Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust

Previous reports describe a population of non-cardiac surgical patients at high risk of complications and death. Outcomes are sub-optimal for such patients, perhaps in part related to inadequate provision or ineffective utilisation of critical care resources. In this study, data describing 26,051 in-patient non-cardiac surgical procedures performed in a large NHS Trust between April 2002 and March 2005 were extracted from local databases. Of these procedures, 2 414 (9.3%) were high risk with an overall mortality rate of 12.2% and a prolonged hospital stay (high-risk population median (IQR) 16 (9-30) days vs standard risk 3 (2-6) days). Mortality rates for specific procedures were consistent with UK averages. However, only 852 (35.3%) high-risk patients were admitted to a critical care unit at any stage after surgery. Of 294 high-risk patients who died, only 144 (49.0%) were admitted to a critical care unit at any time and only 75 (25.6%) of these deaths occurred within a critical care area. Mortality rates were high amongst patients discharged and readmitted to critical care (37.7%) and amongst those admitted to critical care following initial postoperative care on a standard ward (29.9%). These data suggest that the outcome of high-risk general surgical patients could be improved by adequate provision and more effective utilisation of critical care resources.

Rhabdoid and papillary meningioma with leptomeningeal dissemination

Rhabdoid meningioma is a rare variant of meningioma classified as grade III under the new World Health Organization (WHO) classification of brain tumors. Although this tumor is known for its aggressive behavior, dissemination into cerebral spinal fluid (CSF) is extremely rare. We report here a case of rhabdoid meningioma in a young man, operated on twice previously, who presented with multiple CSF areas of seeding in the brain and spinal cord. The imaging findings for this tumor, including diffusion and perfusion MR sequences, are highlighted. This particular histological subtype of meningioma has a poor prognosis and must be treated aggressively.

Intratumoral microhemorrhages on T2*-weighted gradient-echo imaging helps differentiate vestibular schwannoma from meningioma

BACKGROUND AND PURPOSE

Vestibular schwannomas (VS) may be difficult to differentiate from cerebellopontine angle (CPA) meningiomas. Demonstration of microhemorrhages in VS on T2*-weighted gradient-echo (GRE) sequences may have potential value to differentiate VS from CPA meningiomas.

MATERIALS AND METHODS

In this prospective study of 20 patients, MR imaging was performed with T2*-weighted GRE in addition to all basic sequences. Histopathologic examination was performed after surgery. Intratumoral hemosiderin was confirmed by pigment staining.

RESULTS

There were 15 patients in the VS group with 16 VS and 5 in the meningioma group with 5 posterior fossa meningiomas. Fourteen of the 16 VS and all 5 meningiomas were treated surgically and were confirmed on histopathologic examination. T2*-weighted GRE identified microhemorrhages on T2*-weighted sequence in 15 (93.75%) of the 16 VS. CT excluded calcification in all VS. T2-weighted turbo spin-echo (TSE) and fluid-attenuated inversion recovery (FLAIR) images recognized microhemorrhages in 2 cases. Pigment staining confirmed hemosiderin in all 14 surgically treated VS, and none of the meningiomas showed microhemorrhages on MR imaging. For the detection of microhemorrhages, T2*-weighted GRE showed a sensitivity of 93.8%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 83.3%. The sensitivity of T2 TSE and FLAIR for microhemorrhage was 12.5%. The Fisher exact test showed a statistically significant difference in the differentiation of VS from meningioma on the basis of detection of microhemorrhages (P < .01).

CONCLUSION

Most VS demonstrate microhemorrhages on T2*-weighted GRE. This finding is useful to differentiate VS from CPA meningiomas. T2*-weighted GRE should be used as a basic sequence to evaluate CPA tumors. Identification of microhemorrhages may have the potential to assess the aggressive biologic behavior of VS.

Fluoroscopic-guided balloon dilatation and stenting in tracheal stenosis with metallic self-expandable stents and long-term follow-up results

The purpose of this study was to assess the safety and long-term efficacy of self-expandable stents in the treatment of benign tracheal stenosis. Nine patients (seven men) with tracheal stenosis (including one with fistula) of varied cause were treated by fluoroscopically guided balloon dilatation and stenting with self-expandable metallic stents. The procedure was carried out under topical spray in eight patients and under general anaesthesia in one patient. The patients were followed up for a period ranging between 13 and 60 months. In eight of the nine patients, satisfactory positioning of the stent was achieved at the first instance, with immediate relief of dyspnoea. One patient with innominate artery aneurysm died 16 days after the procedure because of renal failure. At 1 month of follow up, six out of eight (75%) of our live patients were without any respiratory embarrassment. This dyspnoea-free result reached almost 90% by the end of 1 year especially so in the fibrous strictures. Four out of the eight live patients (50%) had cough for 2 months and two (25%) had mild blood-tinged sputum treated by inhalation and mucolytic agents. Secondary intervention was required in one patient at 1 month because of recurrent symptoms. The patient with tracheo-oesophageal fistula required surgical intervention because of fracture of the stent. Fluoroscopically guided balloon dilatation and stenting of the tracheal stenosis is an effective non-surgical therapy resulting in cure of fibrous strictures and palliation in cases of malignancy.

Consequences of the ESPE/LWPES guidelines for diagnosis and treatment of disorders of sex development

Ambiguous genitalia of the newborn is the paradigm of a disorder of sex development that demands a multidisciplinary team approach to management. The problem is immediately apparent at birth. Abnormalities of the external genitalia sufficient to warrant genetic and endocrine studies occur in one in 4500 births. In recent decades there have been improvements in diagnosis and early management, particularly with respect to congenital adrenal hyperplasia, the commonest cause of ambiguous genitalia of the newborn. However, dissatisfaction with overall management remains. A Clinical Guidelines and Handbook for Parents generated by a partnership of health professionals and support groups is available on the internet. The professional societies representing paediatric endocrinology responded by organizing a consensus meeting on the management of intersex. This resulted in the publication of a Consensus Statement encompassing many aspects of management, extending from birth to adulthood.

Delayed onset of deep infection after total knee arthroplasty: comparison based on the infecting organism

PURPOSE

To identify the organisms causing delayed deep infection following primary total knee arthroplasty (TKA) and to compare the differences in outcome based on the infecting organism.

METHODS

Between the period April 1998 and March 2004 inclusive, patients presenting with delayed deep infection following primary TKA and/or those who underwent a salvage procedure (amputation or arthodesis) were retrospectively studied.

RESULTS

Organisms were isolated in 27 patients; 44% were methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis. When the organism was resistant, the mean number of surgical procedures per patient was significantly higher and the proportion of patients with satisfactory outcomes was significantly lower.

CONCLUSION

Deep infection with methicillin-resistant S. aureus or S. epidermidis is increasing. Strict infection control measures must be in place to combat such problems.

Altered endothelial gene expression associated with hereditary haemorrhagic telangiectasia

BACKGROUND

Mutations in endoglin (ENG) and activin receptor-like kinase 1 (ALK-1 or ACVRL1) genes are the underlying basis of hereditary haemorrhagic telangiectasia (HHT) types 1 and 2, respectively. Both genes belong to the transforming growth factor-beta (TGF-beta) receptors superfamily and are expressed in endothelial cells. The current model for HHT is that ENG or ALK-1 haplo-insufficiency affects angiogenesis and predisposes to vascular dysplasia and arteriovenous malformations.

MATERIALS AND METHODS

Using microarray technology, we compared human umbilical vein endothelial cells (HUVEC) from newborns with ENG or ALK-1 mutations to control cells to search for gene profiles associated with early stages of the disease. Real-time polymerase chain reaction and Western blot analysis were used to validate a subset of the modulated genes and functionally related genes.

RESULTS

Our results indicate that HHT endothelial cells in vitro display several gene expression disturbances, including genes associated with the activation phase of angiogenesis, with cell guidance and intercellular connections, and also with the TGF-beta pathway. Hierarchical clustering using modulated genes enables discrimination between affected and non-affected samples.

CONCLUSION

HHT HUVECs display gene modulations which can suggest that ENG and ALK-1 haplo-insufficiency induces compensatory regulatory mechanisms at the expression levels.

Advanced MR imaging in Lhermitte-Duclos disease: moving closer to pathology and pathophysiology

INTRODUCTION

Lhermitte-Duclos disease (LDD, dysplastic gangliocytoma) is an extremely rare cerebellar lesion of uncertain etiology. The debate as to whether it constitutes a neoplastic, malformative, or hamartomatous lesion is still continuing. In this report we explore the usefulness of susceptibility-weighted imaging (SWI), diffusion weighted imaging (DWI), perfusion imaging, and chemical shift imaging (CSI) in demonstrating the pathology and pathophysiology in two patients with LDD.

METHODS

MR imaging of the brain and the cervicodorsal spine was performed on a 1.5-T scanner in a 47-year-old woman presenting with numbness and paresthesia of both upper and lower limbs, and in a 17-year-old male with right frontal headache associated with neck pain.

RESULTS

Routine imaging in the first patient showed a left-side cerebellar mass with characteristic 'tiger-striped' thick folia associated with Chiari I malformation, tonsillar herniation and cervicodorsal syringomyelia and in the second patient a right cerebellar mass with similar findings. The SWI demonstrated the characteristic deep running veins between the folia, which is thought to be the cause for vascular contrast enhancement. Diffusion showed a T2 shine-through effect with mild increased diffusivity, and perfusion showed increase in relative cerebral blood volume, relative cerebral blood flow, and mean transit time in the lesion. MR spectroscopy demonstrated reduction in metabolites and a prominent lactate peak in both the patients. The pathological and pathophysiological significance of these findings is discussed.

CONCLUSION

MRI with the newer imaging capabilities can demonstrate the pathology and pathophysiology in Lhermitte-Duclos disease better. SWI helps in detecting the veins around the thickened folia.

Alanine peak in central neurocytomas on proton MR spectroscopy

INTRODUCTION

We present three consecutive patients with central neurocytoma in whom proton MRS demonstrated the presence of alanine.

MATERIALS AND METHODS

Three patients in the age range 24 to 30 years underwent MRI and proton MRS using a 1.5-T system. MRS was performed with the multivoxel PRESS sequence. All three patients underwent surgery and the diagnosis of central neurocytoma was established by histopathological examination and immunostaining.

RESULTS

With an echo time of 135 ms glycine, high choline, small NAA and alanine were observed in all three patients.

CONCLUSION

Alanine may be observed in central neurocytomas as it is in meningiomas. Other spectral peaks such as those for glycine and NAA should help to identify this tumor correctly.

Patient satisfaction following carpal-tunnel decompression: a comparison of patients with and without osteoarthritis of the wrist

The aim of this study was to assess whether surgical decompression for carpal-tunnel syndrome (CTS) in the presence of primary or secondary osteoarthritis of the wrist is associated with poorer patient satisfaction. We did a retrospective matched cohort study. Twenty-four patients who underwent surgical decompression for CTS secondary to osteoarthritis were identified by reviewing the notes and the radiographs. A control group consisted of 24 patients without osteoarthritis of the wrist who underwent carpal-tunnel decompression. The control group was matched for age, sex, side, and neuro-physiological severity of the nerve compression. In the group with osteoarthritis of the wrist, 17 (71%) patients reported their symptom relief as satisfactory, and 7 (29%) reported the results as unsatisfactory. In the control group, 23 (96%) patients reported their symptom relief as satisfactory, and 1 (4%) reported the results as unsatisfactory (P=0.0325). In conclusion, patient satisfaction following surgical decompression in patients with secondary CTS due to osteoarthritis was significantly lower compared to patients without osteoarthritis of the wrist.

Near-field reflection backscattering apertureless optical microscopy: Application to spectroscopy experiments on opaque samples, comparison between lock-in and digital photon counting detection techniques

An apertureless scanning near-field optical microscope (ASNOM) in reflection backscattering configuration is designed to conduct spectroscopic experiments on opaque samples constituted of latex beads. The ASNOM proposed takes advantage of the depth-discrimination properties of confocal microscopes to efficiently extract the near-field optical signal. Given their importance in a spectroscopic experiment, we systematically compare the lock-in and synchronous photon counting detection methods. Some results of Rayleigh's scattering in the near field of the test samples are used to illustrate the possibilities of this technique for reflection backscattering spectroscopy.

Percutaneous vertebroplasty in the management of vertebral lesions

BACKGROUND

Debilitating backache due to different types of vertebral lesions is a common cause of morbidity in all age groups. Percutaneous vertebroplasty (PV) gives substantial pain relief and stabilizes the weak vertebrae. Most of the information regarding PV comes from the Western literature. The effect of PV in our population should be studied.

AIMS

The primary objective is to assess the therapeutic benefit of PV in alleviating back pain and improving the functional status in patients with painful pathologic vertebrae. The secondary objectives are to study the technical aspects of the procedure and their relation to outcome and complications.

SETTINGS AND DESIGN

This is a retrospective hospital-based (tertiary teaching hospital) study.

MATERIALS AND METHODS

From January 2001 to December 2004, 46 patients underwent PV procedures. Sixty-five vertebroplasties were done in 13 males and 33 female patients. Twenty-four (36.92%) procedures were done for osteoporotic compression collapse, 26 (40.0%) for hemangioma, and 15 (23.07%) for different vertebral body tumors and metastasis. The Wilcoxon signed rank test was used to evaluate the statistical significance of differences between the preoperative and postoperative levels of pain, mobility and analgesic usage.

RESULTS

Most of the patients had pain relief within 48 h. Only minor side effects were encountered. No patient had any deficit related to the procedure. On follow up of 3-48 months, all patients had statistically significant improvement in clinical condition (P < 0.001).

CONCLUSION

Percutaneous vertebroplasty is a safe and effective procedure in relieving debilitating backache and can be used to treat vertebral lesions in selected cases.

Effects of prolonged stimulation at the electrode-retina interface

Prolonged electrical stimulation can lead to temporary or permanent changes in neural response. Stimulation of neurons at levels sufficient to cause overlapping zones of excitation can induce multiple effects, leading to permanent damage to neurons or temporary depression not detectable through histopathological analysis. The present study focuses on determining the effects of prolonged, continuous electrical stimulation in the retina. One hour stimulation was performed in the rat retina and electrically evoked responses in the superior colliculus were recorded before and after the continuous stimulation. Comparison of the pre and post stimulation responses indicates a depression in the excitability of the neurons.

Carotid artery stenting: Results and long-term follow-up

BACKGROUND AND PURPOSE

The role of carotid artery stenting (CAS) as an alternative to carotid endarterectomy in the treatment of for symptomatic carotid artery stenosis is investigated.

MATERIALS AND METHODS

Forty-seven patients underwent CAS over 10-year period. Forty-nine vessels were treated. Stenosis quantification was done using North American symptomatic carotid endarterectomy trial method. The mean follow-up period by clinical and Duplex examination ranged is 5.6 years.

RESULTS

The technical success rate was 100%. There were four deaths (8.1%) and two (4.1%) minor strokes within thirty days of procedure. There was no major strokes. All patients with minor stroke achieved complete recovery at 1-month follow up. Two deaths occurred probably due to hyperperfusion syndrome (HS) and two due to cardiac arrest.

CONCLUSION

CAS is an effective treatment modality of symptomatic carotid artery disease but should be carefully done in high-risk groups having severe medical ailments and those having severe bilateral stenosis of the carotid arteries.

High-Flow Traumatic arotico-Jugular Fistula Manifesting as Venous Hypertensive Encephalopathy

We report the clinical and angiographic findings in a patient who presented with venous hypertensive encephalopathy secondary to a traumatic carotico-jugular fistula. Endovascular entrapment of the fistula by occluding the common carotid artery and internal jugular vein at the base of the skull resulted in near total improvement of the patient's neurological status.

Spurious absence of signal on 3D time-of-flight MR angiograms on 1 and 3 tesla magnets in cerebral arteries associated with a giant ophthalmic segment aneurysm: the need for alternative techniques

There are many high-resolution MR angiographic techniques available today for the evaluation of circle of Willis. We report a case of bilateral aneurysms of the carotico-ophthalmic segment, the left one being a giant aneurysm, in a 41-year-old woman. She underwent different MRA sequences on both 1 and 3Tesla magnets and a digital subtraction angiography. 3D time-of-flight angiograms can give spurious information on giant aneurysms and other techniques like phase contrast and dynamic contrast enhanced angiographies can supplement if not replace it. High field strength improves the objective quality of MR angiograms, but in the case of large aneurysms, intra aneurysmal and distal vessel signal loss can be a significant problem.

Phosphorus-31 MAS NMR investigations of pyridine stabilized dithiomonometaphosphoryl halides

Phosphorus-31 magic-angle spinning NMR spectroscopy was chosen in order to study a series of N-donor stabilized dithiomonometaphosphoryl halides (F, Cl, and Br) and to extract structural and bonding information from their spectra. Additionally, an unusual line splitting was observed in the 31P MAS NMR spectra of pyridine dithiomonometaphosphoryl chloride (Py-->PS2Cl) and the analogous bromide (Py-->PS2Br). It is shown that this effect is due to a residual dipolar coupling between phosphorus and chlorine or bromine, respectively. This work is to our knowledge the first observation of this effect between P and Br in 31P MAS NMR spectra.

Fetal erythrocyte membrane lipids modification: preliminary observation of an early sign of compromised insulin sensitivity in offspring of gestational diabetic women

AIMS

Intrauterine exposure to diabetes is a significant determinant of the development of obesity and early onset of Type 2 diabetes mellitus in the offspring. Both conditions are characterized by insulin resistance and the latter is associated with reduced membrane arachidonic and docosahexaenoic acids. Hence, we investigated if the membrane arachidonic and docosahexaenoic acids are depressed in the cord blood of babies born to women with gestational diabetes.

METHODS

Cord (fetal) and maternal blood were obtained at delivery from control subjects (n = 33) and women with gestational diabetes (n = 40) and analysed for plasma triglycerides and cholinephosphoglycerides, and erythrocyte choline- and ethanolaminephosphoglycerides fatty acids.

RESULTS

Babies of gestational diabetic mothers had reduced docosahexaenoic acid in the plasma (5.9 +/- 1.4 vs. 7.1 +/- 2.0, P < 0.01) and erythrocyte (4.0 +/- 2.2 vs. 5.4 +/- 2.9, P < 0.05) cholinephosphoglycerides. Moreover, the total omega-6 and omega-3 fatty acids of the erythrocyte cholinephosphoglycerides were significantly lower (P < 0.05) in these babies. A similar trend was observed in plasma triglycerides and erythrocyte ethanolaminephosphoglycerides. The maternal plasma triglycerides and erythrocyte ethanolaminephosphoglycerides fatty acids profile were not different between the two groups. However, there was a reduction in arachidonic acid and total omega-6 fatty acids in the erythrocyte cholinephosphoglycerides of the gestational diabetic women.

CONCLUSION

The altered plasma and erythrocyte fatty acids in the cord blood of babies born to women with gestational diabetes suggests a perturbation in the maternal-fetal nutrient transport and/or fetal lipid metabolism.

Randomised controlled trial of mammographic screening in women from age 40: results of screening in the first 10 years

Debate continues over the effectiveness of screening by mammography in women below age 50. We report here on results of screening in the first 10 years of a randomised trial to study the effect on breast cancer mortality of invitation to annual mammography from age 40 to 41 compared to first invitation to the 3-yearly UK national programme at age 50–52. The trial is taking place in 23 NHS breast screening centres. Between 1991 and 1997, 160 921 women were randomised in the ratio 1 : 2 to intervention and control arms. Screening is by two views at first screen and single view subsequently; data on screening up to and including round five are now complete. Uptake of invitation to screening is between 68 and 70% at all but the latest screening rounds. Rates of referral for assessment are 4.6% at first screen and 3.4% at subsequent screens. Invasive cancer detection rates are 0.09% at first screen, and similar at rescreens until the sixth and later screens. There is little evidence of regular mammography in the trial control arm. The setting of this trial within the NHS breast screening programme should ensure applicability of results to a national programme.

Interactions between selenium and sulphur nutrition in Arabidopsis thaliana

Selenium (Se) is an essential plant micronutrient, but is toxic at high tissue concentrations. It is chemically similar to sulphur (S), an essential plant macronutrient. The interactions between Se and S nutrition were investigated in the model plant Arabidopsis thaliana (L.) Heynh. Arabidopsis plants were grown on agar containing a complete mineral complement and various concentrations of selenate and sulphate. The Se/S concentration ratio in the shoot ([Se](shoot)/[S](shoot)) showed a complex dependence on the ratio of selenate to sulphate concentration in the agar ([Se](agar)/[S](agar)). Increasing [S](agar) increased shoot fresh weight (FW) and [S](shoot), but decreased [Se](shoot). Increasing [Se](agar) increased both [Se](shoot) and [S](shoot), but reduced shoot FW. The reduction in shoot FW in the presence of Se was linearly related to the shoot Se/S concentration ratio. These data suggest (i) that Se and S enter Arabidopsis through multiple transport pathways with contrasting sulphate/selenate selectivities, whose activities vary between plants of contrasting nutritional status, (ii) that rhizosphere sulphate inhibits selenate uptake, (iii) that rhizosphere selenate promotes sulphate uptake, possibly by preventing the reduction in the abundance and/or activity of sulphate transporters by sulphate and/or its metabolites, and (iv) that Se toxicity occurs because Se and S compete for a biochemical process, such as assimilation into amino acids of essential proteins.

Plasma AA and DHA levels are not compromised in newly diagnosed gestational diabetic women

OBJECTIVE

The polyunsaturated fatty acids, arachidonic (AA) and docosahexaenoic (DHA), are vital structural and functional components of the neural, vascular and visual systems. There is increased demand for these fatty acids during pregnancy. Diabetes impairs the synthesis of both AA and DHA. We have investigated the possibility that pregnancy-induced diabetes compromises the levels of plasma AA and DHA in newly diagnosed expectant mothers.

DESIGN

Cross-sectional study.

SETTING

London, UK.

SUBJECTS AND METHODS

Venous blood was obtained from 44 women with gestational diabetes mellitus (GDM) and from the same number of nondiabetics, during the third trimester. Fatty acid composition of plasma choline phosphoglycerides (CPG), triglycerides (TG) and cholesterol esters (CE) was analysed.

RESULTS

The GDM women had higher levels of AA (20:4n-6; P<0.0001) and AA/linoleic acid ratio (20:4n-6/18:2n-6; P<0.01) in the CPG, and linoleic acid (LA; P<0.0001), total n-6 (P<0.01), DHA (P<0.05) and n-3 metabolites (P<0.05) in TG compared to their nondiabetic counterparts. Similarly, AA (P<0.0001), osbond acid (22:5n-6; P<0.05), total n-6 metabolites (P<0.0001), AA/LA (P<0.0001) and n-6 metabolites/LA (P<0.01) were higher in the CE of the GDM women. There was no difference in the levels of DHA in CPG and CE between the two groups (P>0.05).

CONCLUSIONS

The results of this study do not provide evidence that the activity of delta-6 or delta-5 desaturases, which are vital for the synthesis of AA and DHA, is compromised by pregnancy-induced diabetes. However, since the samples were taken at diagnosis, it is conceivable that the duration of the diabetes was too short to have a discernable adverse effect on the levels of AA and DHA in plasma lipids.

Complex fracture-dislocation of the proximal interphalangeal joint of the hand

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment.

The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand.

Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply.

Adverse effect of obesity on red cell membrane arachidonic and docosahexaenoic acids in gestational diabetes

AIMS/HYPOTHESIS

Gestational diabetes is a metabolic disorder affecting 2-5% of women and is a predictor of obesity, Type 2 diabetes mellitus and cardiovascular disease. Insulin resistance, a characteristic of gestational diabetes and obesity, is correlated with the fatty acids profile of the red cell and skeletal muscle membranes. We investigated the plasma and red cell fatty acid status of gestational diabetes. The effect of obesity on membrane fatty acids was also examined.

METHODS

Fasting blood obtained at diagnosis was analysed for the fatty acids in plasma choline phosphoglycerides and red cell choline and ethanolamine phosphoglycerides.

RESULTS

There were reductions in arachidonic acid (controls 10.74+/-2.35 vs gestational diabetes 8.35+/-3.49, p<0.01) and docosahexaenoic acid (controls 6.31+/-2.67 vs gestational diabetes 3.25+/-2.00, p<0.0001) in the red cell choline phosphoglycerides in gestational diabetes. A similar pattern was found in the ethanolamine phosphoglycerides. Moreover, the arachidonic and docosahexaenoic acids depletion in the red cell choline phosphoglycerides was much greater in overweight/obese gestational diabetes (arachidonic acid=7.49+/-3.37, docosahexaenoic acid=2.98+/-2.18, p<0.01) compared with lean gestational diabetes (arachidonic acid=10.03+/-2.74, docosahexaenoic acid=4.18+/-1.42).

CONCLUSION/INTERPRETATION

Apparently normal plasma choline phosphoglycerides fatty acids profile in the gestational diabetic women suggested that membrane lipid abnormality is associated specifically with perturbation in the membrane. The fact that the lipid abnormality is more pronounced in the outer leaflet of the membrane where most of receptor binding and enzyme activities take place might provide an explanation for the increased insulin resistance in gestational diabetes and obesity.

Multicenter clinical trials on a novel polyherbal formulation in allergic rhinitis

Allergic rhinitis is the most frequently occurring immunological disorder. It affects men, women and children and represents significant cost in terms of suffering and loss of productivity. Allergy is termed as an excessive reaction to an environmental allergen. Pollen, mold, dust, mite and animal allergens that contact the nasal or eye lining cause sneezing, nasal congestion and itchy, watery, swollen, red eyes. Although a broad spectrum of therapeutic options is available, the treatment of allergic rhinitis appears to be far from satisfactory. A novel polyherbal formulation (PF; Aller-7/NR-A2) comprising seven medicinal herbal extracts was assessed in a multicenter clinical trial involving 545 patients (321 males and 224 females) aged 18-59 years for 12 weeks to evaluate its clinical efficacy in patients suffering from allergic rhinitis. A total of 171 patients participated in double-blind, randomized, placebo-controlled studies in three centers, while 374 patients were included in the open-label studies in 11 centers. The three major symptoms (sneezing, rhinorrhea and nasal congestion) of allergic rhinitis were significantly reduced. Significant improvement was also observed in absolute eosinophil count, mucociliary clearance time, peak expiratory flow rate and peak nasal flow rate. No serious adverse events that warranted cessation of treatment were observed. Minor adverse effects were noted in both the treatment and placebo groups. Thus, this study demonstrates that Aller-7/NR-A2 is well tolerated and efficacious in patients with allergic rhinitis.

Automated identification of diabetic retinal exudates in digital colour images

AIM

To identify retinal exudates automatically from colour retinal images.

METHODS

The colour retinal images were segmented using fuzzy C-means clustering following some key preprocessing steps. To classify the segmented regions into exudates and non-exudates, an artificial neural network classifier was investigated.

RESULTS

The proposed system can achieve a diagnostic accuracy with 95.0% sensitivity and 88.9% specificity for the identification of images containing any evidence of retinopathy, where the trade off between sensitivity and specificity was appropriately balanced for this particular problem. Furthermore, it demonstrates 93.0% sensitivity and 94.1% specificity in terms of exudate based classification.

CONCLUSIONS

This study indicates that automated evaluation of digital retinal images could be used to screen for exudative diabetic retinopathy.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.