al and [010]Sn || [211]Al. The shape of the inclusions is partly faceted and partly rounded with larger flat facets on the {100}Sn/{111}Al interfaces. Melting and solidification of the inclusions, which have been studied by in-situ transmission electron microscopy (TEM) and Rutherford backscattering spectrometry (RBS) in combination with channeling, shows a distinct hysteresis. Melting of the inclusions which is associated with a distinct premelting, takes place in the range from about 430 K to 485 K, i.e. significantly below the bulk melting point of 505 K. The premelting is size dependent and the smallest inclusions melt at the lowest temperatures. Solidification requires a substantial undercooling and takes place from around 400 K with a much weaker size dependence.

Emergency department presentation following falls: development of a routine falls surveillance system

INTRODUCTION

Falls are recognised as a major public health issue, particularly among older people, and have been targeted for attention by national service frameworks and National Institute for Health and Clinical Excellence guidelines in the UK. However, reliable epidemiological data are not easily available, and it remains difficult to monitor the effect of interventions that seek to reduce the public health impact of falls.

METHOD

In a 1-year study based in the emergency department (ED) of the University Hospital of Wales all Cardiff residents who described their presentation as following a fall were identified. From a catchment population of 305,353 people a total of 86,031 such ED presentations were recorded, 20,154 (23.4%) of which followed a fall.

RESULTS

This gives an overall falls incidence of 66/1000 population per year, meaning that in just a year one resident in 15 attended the ED following a fall. The impact of falls was greatest in the oldest age groups, and in women aged over 75 years the falls incidence of 139/1000 per year was significantly higher than the figure of 99/1000 per year observed in men of the same age.

CONCLUSIONS

This study describes a simple way for ED to establish routine falls surveillance. It offers the first estimate of the impact of falls on ED in the UK, suggesting that such services are dealing with 4 million falls-related attendances every year.

Epidemiology of persistent postoperative pain: Association of persistent pain and sensory abnormalities

Background

The prevalence of persistent postoperative pain in the general population is poorly documented, but clinical studies indicate that the problem is common.

Aim

The aim of this study was (1) to assess the prevalence of persistent postoperative pain among individuals operated during the last 3 years in a general population and (2) to describe factors associated with chronic postoperative pain.

Materials and methods

As part of a cross-sectional health survey in the municipality of Tromsø, North Norway, all participants answered questions on surgery, persisting pain and sensory abnormalities in the area of surgery. N = 12,984. Age 30–87 years, median 59. 53.4% women.

Pain intensity was reported using a 0–10 Numeric Rating Scale (0–10 NRS). Logistic regression was used to reveal any associations between pain and self-reported hyposensitivity, hypersensitivity and allodynia.

Results

2316 individuals (17.8%) had surgery between 3 months and 3 years prior to the survey.

826 (40.4%)of the 2044 who answered a questionnaire on postsurgical pain, reported having some degree of pain in the area of surgery. Of these 826 individuals, 45.2% had pain, when at worst, of moderate or severe intensity, i.e. 0–10 NRS of 4 or higher.

The areas of surgery carrying the strongest association with persistent pain were (in descending order of frequency): (1) Shoulder/ upper arm [74.5% (108/145)], (2) back [73.9% (65/88)], (3) lungs [66.7% (8/12)], (4) knee/lower leg [63.7% (179/281)], (5) hand [58.8% (90/153)]. (6) hip/thigh [58.3% (74/127)] and (7) ankle/foot [58.7% (84/143)].

18.3% (413) had reduced sensitivity in the area near the surgical scar, while 10.6% (240) reported hypersensitivity and 5.6% (127) allodynia.

For those reporting hypoesthesia, the odds ratio (OR) for having pain was 2.71 (95% confidence interval 2.08–3.53), for those reporting hyperesthesia, OR was 4.82 (3.24–7.18) and for those with allodynia 5.83 (3.12–10.90).

Conclusions

3 months or more after surgery, nearly half of the respondents report having pain in the area of surgery. In this survey, there is a strong association between persistent pain and the presence of both hyposensitivity, hypersensitivity and allodynia.

Performance monitoring in hip fracture surgery--how big a database do we really need?

Systems for collecting information about patient care are increasingly common in orthopaedic practice. Databases can allow various comparisons to be made over time. Significant decisions regarding service delivery and clinical practice may be made based on their results. We set out to determine the number of cases needed for comparison of 30-day mortality, inpatient wound infection rates and mean hospital length of stay, with a power of 80% for the demonstration of an effect at a significance level of p<0.05. We analysed 2 years of prospectively collected data on 1050 hip fracture patients admitted to a city teaching hospital. Detection of a 10% difference in 30-day mortality would require 14,065 patients in each arm of any comparison, demonstration of a 50% difference would require 643 patients in each arm; for wound infections, demonstration of a 10% difference in incidence would require 23,921 patients in each arm and 1127 patients for demonstration of a 50% difference; for length of stay, a difference of 10% would require 1479 patients and 6660 patients for a 50% difference. This study demonstrates the importance of considering the population sizes before comparisons are made on the basis of basic hip fracture outcome data. Our data also help illustrate the impact of sample size considerations when interpreting the results of performance monitoring. Many researchers will be used to the fact that rare outcomes such as inpatient mortality or wound infection require large sample sizes before differences can be reliably demonstrated between populations. This study gives actual figures that researchers could use when planning studies. Statistically meaningful analyses will only be possible with major multi-centre collaborations, as will be possible if hospital Trusts participate in the National Hip Fracture Database.

Identification of asymptomatic type 2 diabetes mellitus patients with a low, intermediate and high risk of ischaemic heart disease: is there an algorithm?

AIMS/HYPOTHESIS

The leading cause of death in type 2 diabetes is cardiovascular disease (CVD). We examined the prevalence of myocardial ischaemia in type 2 diabetes patients and tried to establish an algorithm to identify patients with a high risk of ischaemic heart disease.

METHODS

Type 2 diabetes patients who had no known or suspected CVD, and had been referred consecutively to a diabetes clinic for the first time (n=305; age 58.6+/-11.3 years; diabetes duration 4.5+/-5.3 years) were screened for myocardial ischaemia using myocardial perfusion scintigraphy (MPS).

RESULTS

The univariate predictors of myocardial ischaemia were: atypical or typical angina pectoris, two or more traditional risk factors for CVD, BMI >32 kg/m2, systolic blood pressure >140 mmHg, HbA1c >8.5%, high-sensitivity C-reactive protein >4.0 mg/l, N-terminal pro-brain natriuretic peptide >300 pg/ml, left atrial volume index >32 ml/m2, left ventricular ejection fraction <50%, and carotid and peripheral arterial disease. The algorithm identified low (n=96), intermediate (n=65) and high risk groups (n=115), in which the prevalence of myocardial ischaemia was 15%,23% and 43%, respectively. Overall the algorithm reduced the number of patients referred to MPS from 305 to 144.However, the sensitivity and specificity of the algorithm was just 68% and 62%, respectively.

CONCLUSIONS/INTERPRETATION

Our algorithm was able to stratify which patients had a low, intermediate or high risk of myocardial ischaemia based on MPS. However, the algorithm had low sensitivity and specificity, combined with high cost and time requirements.

TRIAL REGISTRATION

clinicaltrials.gov NCT00298844 FUNDING: The study was funded by the Danish Cardio vascular Research Academy (DaCRA), The Danish Diabetes Association and The Danish Heart Foundation.

Serum immunoglobulin sedimentation patterns and circulating immune complexes in IgA glomerulonephritis and Schönlein-Henoch nephritis

Sera from 8 patients with IgA glomerulonephritis and from 6 patients with Schönlein-Henoch nephritis were investigated by the C1q-binding assay (C1q-BA) test and by sucrose gradient centrifugation followed by sensitive solid phase radioimmunoassay determinations of IgA, IgG and IgM in each fraction obtained. Abnormal sedimentation profiles were found in sera from 3 of 8 patients with IgA nephritis and in 3 of 6 patients with Schönlein-Henoch nephritis. The abnormal fraction consisted of low molecular weight IgA in 2 patients, IgG in 1 patient and IgM in 4 patients. The absolute level of polymeric IgA was increased in 3 of 8 patients with IgA nephritis, but the relative distribution was normal. An abnormal sedimentation pattern of immunoglobulins was correlated to a positive C1q-BA test (p less than 0.001).

The toxicity testing of double-walled nanotubes-contaminated food to Eisenia veneta earthworms

Nanotechnology is playing an increasing role in the society, but very little is known about the environmental toxicity of nanotechnological products. Few previous studies have been published with regard to the effect of nanoparticles on soil organisms. The present paper deals with the toxicity of carbon double-walled nanotubes (DWNT) and C60 fullerenes to the soil-dwelling earthworm Eisenia veneta, with the aim of evaluating the lethal and sub-lethal toxicity. Reproduction of E. veneta was affected by DWNT administered through food at concentrations above 37 mg DWNT/kg food. The most sensitive toxicological parameter was reproduction (cocoon production), with no effect on hatchability, survival or mortality at up to 495 mg DWNT/kg and 1000 mg C60/kg.

Clopidogrel therapy--implications for hip fracture surgery

It remains unclear whether it is justifiable to delay hip fracture surgery in patients who are taking clopidogrel therapy-to allow the drug's anti-platelet effect to wear off. In a follow-up of 740 consecutive admissions with hip fracture we describe the extent of blood loss and complications in 17 (2.3%) who were taking clopidogrel. The peri-operative fall in haemoglobin was 1.3g/dl (95% CI: 0.4-2.3g/dl) less in the 10 patients in whom the surgeon's policy was for surgery to be delayed for at least 5 days. However, this group also experienced thromboembolic complications that were potentially attributable to this approach. Clopidogrel therapy does have implications for peri-operative blood loss, but hip fracture is a complex and multifactorial condition. We propose an individualised approach to patients taking this increasingly common drug.

Missense mutations in the TGM2 gene encoding transglutaminase 2 are found in patients with early-onset type 2 diabetes. Mutation in brief no. 982. Online

Transglutaminase 2 (TG2 or TGM2) is a multi-functional enzyme which catalyzes transamidation reactions or acts as a G-protein in intracellular signalling. Tgm2-/- Mice lacking TG2 activity are glucose intolerant and show impairment of insulin secretion, suggesting an important physiological role for TG2 in the pancreatic beta cell. We have previously described a TGM2 heterozygous missense mutation ((c.998A>G, p.N333S) in a 14 year-old patient with insulin-treated diabetes and in his diabetic father. The aim of this study was to further investigate the role of TG2 in early-onset type 2 diabetes. We analysed the TGM2 gene in 205 patients with clinically defined Maturity Onset Diabetes of the Young (MODY) or early-onset type 2 diabetes. We found two novel heterozygous mutations (c.989T>G, p.M330R; c.992T>A, p.I331N), which were not detected in 300 normoglycemic controls. All mutations were in residues which are located close to the catalytic site and impaired transamidating activity in vitro. Gene expression of TGM family genes and localization of TG2 in normal human pancreas indicated that TG2 is the only transglutaminase significantly expressed in human pancreatic islet cells. We conclude that reduced TG2 activity can contribute to disorders of glucose metabolism possibly via an impairment of insulin secretion.

Preventing fractures among older people living in institutional care: a pragmatic randomised double blind placebo controlled trial of vitamin D supplementation

INTRODUCTION

Osteoporotic fractures in older people are a major and increasing public health problem. We examined the effect of vitamin D supplementation on fracture rate in people living in sheltered accommodation.

METHODS

In a pragmatic double blind randomised controlled trial of 3 years duration, we examined 3,440 people (2,624 women and 816 men) living in residential or care home. We used four-monthly oral supplementation using 100,000 IU vitamin D(2) (ergocalciferol). As a main outcome measure, we used the incidence of first fracture using an intention to treat analysis. This was a multicentre study in 314 care homes or sheltered accommodation complexes in South Wales, UK.

RESULTS

The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, 205 first fractures occurred in the intervention group during a total of 2,846 person years of follow-up (7 fractures per 100 people per year of follow-up), with 218 first fractures in the control group over 2,860 person years of follow-up. The hazard ratio of 0.95 (95% confidence interval 0.79-1.15) for intervention compared to control was not statistically significant.

CONCLUSION

Supplementation with four-monthly 100,000 IU of oral vitamin D(2) is not sufficient to affect fracture incidence among older people living in institutional care.

Modification of the home environment for the reduction of injuries

BACKGROUND

Injury in the home is extremely common, accounting for around a third of all injuries. The majority of injuries of children under five and people aged 75 and over, occur at home. Multifactorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focused specifically on the impact of physical adaptations to the home environment and the effectiveness of such interventions needs to be ascertained.

OBJECTIVES

To review the evidence for the effect on injuries of modification of the home environment with a primary focus on interventions to reduce physical hazards.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, National Research Register and other specialised databases. We also scanned conference proceedings and reference lists. In addition, we contacted experts and trialists in the field. The searches were not restricted by language or publication status. The searches were last updated in December 2004.

SELECTION CRITERIA

Randomised controlled trials.

DATA COLLECTION AND ANALYSIS

All abstracts were screened by two authors for relevance, outcome and design. Two authors independently assessed methodological quality and extracted data from each eligible study.

MAIN RESULTS

We found 18 published and one unpublished trials. Trials were not sufficiently similar to allow pooling of data by statistical analyses, so this review takes a narrative form. Studies were divided into three groups based on the primary population sample; children (five studies), older people (14 studies) and the general population/mixed age group (no studies). None of the studies focusing on children demonstrated a reduction in injuries that might have been due to environmental adaptation in the home; one study reported a reduction in injuries and in hazards but the two could not be linked. Of the 14 included studies in older people, none demonstrated a reduction in injuries due to hazard reduction, although two demonstrated a reduction in falls that could be due to hazard reduction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effects of interventions to modify environmental home hazards. Further interventions to reduce hazards in the home should be evaluated by adequately designed randomised controlled trials measuring injury outcomes. Recruitment of large study samples to measure effect must be a major consideration for future trials.

Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward

OBJECTIVE

To examine how improved attention to nutritional status and dietary intake, achieved through the employment of dietetic assistants (DAs), will affect postoperative clinical outcome among elderly women with hip fracture.

DESIGN

Open prospective randomised controlled trial, comparing conventional nursing care with the additional nutritional support provided by DA.

SETTING

Thirty-eight bedded acute trauma ward in a teaching hospital.

PARTICIPANTS

All but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached. Three hundred and eighteen (93%) agreed to inclusion. Sixteen were ineligible as they were immediately transferred to another acute ward, were managed conservatively or died preoperatively.

PRIMARY OUTCOME MEASURE

Postoperative mortality in the acute trauma unit.

SECONDARY OUTCOME MEASURES

Postoperative mortality at 4 months after fracture, length of stay, energy intake and nutritional status.

RESULTS

DA-supported participants were less likely to die in the acute ward (4.1 versus 10.1%, P = 0.048). This effect was still apparent at 4 month follow-up (13.1 versus 22.9%, P = 0.036). DA-supported subjects had significantly better mean daily energy intake (1,105 kcal versus 756 kcal/24 h, 95% CI 259-440 kcal/24 h, P<0.001), significantly smaller reduction in mid-arm circumference during their inpatient stay (0.39 cm, P = 0.002) and nonsignificantly favourable results for other anthropometric and laboratory measurements.

CONCLUSION

Dietetic or nutrition assistants are being introduced in units across the UK. This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients' risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.

IRS1, KCNJ11, PPARgamma2 and HNF-1alpha: do amino acid polymorphisms in these candidate genes support a shared aetiology between type 1 and type 2 diabetes?

AIMS

Type 1 diabetes mellitus (T1DM) is a chronic disorder primarily triggered by environmental and immunological factors in genetically susceptible individuals. Despite the fact that there are indications of common aetiological features of T1DM and type 2 diabetes (T2DM), variation in genes involved in insulin secretion and insulin signalling has to a large extent been ignored as potential modifiers in the pathogenesis of T1DM. Recent studies suggest, however, that proven T2DM susceptibility gene variants may be involved in the pathogenesis of T1DM. The objective of this study was to estimate the impact of four selected amino acid polymorphisms -IRS-1 Gly972Arg, Kir6.2 Glu23Lys, HNF-1alpha Ala98Val and PPARgamma2 Pro12Ala in a Danish population of T1DM families.

METHODS

All variants were genotyped in 490 simplex- and multiplex-T1DM families applying polymerase chain reaction-restriction fragment length polymorphism, and results were evaluated by means of a transmission disequilibrium test (TDT) analysis.

RESULTS

TDT analysis revealed that the Arg972 IRS-1, the Lys23 Kir6.2 and the Val98 HNF-1alpha variants were transmitted from heterozygous parents to affected probands at frequencies of 49.1%, 47.0% and 54.1%, respectively (p > 0.05 for all). This was similar to the rate of transmission to unaffected siblings. The transmission rate of the Ala12 PPARgamma2 variant to affected probands was 46.5% (p > 0.05) which differed significantly from the transmission to unaffected offspring (p = 0.024). A combined analysis of the present and published pertinent data of 1691 transmissions showed a significantly decreased transmission of the PPARgamma2 Ala12 allele to affected probands (p = 0.0045).

CONCLUSIONS

The Pro12Ala variant of PPARgamma2 is associated with T1DM, the minor Ala allele conferring a reduced risk. This same finding has been reported in patients with T2DM.

Half of clinically defined maturity-onset diabetes of the young patients in Denmark do not have mutations in HNF4A, GCK, and TCF1

AIMS/HYPOTHESIS

Maturity-onset diabetes of the young (MODY) is a genetically heterogeneous monogenic form of diabetes characterized by an autosomal dominant inheritance, an early clinical onset, and a primary defect in beta-cell function. The aims of the present study were to examine the prevalence and nature of mutations in the three common MODY genes, HNF4A, GCK, and TCF1, in Danish patients with a clinical diagnosis of MODY and to describe metabolic differences in probands with and without mutations in HNF4A, GCK, and TCF1.

METHODS

Seventy-eight unrelated subjects of Danish Caucasian origin (29 men, 49 women) and their 351 family members were examined. The promotor and coding regions including intron-exon boundaries of HNF4A, GCK, and TCF1 were examined by denaturing HPLC and/or direct sequencing.

RESULTS

We identified 29 different mutations in 38 MODY families. Fifteen of the mutations were novel. The variants segregated with diabetes within the families, and none of the variants were found in 100 normal Danish chromosomes. Our findings suggest a relative prevalence of 3% of MODY1 (two different mutations in two families), 10% of MODY2 (seven in eight), and 36% of MODY3 (21 in 28) among Danish kindred clinically diagnosed as MODY. No significant differences in biochemical and anthropometric measurements were observed at baseline examinations.

CONCLUSIONS

Forty-nine percent of the families carried mutations in the three examined MODY genes. Our findings highlight that unidentified MODY genes may play a central role for diabetes characterized by autosomal dominant transmission. Furthermore, baseline measurements of various anthropometric and biochemical variables are not appropriate markers of MODYX.

Molecular genetics and phenotypic characteristics of MODY caused by hepatocyte nuclear factor 4alpha mutations in a large European collection

AIMS/HYPOTHESIS

Heterozygous mutations in the gene of the transcription factor hepatocyte nuclear factor 4alpha (HNF-4alpha) are considered a rare cause of MODY with only 14 mutations reported to date. The description of the phenotype is limited to single families. We investigated the genetics and phenotype of HNF-4alpha mutations in a large European Caucasian collection.

METHODS

HNF-4alpha was sequenced in 48 MODY probands, selected for a phenotype of HNF-1alpha MODY but negative for HNF-1alpha mutations. Clinical characteristics and biochemistry were compared between 54 HNF-4alpha mutation carriers and 32 familial controls from ten newly detected or previously described families.

RESULTS

Mutations in HNF-4alpha were found in 14/48 (29%) probands negative for HNF-1alpha mutations. The mutations found included seven novel mutations: S34X, D206Y, E276D, L332P, I314F, L332insCTG and IVS5nt+1G>A. I314F is the first reported de novo HNF-4alpha mutation. The average age of diagnosis was 22.9 years with frequent clinical evidence of sensitivity to sulphonylureas. Beta cell function, but not insulin sensitivity, was reduced in diabetic mutation carriers compared to control subjects (homeostasis model assessment of beta cell function 29% p<0.001 vs controls). HNF-4alpha mutations were associated with lower apolipoprotein A2 (p=0.001), A1 (p=0.04) and total HDL-cholesterol (p=0.02) than in control subjects. However, in contrast to some previous reports, levels of triglycerides and apolipoprotein C3 were normal.

CONCLUSIONS/INTERPRETATION

HNF-4alpha mutations are common when no HNF-1alpha mutation is found in strictly defined MODY families. The HNF-4alpha clinical phenotype and beta cell dysfunction are similar to HNF-1alpha MODY and are associated with reduced apolipoprotein A2 levels. We suggest that sequencing of HNF-4alpha should be performed in patients with clinical characteristics of HNF-1alpha MODY in whom mutations in HNF-1alpha are not found.

Preserved insulin response to tolbutamide in hepatocyte nuclear factor-1alpha mutation carriers

AIMS

Diabetic subjects with mutations in the gene encoding hepatocyte nuclear factor (HNF)-1alpha (MODY3) are prone to develop hypoglycaemia at low doses of glibenclamide, interpreted as sulphonylurea hypersensitivity. The present study was undertaken to compare the plasma insulin responses to glucose and tolbutamide in HNF-1alpha mutation carriers with those of healthy control subjects.

METHODS

Seven mutation carriers; three normoglycaemic, two with impaired glucose tolerance, and two with newly detected diabetes, underwent an oral glucose tolerance test and a tolbutamide-modified intravenous glucose tolerance test with measurements of plasma insulin. Twenty-two healthy subjects served as controls.

RESULTS

The plasma insulin response to intravenous glucose was reduced in the HNF-1alpha mutation carriers compared to the control subjects, with an area under the curve (median (interquartile range)) of 812 min pmol/l (421, 1647) and 1933 min pmol/l (1521, 2908), respectively (P = 0.03). In striking contrast, the plasma insulin response to tolbutamide was preserved, with an area under the curve of 2109 min pmol/l (1126, 3172) and 2250 min pmol/l (1614, 3276) in the mutation carriers and control subjects, respectively.

CONCLUSIONS

HNF-1alpha mutation carriers are characterized by preserved tolbutamide-induced insulin secretion. Compared to healthy subjects, our MODY3 individuals did not show any increased serum insulin response to tolbutamide, suggesting that HNF-1alpha mutation carriers are not characterized by sulphonylurea hypersensitivity.

Using phospholipid fatty acid technique to study short-term effects of the biological control agent Pseudomonas fluorescens DR54 on the microbial microbiota in barley rhizosphere

The biological control agent (BCA) Pseudomonas fluorescens DR54 was applied to seeds (experiment 1) or roots (experiment 2) of barley growing in microcosms, while noninoculated plants served as controls. The fate of the BCA and its effects on the rhizosphere microbial community was evaluated in microcosms destructively sampled at days 2, 4, 6, and 9 after inoculation. In both experiments the number of P. fluorescens DR54 cells decreased immediately after application as enumerated by immunostaining and microscope direct counting. Substrate-induced respiration (SIR) was taken as a measurement of the active microbial biomass, while indicators of the total microbiota (and main taxonomic groups) were obtained using the phospholipid fatty acid (PLFA) technique. In experiment 1, these parameters were unaffected by the relatively small number of BCA cells applied, whereas in experiment 2, the larger BCA input resulted in an enhanced level of both SIR and PLFAs from Gram-negative bacteria (which included the BCA itself). However, at day 9 after inoculation, treatments with P. fluorescens DR54 and controls were similar in all measured parameters in both experiments. This was also illustrated very clearly by principal component analysis of the PLFA data, which in both experiments were able to discriminate between treatments in the first days after BCA inoculation, thus confirming the sensitivity of this method. Laccase activity has a potential as an indicator of fungal stress, e.g., when challenged with an antifungal BCA. This seemed to be supported in experiment 2, where the activity of this enzyme was enhanced four-fold in the BCA treatment at day 2. Our study shows that under the present conditions, P. fluorescens DR54 disappears from the soil and causes only transient effects on the soil microbiota. It also shows that the PLFA technique is a sensitive and reliable monitoring tool in in situ assessment of BCA nontarget effect on indigenous microorganisms in soil.

Cost effectiveness analysis of using quantitative ultrasound as a selective pre-screen for bone densitometry

It has been suggested that quantitative ultrasound (QUS) could be used as a selective population pre-screen, to maximise the cost effectiveness of referral for dual energy X-ray absorptiometry (DXA) assessment of bone mineral density (BMD). We set out to examine how such an approach might perform in the assessment of women who were referred by general practitioners for DXA via the open access service in Cardiff. In 115 women aged 40-80 (mean 69) years we used DXA to measure BMD at lumbar spine and hip, and QUS to measure broadband ultrasound attenuation (BUA) in the heel. A bottom-up approach was used to estimate the costs of DXA and QUS. We examined the cost effectiveness of using QUS as a pre-screen, only referring subjects for the more expensive DXA assessment if BUA were less than a pre-determined threshold. The unit costs of pencil-beam DXA and QUS were approximately 44 UK pounds and 16 UK pounds respectively. We identified a BUA threshold of 60 dB/MHz as the most cost effective, and calculated a sensitivity of 81% and specificity of 89% in identifying those subjects whom DXA assessment subsequently identified as having osteoporosis. At the BUA threshold of 60 dB/MHz, pre-screening saved 969 UK pounds at the expense of missing ten women with osteoporosis as diagnosed by DXA. Therefore the cost per additional woman with osteoporosis identified using DXA alone was only 97 UK pounds. QUS assessment does not appear to have a significant cost effective benefit as a pre-screen for DXA in the studied population. A QUS pre-screen would be cost effective only if this investigation could be performed at a substantially lower cost.

Large-scale studies of the functional K variant of the butyrylcholinesterase gene in relation to Type 2 diabetes and insulin secretion

AIMS/HYPOTHESIS

Polymorphisms of the butyrylcholinesterase gene (BCHE) are reported to associate with Alzheimer's disease and a recent study found a significant association of the BCHE K variant (G1615A/Ala539Thr) with Type 2 diabetes. The objectives of our study were to examine whether the BCHE K variant is associated with Type 2 diabetes or estimates of pancreatic beta cell function in large-scale populations of glucose-tolerant Caucasians.

METHODS

The variant was genotyped in association studies comprising a total of 1408 Type 2 diabetic patients and 4935 glucose-tolerant control subjects. Genotype-phenotype studies were carried out in the 4935 glucose-tolerant control subjects.

RESULTS

There was no difference in allele frequency between Type 2 diabetic patients and control subjects (20.3% [95% confidence interval: 18.8-21.8] vs 20.4% [19.6-21.2], non-significant). In the genotype-phenotype studies we found no consistent association with BMI, fasting or post-OGTT plasma glucose, serum insulin or serum C-peptide levels.

CONCLUSIONS/INTERPRETATION

The present study does not support the suggestion that the BCHE K polymorphism is associated with Type 2 diabetes or with estimates of pancreatic beta cell function in large-scale Danish Caucasian populations.

The effect of socioeconomic deprivation on fracture incidence in the United Kingdom

Lifestyle factors such as diet and physical activity vary in different social and income groups, and are known to be important influences on the incidence of osteoporotic fractures. Financial and social pressures are a common concern for older people. We set out to study the effect of socioeconomic deprivation on the incidence of fracture in older people and to compare the findings with those for younger groups. The All Wales Injury Surveillance System (AWISS) is a computerized system that collects injury data from most A&E departments throughout Wales. In this population-based study of 1.8 million people living in the 445 electoral tracts covered by AWISS in south, west, and northeastern Wales, we identified all 60,106 residents who presented with a fracture in 1999 and 2000. We linked details of their fracture with published Townsend deprivation scores for the electoral tract in which they were living and calculated fracture rates by fifths of deprivation. We observed the expected pattern of increasing fracture incidence in older age groups. Fracture incidence was significantly higher in electoral wards with poorer Townsend scores, resulting from a marked effect of socioeconomic deprivation on fracture incidence among younger adults with a rate ratio of 1.64 (95% CI, 1.57 to 1.72). This effect diminished with age, and was not observed in older age groups. At ages 85 and over the rate ratio was 0.94 (95% CI, 0.87 to 1.01). Socioeconomic factors clearly play a part in the causation of fracture in younger adults. Lifestyle influences are important in older age groups, but socioeconomic deprivation does not appear to be a risk factor for the development of osteoporotic fractures in elderly people.

An analysis of an open access general practitioner bone densitometry service

General practitioners (GPs) are increasingly involved in the selective opportunistic case finding of osteoporosis and treatment of this condition. An open access bone densitometry service has existed for GPs in the Cardiff area since 1993. The purpose of this study was to assess the effectiveness of this service, particularly with respect to the appropriateness of bone densitometry requests and the impact of the service on hospital outpatient referrals. Over a period of 12 months, 560 patients were referred to the open access service by 154 GPs. A total of 229 (41%) patients were given a clinical diagnosis of osteoporosis. Four hundred and seventy-three (84%) referrals followed the clinical referral criteria. In 85% of cases, GPs claimed that they would have referred patients to the hospital outpatient department, if there were no open access bone densitometry service. The majority of the referrals were appropriate, and the service appears to have reduced GP referrals to the specialist clinic.