The pathophysiology of diabetes involves a defective amplification of the late-phase insulin response to glucose by glucose-dependent insulinotropic polypeptide-regardless of etiology and phenotype

The effect of the insulinotropic incretin hormone, glucagon-like peptide-1 (GLP-1), is preserved in typical middle-aged, obese, insulin-resistant type 2 diabetic patients, whereas a defective amplification of the so-called late-phase plasma insulin response (20-120 min) to glucose by the other incretin hormone, glucose-dependent insulinotropic polypeptide (GIP), is seen in these patients. The aim of the present investigation was to evaluate plasma insulin and C-peptide responses to GLP-1 and GIP in five groups of diabetic patients with etiology and phenotype distinct from the obese type 2 diabetic patients. We studied (six in each group): 1) patients with diabetes mellitus secondary to chronic pancreatitis; 2) lean type 2 diabetic patients (body mass index < 25 kg/m(2)); 3) patients with latent autoimmune diabetes in adults; 4) diabetic patients with mutations in the HNF-1alpha gene [maturity-onset diabetes of the young (MODY)3]; and 5) newly diagnosed type 1 diabetic patients. All participants underwent three hyperglycemic clamps (2 h, 15 mM) with continuous infusion of saline, 1 pmol GLP-1 (7-36)amide/kg body weight.min or 4 pmol GIP pmol/kg body weight.min. The early-phase (0-20 min) plasma insulin response tended to be enhanced by both GIP and GLP-1, compared with glucose alone, in all five groups. In contrast, the late-phase (20-120 min) plasma insulin response to GIP was attenuated, compared with the plasma insulin response to GLP-1, in all five groups. Significantly higher glucose infusion rates were required during the late phase of the GLP-1 stimulation, compared with the GIP stimulation. In conclusion, lack of GIP amplification of the late-phase plasma insulin response to glucose seems to be a consequence of diabetes mellitus, characterizing most, if not all, forms of diabetes.

Place of residence and risk of fracture in older people: a population-based study of over 65-year-olds in Cardiff

Fracture prevention strategies will be most cost-effective if targeted on groups of frail elderly people who are at particularly high risk of falls and fractures. Elderly people living in care homes are one potential target population, but fracture incidence in this setting remains poorly defined in many countries. We used the All Wales Injury Surveillance System (AWISS) in a population-based study of people aged over 65 years living in the city of Cardiff. We linked a postcode-based register of all sheltered accommodation and all residential and nursing homes in the city with injury data from Cardiff's single Accident and Emergency Department. Cardiff has 47,700 residents aged over 65 years with 1918 (4.0%) living in residential or nursing homes and 1868 (3.9%) in sheltered accommodation. In 1999 we identified a total of 1305 fractures including 366 hip fractures, giving a crude fracture incidence of 27.4/1000 per year and 7.7/1000 per year, respectively. Care home residents suffered 213 fractures, 95 of which were of the hip, giving a crude fracture incidence of 111.1/1000 per year and 49.5/1000 per year, respectively. People living in sheltered accommodation suffered 94 fractures, including 28 at the hip, giving a crude fracture incidence of 51.4/1000 per year and 15.3/1000 per year, respectively. People in care homes and sheltered accommodation tend to be older than those living in the community, and we adjusted for this by calculating age- and gender-standardized relative ratios for each setting. Compared with the community dwelling population, care home residents had an overall fracture risk of 2.9 (95% CI 2.5-3.3) and a hip fracture risk of 3.3 (95% CI 2.6-4.2). People in sheltered accommodation had a total fracture risk of 1.7 (95% CI 1.4-2.1), and a hip fracture risk of 1.6 (95% CI 1.1-2.4). Such figures support the potential cost-effectiveness of strategies that seek to prevent fractures in care homes and sheltered accommodation, and are of special interest to those planning intervention studies in these settings.

Screening for visual impairment in older people: validation of the Cardiff Acuity Test

Poor visual acuity (VA) is a risk factor for falls, and a common impediment to rehabilitation, but conventional VA testing is difficult in dysphasic, deaf or confused patients. In the Cardiff acuity test (CAT) observation of the subject's eye movements (preferential looking) indicates if they can see a vanishing optotype on a card. The test is quick, and requires no speech or understanding on the part of the subject. We consider its usefulness in frail, elderly patients. Seventy-three patients aged 47-99 (mean 78) years, were tested in good lighting, wearing their usual spectacles. Cards ordered 'A' to 'K' with increasingly faint targets were sequentially presented at 1 m, until the subject's eye movements indicated the target to be invisible. We then performed conventional Snellen acuity chart testing. Twenty-three were retested by a second observer, and 24 subjects were retested by the same observer on another day. We used correlation coefficients to confirm inter-observer (r=0.95, P<0.01), and test-retest (r=0.97, P<0.01) reliability. Snellen chart measurements of VA were possible in all but six subjects. The results of CAT and Snellen acuity tests showed statistically significant correlation (r=0.35, P<0.01). The World Health Organisation (WHO) define significant impairment as a Snellen test acuity below 6/18, and using the 'G' card as a threshold were able to detect this degree of impairment with a sensitivity of 91.7%, and a specificity of 90.9%. The CAT is reliable, and highly acceptable to elderly patients, and may be useful as a screening tool in clinical practice, and for epidemiological purposes.

Seasonal variation in the incidence of wrist and forearm fractures, and its consequences

We have used the All Wales Injury Surveillance System (AWISS) in a population-based study of wrist and forearm fractures. We examined seasonal variation in the incidence of these injuries, and looked at resulting pressures on outpatient and inpatient trauma services. AWISS collected data from eight Accident and Emergency (A&E) departments which between them serve a total of 1.2 million people in South Wales. During a single year, we identified all 5013 people who presented with a wrist or forearm fracture. Seasonal variation in wrist/forearm fracture incidence was apparent, but showed a different pattern in different age groups. Overall incidence figures were dominated by an increase in children's fractures in spring and summer. Children under the age of 15 suffered a total of 360 wrist and forearm fractures during the three winter months; an incidence of 5.9/1000 per year that was only about half that observed during the remainder of the year (10.7/1000 per year). In contrast, older people showed a higher incidence in the winter. During the winter months people aged over 75 sustained a total of 160 wrist/forearm fractures; an incidence of 8.2/1000 per year, significantly higher than the incidence observed in other months (5.8/1000 per year). Seasonality of incidence was not apparent in other age groups. Children presenting during the spring and summer months were significantly more likely to need admission to hospital; 22.8% were admitted compared with just 10.3% of those presenting during the winter months (P<0.001, chi(2)-test). Other age groups showed no significant seasonal variation in the likelihood of hospital admission.

Deletion of V335 from the L2 domain of the insulin receptor results in a conformationally abnormal receptor that is unable to bind insulin and causes Donohue's syndrome in a human subject

An infant with Donohue's syndrome (leprechaunism) was found to be homozygous for an in-frame trinucleotide deletion within the insulin receptor gene resulting in the deletion of valine 335. When transiently transfected into Chinese hamster ovary cells, mutant receptor was produced in a mature form, but at significantly lower levels compared with wild-type receptor. Cell surface biotinylation experiments revealed that significant amounts of the DeltaV335 receptor were expressed on the cell surface. Despite this, cells expressing this receptor showed no significant insulin binding or ligand-induced receptor autophosphorylation. Although the DeltaV335 receptor was capable of being immunoprecipitated with antibodies directed against the beta-subunit of the receptor, the mutant receptor could not be recognized by a panel of antibodies directed against different epitopes of the alpha-subunit, suggesting that the loss of V335 results in a major conformational alteration in the receptor alpha-subunit. This would be predicted by the positioning of V335 at a critical location within a strand that provides the main rigid scaffold for the two beta-sheet faces of the L2 domain of the receptor. The severe biochemical and clinical consequences of this novel mutation, which occur despite substantial expression on the cell surface, emphasize the crucial role of the L2 domain in ligand binding by the insulin receptor.

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. Multi-factorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focussed specifically on the impact of physical adaptations to the home environment and the effectiveness of such intervention 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 following databases: APId, ASSIA, British Nursing Index, CINAHL, Cochrane Library databases, Dissertation Abstracts, EMBASE, HealthSTAR, ICONDA, ISI Science (and Social Science) Citation Index, MEDLINE, National Research Register, PREMEDLINE, SIGLE and Urbadisk. Conference proceedings and reference lists were scanned. Experts in the field and trialists were contacted. Searches were not restricted to English language. Handsearching of relevant journals was not conducted.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We found 28 published trials and one unpublished study. Trials were not sufficiently similar to allow for the combination 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, older people and the general population. None of the 11 childhood studies 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. The majority of studies used hazard reduction as the outcome. Of the 15 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. In the mixed age group there were two trials; neither demonstrated an effect on injuries.

REVIEWER'S 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 may be a major consideration for future trials.

Evaluation of a new commercial assay for diagnosis of pulmonary and nonpulmonary tuberculosis

A new commercial assay for the diagnosis of tuberculosis, the BDProbeTec ET Direct Detection assay (Becton Dickinson, USA), was evaluated using 351 respiratory and 372 nonrespiratory specimens. The results were compared to detection of Mycobacterium tuberculosis complex (MTC) by conventional culture. Among the 351 respiratory specimens, MTC bacteria were identified in 150, of which 85 were positive by both microscopy and the assay. Sixty-five specimens culture positive for MTC were microscopy negative; of these, 39 were positive in the assay. All 26 specimens culture positive for nontuberculous mycobacteria (NTM) were negative by the assay. Of 175 specimens culture negative for MTC, 3 were falsely positive by the assay and 1 yielded inhibition. The overall sensitivity and specificity values were 82.7% and 98.5%, respectively. The sensitivity for microscopy-positive and -negative respiratory specimens was 100% and 60%, respectively. After correction for discrepancies, the specificity was 99% compared with notification data. The BDProbeTec ET assay detected 66 of 67 microscopy-positive and 50 of 125 microscopy-negative nonrespiratory specimens. The result for one specimen was inconclusive. All nine specimens containing NTM were negative by the assay. Of 171 specimens culture negative for MTC, 6 were falsely positive by the assay. The overall sensitivity and specificity values obtained with nonrespiratory specimens were 60.7% and 96.7%, respectively. After examining discrepancies by reviewing the patients' histories, the specificity was 98.9%. The sensitivity was 98.5% in microscopy-positive specimens and 40.3% in microscopy-negative specimens. The overall inhibition rate was 0.3%. The BDProbeTec ET assay is a fast, effective, and user-friendly system that can be used for rapid detection of MTC bacteria in respiratory and microscopy-positive nonrespiratory specimens as an important supplement to smear and culture.

Stroke prevention in atrial fibrillation: physicians’ attitudes to anticoagulation in older people

The increased prevalence of atrial fibrillation (AF) in older people contributes to an increased risk of stroke. Although clear guidelines exist, there is considerable variation in physicians' approaches to the selection of patients appropriate for warfarin treatment as stroke prevention. We compared attitudes to the anticoagulation of elderly patients with AF, in a postal study of geriatricians and specialist physicians (general physicians with specialist interests in Cardiology, Gastroenterology, Diabetes and Endocrinology, Nephrology and Neurology). A structured questionnaire was mailed to all 108 consultant physicians and geriatricians in South East Wales. This explored their attitude to their patients' age and comorbidity when considering the benefits and risks of warfarin prophylaxis for AF. About 25/30 geriatricians (83%) and 43/78 specialist physicians (55%) responded; an overall response rate of 63%. About 94% of the respondents agreed that patients aged over 75 with atrial fibrillation were at a greater risk of stroke than younger patients. About 68% considered warfarin related bleeds more likely in this age group, despite which most thought that the benefits of warfarin outweighed the risks. In people aged above 75, only 13/25 (52%) geriatricians and 17/43 (40%) specialist physicians viewed lone AF (AF with no underlying risk factor) as an indication for anticoagulation. When considering the use of warfarin, geriatricians' appeared more likely to be influenced by coexisting problems such as disability, falls, cerebrovascular disease and limited life expectancy. Only a history of falls (96% geriatricians vs. 86% specialist physicians) and cerebrovascular disease (79% geriatricians vs. 51% specialist physicians) had a significant influence on prescribing practice (P<0.05, chi(2) test). There appears to be widespread uncertainty about the indications for warfarin as stroke prophylaxis, and ageist attitudes or a lack of conviction of benefit appear to be disadvantaging older people. Patients aged below 65 with lone AF who are at the lowest risk of embolic events are often considered for treatment, whilst the use of warfarin in 75-year-olds with lone AF who are at a moderately high risk of embolic events remains disappointing.

Immunostimulatory CpG oligodeoxynucleotides stimulate expression of IL-1beta and interferon-like cytokines in rainbow trout macrophages via a chloroquine-sensitive mechanism

Synthetic oligodeoxynucleotides (ODNs) containing unmethylated CpG motifs are known to stimulate immune responses and are potent adjuvants in higher vertebrates, but so far the effects in fish are poorly described. We here report that CpG ODNs induce IL-1beta expression and production of interferon-like cytokines in rainbow trout head-kidney macrophages, whereas ODNs with an inverted motif (GpC) have a much less stimulatory effect. We further demonstrate that endosomal maturation is essential for CpG signalling, as chloroquine, a compound known to block endosomal acidification, inhibits cytokine expression in the macrophages.

Effects of physical properties of powder particles on binder liquid requirement and agglomerate growth mechanisms in a high shear mixer

A study was performed in order to elucidate the effects of the physical properties of small powder particles on binder liquid requirement and agglomerate growth mechanisms. Three grades of calcium carbonate having different particle size distribution, surface area, and particle shape but approximately the same median particle size (4-5 microm), were melt agglomerated with polyethylene glycol (PEG) 3000 or 20,000 in an 8-l high shear mixer at three impeller speeds. The binder liquid requirement was found to be very dependent on the packing properties of the powder, a denser packing resulting in a lower binder liquid requirement. The densification of the agglomerates in the high shear mixer could be approximately predicted by compressing a powder sample in a compaction simulator. With the PEG having the highest viscosity (PEG 20,000), the agglomerate formation and growth occurred primarily by the immersion mechanism, whereas PEG 3000 gave rise to agglomerate growth by coalescence. Powder particles with a rounded shape and a narrow size distribution resulted in breakage of agglomerates with PEG 3000, whereas no breakage was seen with PEG 20,000. Powder particles having an irregular shape and surface structure could be agglomerated with PEG 20,000, whereas agglomerate growth became uncontrollable with PEG 3000. When PEG 20,000 was added as a powder instead of flakes, the resultant agglomerates became rounder and the size distribution narrower.

Rhizosphere effects on microbial community structure and dissipation and toxicity of polycyclic aromatic hydrocarbons (PAHs) in spiked soil

Phytoremediation of soils polluted with polycyclic aromatic hydrocarbons (PAHs) has so far neglected the possible role of the ubiquitous symbiotic associations between plant roots and fungi known as arbuscular mycorrhizas. A time course laboratory experiment with clover and ryegrass grown on spiked [500 + 500 + 50 mg kg-1 of anthracene, chrysene and dibenz(a,h)anthracene] soil demonstrated for the first time that dissipation of condensed PAHs may be enhanced in the presence of arbuscular mycorrhiza [66 and 42% reductions in chrysene and dibenz(a,h)anthracene, respectively, versus 56 and 20% reductions in nonmycorrhizal controls]. Addition of a surfactant accelerated initial PAH dissipation but did not attain final PAH concentrations below those obtained with nonmycorrhizal plants. Toxicity tests (earthworm survival and bioluminescence inhibition in Vibrio fischeri) indicated that mycorrhiza reduced the toxicity of PAHs and/or their metabolites and counteracted a temporally enhanced toxicity mediated by surfactant addition. Phospholipid fatty acid profiles demonstrated that the imposed treatments altered the microbial community structure and indicated that the mycorrhiza-associated microflora was responsible for the observed reductions in PAH concentrations in the presence of mycorrhiza.

CpG oligodeoxynucleotides and plasmid DNA stimulate Atlantic salmon (Salmo salar L.) leucocytes to produce supernatants with antiviral activity

Unmethylated CpG dinucleotides are more frequent in the genomes of bacteria and viruses than of vertebrates. We report herein that plasmid DNA and synthetic oliogodeoxynucleotides (ODNs) containing unmethylated CpG induce production of antiviral cytokine activity in Atlantic salmon leucocytes, whereas ODNs with an inverted motif (GpC) or with methylated cytosines have nearly no stimulatory effect. The adherent cell population, representing mainly macrophages, is directly activated by CpG-ODN, while the effect on the non-adherent population is weak. Since the peak antiviral activity in ODN-stimulated leucocytes is seen after 48h, this might indicate that the unmethylated DNA stimulates the adherent cells to produce co-stimulatory molecules, which in turn stimulates production of antiviral cytokines in the non-adherent cell population. The potent immune activation by CpG ODNs points to possible new applications as adjuvant in fish vaccines.

Interpretive intra- and interobserver reproducibility of rest/stress 99Tcm-sestamibi myocardial perfusion SPECT in a consecutive group of male patients with stable angina pectoris before and after percutaneous transluminal angioplasty

BACKGROUND

Observer variability of 99Tcm-sestamibi myocardial perfusion imaging (MPI) has rarely been investigated. The aim of our study was to evaluate the interpretive reproducibility with this technique.

PATIENTS

We report on 108 consecutive male patients with stable angina pectoris, investigated before and after percutaneous transluminal angioplasty (PTCA).

METHODS

A 2-day rest/stress 99Tcm-sestamibi gated single photon emission computed tomography (SPECT) protocol was used. MPI was interpreted by two independent observers without knowledge of clinical data, using a 20-segment scoring model.

RESULTS

Intra- and interobserver agreement was found to be good to excellent (kappa = 0.71-0.85) with regard to the overall diagnosis as well as the individual vessel diagnosis (kappa = 0.60-0.87). However, agreement was higher for left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX) vascular territories than for the right coronary artery (RCA) territory. Moderate to good intraobserver agreement (kappa = 00.54-0.68) and slightly lower interobserver agreement (kappa = 0.52-0.56) was found for segmental score interpretation. When comparing the interpretive reproducibility before and after PTCA intra- and interobserver agreement was better after PTCA, probably reflecting the increase in normal scans after revascularization.

CONCLUSIONS

In a group of consecutive male patients with stable angina pectoris interpretive reproducibility (overall and individual vessel diagnosis) was good to excellent. However, segmental scoring reproducibility was moderate to good.

Cost effectiveness analysis of BMD referral for DXA using ultrasound as a selective pre-screen in a group of women with low trauma Colles' fractures

Measurements of bone density (BMD) are central to the World Health Organisation (WHO) approach to the definition of osteoporosis. Dual energy X- ray absorptiometry (DXA) remains the gold standard technique for measuring the bone mineral density (BMD) but Quantitative Ultrasound (QUS) is an attractive alternative method of bone assessment because it is easy to use and relatively inexpensive. It has been suggested that QUS could be used as a selective population pre-screen, to maximise the cost effectiveness of referral for DXA assessment of BMD. We set out to examine how such an approach might perform in the assessment of women with low trauma Colles' fracture. In 46 women aged 50-80 (mean 67) years we used DXA to measure BMD at lumbar spine and hip, and heel bone ultrasound to measure Broad Band Attenuation (BUA) and Velocity of Sound (VOS). We calculated local costs of pounds sterling 45 for DXA and pounds sterling 15 for QUS. We identified a BUA threshold of 60 dB/MHz as most cost effective as pre-screen, and calculated a sensitivity of 93% and specificity of 84% in identifying those subjects who were subsequently identified as having osteoporosis by DXA. DXA assessment of all patients had a cost of pounds sterling 77 per osteoporotic subject identified. We examined the cost-effectiveness of using QUS as a pre-screen, only referring subjects for more expensive DXA assessment if BUA was less than 60 dB/MHz. However this approach had no advantage, still costing pounds sterling 78 per osteoporotic subject identified. QUS assessment does not appear cost-effective as a pre-screen for DXA, even in this high risk group of women with low trauma Colles' fracture. A QUS pre-screen would only be cost-effective if the scan could be performed at a substantially lower cost.

Effects of interactions between powder particle size and binder viscosity on agglomerate growth mechanisms in a high shear mixer

A study was performed in order to elucidate the effects of the interactions between powder particle size and binder viscosity on the mechanisms involved in agglomerate formation and growth. Calcium carbonates having mean particle sizes in the range of 5-214 microm and polyethylene glycols having viscosities in the range of approximately 50-100000 mPas were melt agglomerated in a high shear mixer. Agglomerate growth by nucleation and coalescence was found to dominate when agglomerating small powder particles and binders with a low viscosity. Increasing the binder viscosity increased the formation of agglomerates by immersion of powder particles in the surface of the binder droplets. With a larger powder particle size, an increasing binder viscosity was necessary in order to obtain an agglomerate strength being sufficient to avoid breakage. Due to a low agglomerate strength, a satisfying agglomeration of very large particles (214 microm) could not be obtained, even with very viscous binders. The study demonstrated that the optimum agglomerate growth occurred when the agglomerates were of an intermediate strength causing an intermediate deformability of the agglomerates. In order to produce spherical agglomerates (pellets), a low viscosity binder has to be chosen when agglomerating a powder with a small particle size, and a high viscosity binder must be applied in agglomeration of powders with large particles.

Trauma in elderly people: what proportion of fractures are a consequence of bone fragility?

Epidemiologists have tended to equate osteoporotic fractures with those which occur after only moderate trauma, or which affect elderly people. We set out to critically examine this epidemiological approach, because even among elderly people some fractures will be a result of severe trauma and these cannot be assumed to reflect bone fragility. In a population based study of all Cardiff residents aged over 60 we identified everyone who presented with a fracture during 1996. We considered the events that led to each fracture, to establish which fractures were a result of 'severe' trauma: trauma greater than a fall from a standing height. We identified 1335 people who between them sustained a total of 1372 fractures. 168 (12%) of the fractures resulted from severe trauma, but in people aged over 80 only 6% of all fractures, 4% of hip fractures, and 3% of wrist fractures followed severe trauma. In older subjects severe trauma makes only a very small contribution to the causation of fracture, so that the age-sex distribution of fractures following moderate trauma closely resembles that of fractures overall. For epidemiological purposes it does appear justifiable to equate the consequences of bone fragility with the occurrence of osteoporosis associated fractures in elderly people.

Opinions on and use of alternative medicine among physicians, nurses and clerks in northern Norway

In February 1997 a questionnaire on alternative medicine was distributed to 172 physicians, 374 nurses and 96 clerks, all employed in hospitals in the northern part of Norway. A response rate of 57% was achieved. The aim of the study was to compare different health professions regarding views on and use of alternative medicine. Among all respondents 56% described themselves as having a positive attitude towards alternative medicine (16% of the physicians, 71% of the nurses and 72% of the clerks). Twelve percent of physicians, 32% of nurses and 46% of clerks had been using alternative medicine. Female physicians and female nurses showed a more positive attitude and were more frequent users of alternative medicine than their male counterparts. Physicians had confidence in acupuncture, herbs and diets, mainly as treatment of muscle-skeletal disorders, and migraine. Nurses and clerks on the other hand tended to believe in various alternative methods against a broad range of disorders. Female physicians and nurses emphasised the importance of more information, knowledge and openness towards alternative treatments more than their male counterparts. They also believed that traditional medicine could benefit from adopting principles from alternative medicine.

Evaluation of melt agglomeration properties of polyethylene glycols using a mixer torque rheometer

Lactose was melt agglomerated in a mixer torque rheometer with polyethylene glycol (PEG) 2000, 3000, 6000, 8000, 10 000, or 20 000 as meltable binder. A longer massing time caused an increase in mean torque until a maximum value after which the torque decreased. A smaller particle size of the PEG gave rise to a faster initial rise in mean torque. The higher viscosity of the PEG 20 000 resulted in a higher mean torque, whereas no clear difference in mean torque was obtained with the other PEGs. The binder concentration could be varied within a rather wide range without causing overwetting, the range being wider with PEG 3000 than with PEG 20 000. The mean torque values obtained were found to be related to the liquid saturation of the agglomerates. The reproducibility of the experiments was found to be very dependent on the experimental conditions, the highest binder viscosities and binder concentrations giving rise to a poor reproducibility. The results were compared with a few melt agglomeration experiments with PEG 3000 in a high shear mixer. The mixer torque rheometer was found not to be suitable for predicting melt agglomeration properties in the high shear mixer because of a marked difference in the shear forces in the two mixers.

Bone assessment in elderly women: what does a low bone ultrasound result tell us about bone mineral density?

Access to dual energy X-ray absorptiometry (DXA) can prove difficult for frail or elderly patients, and bone ultrasound may offer a practical alternative. Even after adjustment for bone mineral density (BMD), ultrasound readings are able to predict hip fracture in elderly women. We consider how bone ultrasound might contribute to bone assessment in a clinical setting. DXA remains the gold standard for bone assessment, with osteoporosis defined as a BMD result more than 2.5 S.D. below the young adult mean. Using an equivalent approach we defined an osteoporotic ultrasound result as broadband ultrasound attenuation (BUA)<54 dB/MHz. In 73 women aged 29-86 (mean 65) years DXA was used to measure BMD at lumbar spine and hip, and ultrasound to measure BUA at the heel. Correlation of BUA with BMD at femoral neck (r=0.64, P<0.001), and lumbar spine (r=0.55, P<0.001) was consistent with previously reported figures for this ultrasound system. All subjects with BUA below the 54 dB/MHz threshold value were shown to have low femoral neck BMD. Women (42%) aged over 65, but only 18% of younger women had low BUA results. In women over 65 years of age measurements of BUA achieved a sensitivity of 61% and specificity of 100% in prediction of low femoral neck BMD. Although a normal BUA did not exclude an osteoporotic BMD result at hip or lumbar spine, a low BUA appeared a highly specific predictor of low BMD at these sites. Since all those women identified as having a low BUA at the heel also had low BMD results, ultrasound appeared to identify a subgroup of elderly patients at a very high risk of fracture.

Trauma admissions in the elderly: how does a patient's age affect the likelihood of their being admitted to hospital after a fracture?

In two projects we have studied patients presenting to Accident and Emergency (A&E) departments with a fracture, to examine how their age influences their likelihood of admission. Over 1 year from April 1994 we collected data on all 6467 Cardiff residents who presented to the city's A&E department with a fracture. In total 1226 (19%) were admitted. Overall, only 12% of those under 65, but 47% of older patients required admission. This was largely a reflection of the age-distribution of hip fracture, an injury for which admission is inevitable. In a subsequent study of eight A&E departments in South Wales we therefore considered the proportion of patients admitted following fractures at specific anatomical sites. In people over the age of 55 we identified 6889 fractures, 2115 (31%) of which led to admission. After standardisation to control for the age-distribution of incidence for different fracture sites, we found that the likelihood of admission was 22% greater for people aged over 65 years. Elderly people very often require hospital admission after a fracture, primarily as a consequence of the types of fractures that they tend to sustain. Admissions directly attributable to the effects of age and age-related medical, psychiatric and social comorbidity appear of more limited significance.

Cutis/subcutis thickness at insulin injection sites and localization of simulated insulin boluses in children with type 1 diabetes mellitus: need for individualization of injection technique?

The study aimed to describe the variations of cutis/subcutis thickness at insulin injection sites in children with Type 1 diabetes mellitus and to localize the tissue position of a simulated insulin bolus in order to evaluate the need for individualization of injection technique in children. Cutis/subcutis thickness was measured by ultrasound in 47 children (25 girls and 22 boys) without compression (CSCUT) and with compression (CSCT) of the skin at 11 insulin injection sites. Tissue deposition of insulin was measured by ultrasound of a simulated insulin bolus of 200 microl of sterile air injected by the patients using their usual technique and site. On the thigh, 44% of girls and 95% of boys had a CSCT of less than 8 mm at one of the measured sites, while 16% of girls and 50% of boys had a CSCT of less than 6 mm at one injection site on the thigh and buttock. Significant differences in cutis/subcutis thickness in the same anatomical region were shown. CSCT was up to 35% less than CSCUT. The air bolus injection was placed inappropriately by 19% of children (using 8 mm needles). Unawareness of the skin thickness at the injection sites may contribute to inappropriate deposition. We propose that regular ultrasound measurements of subcutis depth at insulin injection sites be taken. This will allow the injection technique to be individualized (vertical or at an angle of 45 degrees). More children would be able to use the simpler vertical technique if 6 mm needles were used where available, or if even shorter (4 mm) needles were produced.

[Prevention of thrombosis in medical patients--documentation is missing]

A questionnaire regarding current routines for thromboprophylaxis was distributed to all 63 medical departments in Norwegian hospitals; 58 (92%) responded. All departments declared that they practiced prophylaxis against venous thromboembolism, and in most departments the decision (as to whether to practice prophylaxis) was left to the physicians. Written guidelines were used in only 12 departments, 21% of those who responded. The indications listed were those associated with a particular risk of thrombosis. Previous thrombosis and malignancy were listed less frequently than expected. There is a need for specific evidence regarding the efficacy and safety of thromboprophylaxis in medical patients. In our opinion this requires that further placebo-controlled studies be carried out.

Effect of leflunomide and cyclosporine on graft survival and changes in lymphocyte phenotypes in a rat heart allotransplantation model

Cyclosporine-A (CSA) and leflunomide (LF) can delay or prevent organ graft rejection. We investigated the combination of LF, CSA and splenectomy on graft survival and changes in lymphocyte phenotypes (LP) in a rat allotransplantation model. In the study 19 Lewis rats were splenectomized prior to heterotopic heart transplantation. SPRD rats served as donors. The recipients were divided into three groups: A--five animals received CSA and LF for two weeks, B--five received intermittent CSA and LF for the whole investigation period and C--nine received no drug therapy. LP was quantified relatively by flow cytometric analysis. We found that graft survival was longer in group A (median 155 days, range 52-348) and B (341, range 338-342), compared to group C (8, range 7-13). The histological examination, however, revealed signs of rejection in all allografts. In group A all except one animal and in group C the morphological changes were characterized by severe acute rejection. In contrast, one animal in group A and all the animals in group B revealed signs of moderate acute rejection and in most animals signs of chronic rejection were also found. The reduction of Pan-T and CD4+ cells in group B compared to the control group was associated with no clinical rejection, while the increase of CD8+ cells in group C and partly in group A (except for animal 3) was associated with clinical rejection. No difference in LP was detected between groups A and B in the study period. We concluded that a combination of CSA, LF and splenectomy was efficient in preventing clinical rejection, however, there were signs of rejection morphologically even in animals without clinical rejection. The changes in LP over time could not predict the clinical outcome. However, increase in CD8+ cells was highly associated to clinical rejection among nonimmunosuppresed animals.

Using audit to improve senior house officer training

The British Geriatrics Society has described 16 training objectives for senior house officers (SHOs) in geriatric medicine. We have developed these into an audit standard, and in a controlled trial we consider the effectiveness of audit as a means of monitoring and improving SHO training. SHOs from three hospitals were sent a questionnaire asking about the adequacy of formal and informal training for each objective; there was a response rate of 87%. Results were presented at an audit meeting in one hospital, inadequacies of training identified and the hospital's programme of teaching modified appropriately. Two control hospitals remained unaware of the audit findings and were therefore unable to modify their training programmes. Re-audit at six months completed the audit cycle; the control hospitals showing no change between the two audits. In the intervention hospital the adequacy of training over the 16 objectives improved from 59% at first audit to 73% at re-audit. The initial audit had highlighted three target objectives as needing special attention; here the improvement from 38% to 69% was even more impressive, and statistically significant at p < 0.05 on chi 2 test. Thus, although a questionnaire approach is inevitably subjective and affected by SHO satisfaction, the discipline of audit appeared effective in identifying and correcting deficiencies in an SHO training programme.

Fracture incidence in England and Wales: a study based on the population of Cardiff

Despite the importance of fractures as an economic and health problem, and consequent interest in osteoporosis, few workers have previously attempted to define the overall incidence of fracture. This population based study was based in the Accident and Emergency Department of Cardiff Royal Infirmary and identified all patients presenting with fractures of any type. Over a single year a total of 6467 fractures were identified among the 306,600 people who live in the city of Cardiff. This gives an overall fracture incidence of 21.1/1000/year, (23.5/1000/year in males and 18.8/1000/year in females); a result very similar to those from similar work in the USA, Australia and Norway. This result is over twice the previous estimate of fracture incidence in the UK; the figure of 9/1000/year from the only equivalent study performed since the 1960s. In part, this discrepancy appears to reflect our more rigorous definition of the study population, and our improved ascertainment of minor fractures. We believe our result to offer the most accurate estimate of fracture incidence currently available for a UK population.

Chitooligosaccharides stimulate Atlantic salmon, Salmo salar L., head kidney leukocytes to enhanced superoxide anion production in vitro

Chitosans and chitooligosaccharides stimulated Atlantic salmon, Salmo salar L., head kidney leukocytes in vitro to produce elevated levels of superoxide anion. Both soluble and insoluble chitooligosaccharides were stimulatory 2 and 7 days after addition. Protein-chitooligosaccharide conjugates were also stimulatory in vitro both at 2 and 7 days after addition. Deacetylation seemed to be of little importance for the stimulatory capacity. High concentrations of the 80% deacetylated chitosan/chitooligosaccharides were toxic to the leukocytes as judged by reduced reduction of nitroblue tetrazolium and morphology.

Reliability of parathyroid hormone measurements in the period immediately following hip fracture

AIM

As it is unclear whether parathyroid hormone (PTH) measurements performed immediately after hip fracture are reliable indicators of pre-fracture metabolic status, we set out to define how PTH levels are affected by hip fracture and its surgical repair.

METHOD

In two longitudinal projects, we studied 12 patients presenting with hip fracture and eight patients undergoing elective hip replacement. PTH, calcium and 25-hydroxyvitamin D (25OHD) levels were measured on admission, 2 days and 1 week later and after recovery at least 2 months after initial admission.

FINDINGS

In the subjects presenting with hip fracture, PTH levels during inpatient care were no different from those subsequently measured during the recovery period. In subjects undergoing elective hip surgery, PTH levels did not change following surgery and again remained unchanged into the recovery period.

CONCLUSIONS

Measurements of PTH performed during inpatient care of those with hip fracture appear sufficiently reliable for use in assessment of metabolic status.

The effect of ankle oedema on bone ultrasound assessment at the heel

Relatively inexpensive, portable bone ultrasound systems are of particular relevance to disabled or elderly subjects, who may have problems with access to other forms of densitometry. The effects of local soft tissues on ultrasound measurements are poorly understood and, as ankle oedema is common in such subjects, we examined its consequences for bone ultrasound readings at the heel. Eleven elderly subjects (mean age 81 years) with below-knee pitting oedema were assessed using a direct-contact bone ultrasound system (CUBA Clinical). We made a total of 16 series of readings, 6 unilateral and 5 bilateral. In each series an initial reading was followed by repeated pressure over the measurement site to disperse oedema; subsequent readings were thus subject to a progressively lessening degree of local oedema, until a steady state was eventually reached in which no further oedema could be displaced. Heel width fell by a mean of 6.3 mm between initial and steady-state readings; consistent with the clinical appearance of moderate oedema, pitting to a mean depth of only 3.15 mm. Measurements in the presence of oedema were compared with those after its elimination, and oedema was shown to cause a mean reduction of 23.9 m/s in velocity of sound (VOS) and of 5.5 dB/MHz in broadband ultrasound attenuation (BUA). Both changes were equivalent to a fall by a quarter of one standard deviation of the reference range, and were significant at p < 0.05 on paired t-test. As the severity of oedema will vary through the day, and from day to day, measurement protocols for bone ultrasound should pay attention to the confounding effects of oedema.

Squamous cell carcinoma of the penis and of the cervix, vulva and vagina in spouses: is there any relationship? An epidemiological study from Norway, 1960-92

Four hundred and twenty-three wives of 671 men with cancer of the penis were compared with 444 wives of 569 men who did not have this disease. The risk among the wives of patients with cancer of the penis of preinvasive and invasive cancer of the neck of the uterus was 1.75 (95% CI 0.42-7.37).

Bisphosphonates and the treatment of bone disease in the elderly

Recognition of the way in which naturally occurring pyrophosphate affects bone metabolism has stimulated the development of a whole series of related compounds, the bisphosphonates. Although the precise mechanism of action of these compounds remains incompletely understood, they have been proven profoundly effective in clinical practice and already constitute a major advance in the therapy of conditions characterised by excessive bone resorption. Serious adverse effects are rare; however, mineralisation problems are a concern, particularly with etidronate. The reduction in bone turnover during prolonged treatment for osteoporosis is also a concern but as yet of uncertain clinical importance. The wide variation in potency of different bisphosphonates in inhibiting the resorption, mineralisation and turnover of bone will increasingly determine which agents are used in various clinical situations. Bisphosphonates are the treatment of choice in Paget's disease and hypercalcaemia of malignancy. They also appear to have potential to alter the course of metastatic bony disease, although the magnitude and clinical importance of any such effect remains unclear. Bisphosphonates show promise in the prevention and treatment of osteoporosis and increase bone mass in postmenopausal and steroid-induced osteoporosis. The effects of these drugs in other situations are less clear and the effects on fracture rates are not yet fully characterised. Optimal regimens have yet to be established but the long half-lives of these agents makes intermittent treatment a rational and convenient approach.