Application of the Kvaal method with cone beam for the determination of a local formula for the age estimation of adult African melanoderma subject, Côte d'Ivoire

BACKGROUND

Age estimation by invasive dental methods is a destructive, costly and time-consuming approach, whereas, age estimation methods using dental radiographs are simple, non-destructive and provide reliable information. Age estimation by the Kvaal radiographic method has proven to be a reliable method, but possible ethnic variations may limit its uses in other populations. The objective of this study was to reproduce the original Kvaal method with CBCT for the estimation of the age of the adult melano-African subject in Côte d'Ivoire, in order to propose an age estimation formula, specific to our study population, by taking into account the measurements of tooth and pulp ratios.

METHODS

A cross-sectional study used 102 radiographic data from a CBCT Planmeca® examination in a private dental clinic in Abidjan. It was data from subjects of at least 18 years of age. Dental measurements in length and width of the entire tooth, root and pulp were performed on maxillary central incisors and the different ratios were calculated according to the Kvaal method. The correlation between age and ratios was also assessed. Age estimated using the Kvaal formula was compared to the chronological age. A linear regression equation was developed using ratios and age predictive factors to evaluate the accuracy of the Kvaal formula.

RESULTS

In all, a total of 102 radiographs of 102 subjects, of whom 55 (53.9%) were females, were analyzed. The median age was 51 years (inter-quartile range [IQR] 41- 58). Using the Kvaal formula, the Standard error of the estimated age was higher in the African melanoderma population compared to the Kvaal population. The new formula derived from that of the Kvaal formula was developed and applied to our study population (Age = 84.7- 114.2 (M) - 29.4 (W - L) gave more than double the standard error of estimated age by Kvaal (26.03).

CONCLUSION

Our study showed that the measurements made by Kvaal are reproducible with CBCT and there is a correlation between age and the dental parameters studied. However, the age estimation formula determined by Kvaal et al. is not valid for African melanoderma subjects living in Côte d'Ivoire.

Genetic risk for the polycystic ovary syndrome, bone mineral density and fractures in women and men: A UK Biobank Mendelian randomisation study

INTRODUCTION

There is conflicting data on the effect of polycystic ovary syndrome (PCOS) on bone mineral density (BMD) and fracture risk. Recent genetic data suggest that men may also carry genetic risk factors for PCOS; the associations of these factors with parameters of bone health remains unknown. We aimed to investigate if the genetic risk of PCOS is associated with BMD and fracture risk in women and men in the UK Biobank dataset.

METHODS

We used Mendelian randomisation (MR) analysis to test the association of genetic risk of excess testosterone in PCOS with BMD and fractures in the UK biobank study. The MR analysis was performed using linear regression analysis with the weighted genetic risk score (wGRS) as an independent variable adjusting for age, BMI and population eigenvectors. The horizontal pleiotropy in the MR analysis was tested using MR-Egger regression analysis.

RESULTS

The study consisted of 221,086 Caucasian women (mean age ± SD: 56.7 ± 7.9 years, mean body mass index [BMI] ± SD: 27.0 ± 5.1 kg/m², mean BMD ± SD: 0.50 ± 0.11 g/cm²) and 187,816 Caucasian men (mean age ± SD: 57.1 ± 8.1 years, mean BMI ± SD: 27.7 ± 4.1 kg/m² and mean BMD ± SD: 0.56 ± 0.12 g/cm²). Women and men self-reported 24,797 (11%) and 17,076 (10%) fractures over the last 5 years, respectively. The MR analysis showed that one SD increase in the wGRS for clinical or biochemical hyperandrogenism in PCOS was associated with significantly higher heel BMD (Beta = 0.0007 [±0.0002], P-value = 0.001) and a significantly reduced risk of fractures (OR = 0.97, P-value = 0.003) in women. A similar wGRS in men was not associated with BMD or risk of fractures.

CONCLUSION

In this study, we showed that the excess genetic risk for hyperandrogenism in women with PCOS is associated with a higher BMD and reduced risk of fractures.

Increased development of radiographic hip osteoarthritis in individuals with high bone mass: a prospective cohort study

BACKGROUND

Individuals with high bone mass (HBM) have a greater odds of prevalent radiographic hip osteoarthritis (OA), reflecting an association with bone-forming OA sub-phenotypes (e.g. osteophytosis, subchondral sclerosis). As the role of bone mineral density (BMD) in hip OA progression is unclear, we aimed to determine if individuals with HBM have increased incidence and/or progression of bone-forming OA sub-phenotypes.

METHODS

We analysed an adult cohort with and without HBM (L1 and/or total hip BMD Z-score > + 3.2) with pelvic radiographs collected at baseline and 8-year follow-up. Sub-phenotypes were graded using the OARSI atlas. Superior/inferior acetabular/femoral osteophyte and medial/superior joint space narrowing (JSN) grades were summed and Δosteophyte and ΔJSN derived. Pain and functional limitations were quantified using the WOMAC questionnaire. Associations between HBM status and change in OA sub-phenotypes were determined using multivariable linear/logistic regression, adjusting for age, sex, height, total body fat mass, follow-up time and baseline sub-phenotype grade. Generalised estimating equations accounted for individual-level clustering.

RESULTS

Of 136 individuals, 62% had HBM at baseline, 72% were female and mean (SD) age was 59 (10) years. HBM was positively associated with both Δosteophytes and ΔJSN (adjusted mean grade differences between individuals with and without HBM β_osteophyte = 0.30 [0.01, 0.58], p = 0.019 and β_JSN = 0.10 [0.01, 0.18], p = 0.019). Incident subchondral sclerosis was rare. HBM individuals had higher WOMAC hip functional limitation scores (β = 8.3 [0.7, 15.98], p = 0.032).

CONCLUSIONS

HBM is associated with the worsening of hip osteophytes and JSN over an average of 8 years, as well as increased hip pain and functional limitation.

Hyperthyroidism and bone mineral density: Dissecting the causal association with Mendelian randomization analysis

INTRODUCTION

Untreated hyperthyroidism is associated with accelerated bone turnover, low bone mineral density (BMD) and increased susceptibility to fragility fractures. Although treatment appears to improve or even reverse some of these adverse skeletal effects, there is limited guidance on routine BMD assessment in hyperthyroid patients following treatment. By using Mendelian randomization (MR) analysis, we aimed to assess the causal association of hyperthyroid thyroid states with BMD and fractures using the UK Biobank.

METHODS

This MR analysis included data from 473 818 participants (women: 54% of the total sample, the median age of 58.0 years (IQR = 50-63 years), median body mass index (BMI) of 26.70 (IQR + 24.11-29.82 kg/m² ) as part of the UK Biobank study. The study outcomes were heel BMD assessed by quantitative ultrasound of the heel and self-reported fractures. Beta-weighted genetic risk score analysis was performed using 19 single nucleotide polymorphisms (SNPs) for Graves' disease, 9 SNPs for hyperthyroidism and 11 SNPs for autoimmune thyroiditis. Since the unadjusted risk score MR is equivalent to the inverse-variance weighted method, the genetic risk score analysis was adjusted for age, gender and BMI. Sensitivity analyses were conducted using the Mendelian randomization-Egger (MR-Egger) and the inverse-variance weighted estimate methods. Replication analysis was performed using the GEnetic Factors for Osteoporosis (GEFOS) consortium data.

RESULTS

MR analysis using beta-weighted genetic risk score showed no association of genetic risk for Graves' disease (Beta = -0.01, P-value = .10), autoimmune thyroiditis (Beta = -0.006 P-value = .25) and hyperthyroidism (Beta = -0.009, P-value = .18) with heel ultrasound BMD. MR-Egger and inverse-variance MR methods in UK Biobank and GEFOS consortium confirmed these findings. The genetic risk for these hyperthyroid conditions was not associated with an increased risk of fractures.

CONCLUSION

Our study shows that excess genetic risk for Graves' autoimmune thyroiditis and hyperthyroidism does not increase the risk for low BMD and is not associated fractures in the Caucasian population. Our findings do not support routine screening for osteoporosis following definitive treatment of hyperthyroid states.

Individuals with high bone mass have increased progression of radiographic and clinical features of knee osteoarthritis

OBJECTIVE

High bone mass (HBM) is associated with an increased prevalence of radiographic knee OA (kOA), characterized by osteophytosis. We aimed to determine if progression of radiographic kOA, and its sub-phenotypes, is increased in HBM and whether observed changes are clinically relevant.

DESIGN

A cohort with and without HBM (L1 and/or total hip bone mineral density Z-score≥+3.2) had knee radiographs collected at baseline and 8-year follow-up. Sub-phenotypes were graded using the OARSI atlas. Medial/lateral tibial/femoral osteophyte and medial/lateral joint space narrowing (JSN) grades were summed and Δosteophytes, ΔJSN derived. Pain, function and stiffness were quantified using the WOMAC questionnaire. Associations between HBM status and sub-phenotype progression were determined using multivariable linear/poisson regression, adjusting for age, sex, height, baseline sub-phenotype grade, menopause, education and total body fat mass (TBFM). Generalized estimating equations accounted for individual-level clustering.

RESULTS

169 individuals had repeated radiographs, providing 330 knee images; 63% had HBM, 73% were female, mean (SD) age was 58 (12) years. Whilst HBM was not clearly associated with overall Kellgren-Lawrence measured progression (RR = 1.55 [0.56.4.32]), HBM was positively associated with both Δosteophytes and ΔJSN individually (adjusted mean differences between individuals with and without HBM 0.45 [0.01.0.89] and 0.15 [0.01.0.29], respectively). HBM individuals had higher WOMAC knee pain scores (β = 7.42 [1.17.13.66]), largely explained by adjustment for osteophyte score (58% attenuated) rather than JSN (30% attenuated) or TBFM (16% attenuated). The same pattern was observed for symptomatic stiffness and functional limitation.

CONCLUSIONS

HBM is associated with osteophyte progression, which appears to contribute to increased reported pain, stiffness and functional loss.

Soy isoflavones improve cardiovascular disease risk markers in women during the early menopause

BACKGROUND

Hormone replacement therapy may be beneficial for cardiovascular disease risk (CVR) in post-menopausal women. Soy isoflavones may act as selective estrogen receptor modulators. The aim of this study was to evaluate whether soy isoflavones had an effect on CVR markers.

METHODS

The expected 10-year risk of cardiovascular disease and mortality were calculated as a secondary endpoint from a double blind randomised parallel study involving 200 women (mean age 55 years, Caucasian, Hull, UK, 2012) in the early menopause who were randomised to 15 g soy protein with 66 mg isoflavone (SPI) or 15 g soy protein alone (depleted of all isoflavones; SP) given as a snack bar between meals daily for 6 months. Age, diabetes, smoking, blood pressure and lipid profiles were used to calculate CVR using the Framingham CVR engine.

RESULTS

SPI treatment resulted in a significant reduction in the metabolic parameters and systolic blood pressure compared to SP (p < 0.01). There were no changes in fasting lipid profile and diastolic blood pressure with either treatment. At 6 months, changes in these parameters with SPI treatment were reflected in a calculated 27% (p < 0.01) reduction in 10 year coronary heart disease risk, a 37% (p < 0.01) reduction in myocardial infarction risk, a 24% (p < 0.04) reduction in cardiovascular disease and 42% (p < 0.02) reduction in cardiovascular disease death risk.

CONCLUSIONS

Supplementation with soy protein with isoflavones for 6 months significantly improved CVR markers and calculated CVR at 6 months during early menopause compared to soy protein without isoflavones.

ISRCTN REGISTRY

ISRCTN34051237.

Soy Reduces Bone Turnover Markers in Women During Early Menopause: A Randomized Controlled Trial

Menopausal estrogen loss leads to an increased bone loss. Soy isoflavones can act as selective estrogen receptor modulators, their role in bone turnover is unclear. The primary outcome was assessing changes in plasma bone turnover markers. The secondary outcomes were assessing changes in cardiovascular risk markers including insulin resistance, blood pressure, and lipid profile. We performed a double-blind randomized parallel study in which 200 women within 2 years after the onset of their menopause were randomized to 15 g soy protein with 66 mg isoflavone (SPI) or 15 g soy protein alone (SP), daily for 6 months. There was a significant reduction in type I collagen crosslinked beta C-telopeptide (βCTX) (bone-resorption marker) with SPI supplementation (0.40 ± 0.17 versus 0.15 ± 0.09 μg/L; p < 0.01) compared to SP supplementation (0.35 ± 0.12 versus 0.35 ± 0.13 μg/L; p = 0.92) after 6 months. There was also a significant reduction in type I procollagen-N-propeptide (P1NP) (bone formation marker) with SPI supplementation (50.5 ± 25.0 versus 34.3 ± 17.6 μg/L; p < 0.01), more marked between 3 and 6 months. Following SPI there was a significant reduction in fasting glucose, fasting insulin, insulin resistance, and systolic blood pressure whereas no significant changes in these parameters was observed with SP. There were no significant changes in fasting lipid profile and diastolic blood pressure with either preparation. There was a significant increase in TSH and reduction in free thyroxine (p < 0.01) with SPI supplementation though free tri-iodothyronine was unchanged. In conclusion, soy protein with isoflavones may confer a beneficial effect on bone health, analogous to the mode of action of antiresorptive agents, albeit to a less magnitude. There was a significant improvement of cardiovascular risk markers, but a significant increase in TSH and reduction in free thyroxine after SPI supplementation indicating a detrimental effect on thyroid function. © 2016 American Society for Bone and Mineral Research.

Interpretation of the short Synacthen test in the presence of low cortisol-binding globulin: two case reports

Context: Ten percent of serum total cortisol (TC) is unbound; the remainder is bound to cortisol-binding globulin (CBG) and, to a lesser extent, albumin. CBG concentrations can drop significantly, particularly in critical illness, resulting in a low TC although the free, active, cortisol may be normal or increased. In the context of a low CBG, the diagnosis of pituitary-adrenal insufficiency with measurements of TC is difficult.

Objective: To remind clinicians of the difficulty in interpreting TC when the CBG is low, the circumstances when CBG concentrations may decrease and that measurement of CBG and calculation of the free cortisol index can help in the assessment of pituitary-adrenal reserve.

Case: We present two patients at risk of primary and secondary adrenal insufficiency with a poor response to 250 μg Synacthen. In both cases we confirmed low CBG concentrations but a normal free cortisol index (FCI), confirming normal pituitary-adrenal reserve.

Intervention: In case one, we have been able to avoid long-term steroid replacement therapy. We continue to reduce the steroid dose in case 2 but have been limited by the need for high-dose steroid treatment for exacerbations of the patient's airways disease.

Conclusion: The use of TC in the assessment of the hypothalamic-pituitary-adrenal (HPA) axis may give rise to misleading results if the CBG concentration is low. The FCI may be a better marker of pituitary-adrenal reserve in these subjects. Clinicians should be cautious when interpreting abnormal cortisol results and we emphasize the importance of good clinical assessment.

Genotoxicity of mixtures of glyphosate and atrazine and their environmental transformation products before and after photoactivation

The photo-inducible cytogenetic toxicity of glyphosate, atrazine, aminomethyl phosphoric acid (AMPA), desethyl-atrazine (DEA), and their various mixtures was assessed by the in vitro micronucleus assay on CHO-K1 cells. Results demonstrated that the cytogenetic potentials of pesticides greatly depended on their physico-chemical environment. The mixture made with the four pesticides exhibited the most potent cytogenetic toxicity, which was 20-fold higher than those of the most active compound AMPA, and 100-fold increased after light-irradiation. Intracellular ROS assessment suggested the involvement of oxidative stress in the genotoxic impact of pesticides and pesticide mixtures. This study established that enhanced cytogenetic activities could be observed in pesticide mixtures containing glyphosate, atrazine, and their degradation products AMPA and DEA. It highlighted the importance of cocktail effects in environmental matrices, and pointed out the limits of usual testing strategies based on individual molecules, to efficiently estimate environmental risks.

[Genotoxicity risk assessment and oocytes: basis of genetic toxicology and application in reproductive science]

The aim of genotoxicity tests in germ cells is to assess the impact of exposure to environmental mutagens that may represent a risk for the fertility or for the offspring of exposed subject. The comet assay on mature mouse oocytes is a simple, reproductive and rapid test to study primary DNA damage in oocytes. This test is used to complete toxicology assays applied in first line to somatic cells, and could find many applications in reproductive toxicology to study impact of environmental factors on female germ cells. We describe a practical application of comet assay in reproductive biology to assess the genotoxicity of cryoprotectants used at high concentrations in oocyte vitrification protocols. This test allowed us to demonstrate that dimethylsulfoxide and ethylene glycol are non-genotoxic for the mouse oocytes and led us to hypothesize a genotoxic effect of 1,2-propanediol (PrOH) at high concentrations after having observed induction of significant DNA damage on CHO cell line and on mouse oocytes.

Glucocorticoid replacement therapy and fibrinolysis in patients with hypopituitarism

BACKGROUND

Hypopituitarism is associated with increased cardiovascular mortality, and it has been suggested that unphysiological glucocorticoid replacement regimens might contribute to this risk. Traditional glucocorticoid replacement regimens have often led to excessive serum cortisol levels. The hypercortisolaemia of Cushing's syndrome is associated with an increased risk of thromboembolism.

OBJECTIVE

To examine whether short-term higher-dose hydrocortisone replacement regimens adversely affect the fibrinolytic system.

DESIGN

Crossover study comparing tailored low-dose (LD) glucocorticoid regimen (mean, 17·5 mg hydrocortisone daily), with a traditional high-dose (HD, 30-mg hydrocortisone daily) regimen for 2 weeks.

PATIENTS

Ten patients with hypopituitarism and ACTH deficiency - median (range) age, 59 (41-75) years - and 10 age- and sex-matched controls. Nine patients had growth hormone deficiency (five replaced), nine patients had TSH deficiency (nine replaced), eight had gonadotrophin deficiency (five replaced). During the study, other pituitary hormone replacement therapy remained unchanged. Patients with acromegaly and Cushing's syndrome were excluded.

MEASUREMENTS

Hourly serum cortisol for 11 h, plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA) and fibrinogen levels after 2 weeks of treatment with both LD and HD regimens.

RESULTS

No overall significant differences were found between the three groups using the Kruskal-Wallis test: PAI-1: [median (range)] HD, 25 (5-53) ng/ml; LD, 21 (4-56) ng/ml; controls, 27 (8-51); P = 0·3; tPA: HD, 10 (5-15) ng/ml; LD, 10 (4-13) ng/ml; controls 10 (3-13); P = 0·46; and fibrinogen: HD, 2·5 (1·8-3·5) g/l; LD, 3·0 (2·3-4·4) g/l; controls, 2·6 (1·6-3·2): P = 0·97 In addition, no significant differences between HD and LD using Wilcoxon's paired test; PAI-1 (P = 0·91), tPAag (P = 0·47) and fibrinogen (P = 0·09).

CONCLUSIONS

An increased dose of hydrocortisone for 2 weeks creates excessive glucocorticoid exposure, but does not significantly affect fibrinolytic-coagulation parameters.

The effect of parathyroidectomy on neuropsychological symptoms and biochemical parameters in patients with asymptomatic primary hyperparathyroidism

BACKGROUND

With increased biochemical screening, primary hyperparathyroidism (pHPT) is often discovered incidentally whilst patients are asymptomatic.

OBJECTIVE

To assess the impact of parathyroidectomy on neuropsychological symptoms and biochemical parameters in people with asymptomatic pHPT, whilst controlling for the surgical procedure. PATIENTS/DESIGN/MEASUREMENTS: Twenty-four patients with asymptomatic pHPT requiring parathyroidectomy, in accordance with National Institutes for Health recommendations, were recruited prospectively. A control group of 23 subjects was recruited simultaneously from consecutive patients undergoing diagnostic hemithyroidectomy (HT) for benign thyroid nodules. Operations were performed by a single surgeon. Biochemical investigations and neuropsychological symptoms were measured preoperatively and 3 months after surgery. Neuropsychological symptoms were measured using the Hospital Anxiety (HAD-A) and Depression (HAD-D) scales and the Mood Rating Scale (MRS).

RESULTS

Postoperatively, calcium and parathyroid hormone normalized in all patients in the pHPT group. Patients with pHPT showed a significant improvement in neuropsychological symptoms with a pre- and postoperative mean change of 2·45 ± 2·57 (P < 0·05) on HAD-A, 2·79 ± 3·85 (P < 0·05) on HAD-D, and 3·2 ± 4·57 (P < 0·05) on MRS, parameters that were unaltered in the HT group. The differences between the two groups remained statistically significant after adjustment for age and sex for HAD-D (mean change 2·8, 95% CI = 0·3, 5·3, P = 0·025) and MRS (mean difference 3·5, 95% CI = 0·4, 6·7, P = 0·027) but not for HAD-A (mean difference 1·5, 95% CI = -0·8, 3·8, P = 0·20). For all three mental health scores, there were no significant associations with either age or sex.

CONCLUSIONS

Asymptomatic pHPT is associated with neuropsychological symptoms that improve after parathyroidectomy.

The effect of prior bisphosphonate therapy on the subsequent therapeutic effects of strontium ranelate over 2 years

Many osteoporotic women prescribed strontium ranelate have previously received bisphosphonates. Prior bisphosphonate use blunted the spinal bone mineral density (BMD) response for 6 months. Hip BMD was blunted to a degree for 2 years, although there was an overall increase in hip BMD in contrast to the heel where BMD did not increase.

INTRODUCTION

Many osteoporotic women commenced on strontium ranelate have already received treatment with bisphosphonates. This study investigates whether prior bisphosphonate use impairs the subsequent therapeutic response to strontium ranelate.

METHODS

Women were recruited who were either bisphosphonate naïve or currently receiving a bisphosphonate. All women received strontium ranelate and were followed up for 2 years.

RESULTS

One hundred and twenty women were recruited. After 2 years, the bisphosphonate-naïve group had significant BMD increases of 8.9%, 6.0% and 6.4% at the spine, hip and heel, respectively. In the prior bisphosphonate group, BMD increased significantly at the spine (4.0%) and hip (2.5%) but not at the heel. At all time points at all sites, the BMD increase was greater in the bisphosphonate-naïve group. BMD at the spine did not increase during the first 6 months in the prior bisphosphonate group but then increased in parallel with the bisphosphonate-naïve group. In contrast, the difference between the two groups in hip BMD continued to increase throughout the 2 years. P1NP was suppressed in the prior bisphosphonate group for the first 6 months.

CONCLUSIONS

After bisphosphonate exposure, the BMD response to strontium ranelate is blunted for only 6 months at the spine. At the hip, a degree of blunting was observed over 2 years, although there was an overall increase in hip BMD in contrast to the heel where no increase in BMD was observed.

Smell perception during early pregnancy: no evidence of an adaptive mechanism

OBJECTIVE

It has been suggested that nausea and vomiting in pregnancy is an evolutionary adaptive mechanism to avoid the ingestion of potentially harmful foods. It has also been suggested that the mechanism that triggers nausea and vomiting in pregnancy may be olfaction and that olfactory senses are invoked to provide this protection. This study aimed to test this theory in a systematic design.

DESIGN

Cross sectional study.

SETTING

The antenatal department of a maternity hospital in the north of England.

SAMPLE

Three groups of participants: pregnant women (n= 55), non-pregnant women (n= 42) and men (n= 48).

METHODS

Sensitivity was tested towards the odours of six standard stimuli (half safe and half associated with potentially harmful compounds).

MAIN OUTCOME MEASURES

Odour rating of likeness, strength and pleasantness.

RESULTS

Pregnant women rated safe and odours with potentially harmful compounds differently but not more so than men or non-pregnant women. There was no evidence that pregnancy changed the olfactory processes from the non-pregnant state and only slight differences between pregnant women and men were recorded.

CONCLUSIONS

There was no evidence that olfactory processes had undergone any adaptation during pregnancy. The ability to differentiate safe from potentially harmful compounds was common to all three groups studied.

Pulmonary vasodilation in the rat by insulin in vitro could indicate potential hazard for inhaled insulin

AIMS/HYPOTHESIS

Hypoxic pulmonary vasoconstriction is an essential mechanism to prevent hypoxaemia in lung diseases. Insulin is known to be a systemic vasodilator but its effect on the pulmonary circulation is not known. Inhaled particulate insulin can generate locally high concentrations in the lung which could be physiologically important.

METHODS

We therefore studied the effects of insulin in vitro on isolated rat pulmonary artery in a small vessel myograph.

RESULTS

We have shown that pulmonary artery vasodilatation with insulin occurs in a dose-dependent manner. Pre-constriction with PGF2alpha can be abolished (105.7+/-2.9%, mean+/-SEM) and pre-constriction with hypoxia reduced (68.9+/-6.5%) by pharmacologically relevant concentrations of insulin. The characteristic phasic vasoconstriction by pulmonary vessel to hypoxia is substantially modified, resulting in sustained vasodilatation.

CONCLUSIONS/INTERPRETATION

These effects could be clinically important for patients using inhaled insulins who have acute or occult chronic lung disease.

Dermatological care of the diabetic foot

Approximately 30% of patients with diabetes mellitus will have disease-related dermatological problems. Dry skin can be associated with autonomic neuropathy and may be fragile, promoting bacterial invasion. Any potentially infected 'diabetic foot' must be taken seriously, and non-painful deep sepsis suspected if there is evidence of sensory loss. Consideration should be given to eliminating nasal carriage of staphylococci if recurrent superficial sepsis occurs in the presence of poor diabetic control. Fungal infections, both of skin and nails, are common but usually not serious in the absence of immunosuppression. Treatment with topical antifungals may need to be combined with systemic therapy for successful eradication. Systemic antifungal therapy should be carefully considered as treatment needs to be prolonged and is potentially toxic, particularly in individuals with diabetes mellitus who often have co-morbidities. Varicose eczema should be treated by physical therapies intended to improve venous return and prevent peripheral edema and tissue injury. Allergic dermatitis is commonly associated with topical treatments and other sensitizers. Many reactions are not apparent from history, and patch testing for sensitivity is recommended. There are several diabetes mellitus-specific conditions that dermatologists must be aware of, including, necrobiosis lipoidica diabeticorum, granuloma annulare, diabetic dermopathy (spotted leg syndrome or shin spots), diabetic bullae (bullosis diabeticorum), and limited joint mobility and waxy skin syndrome. Ulceration, due to varying combinations of peripheral vascular disease and sensory neuropathy, is the province of the specialist team dealing with the diabetic foot and should ideally be referred to an appropriate multidisciplinary team.

A truncation mutant of the 95-kilodalton subunit of transcription factor IIIC reveals asymmetry in Ty3 integration

Position-specific integration of the retroviruslike element Ty3 near the transcription initiation sites of tRNA genes requires transcription factors IIIB and IIIC (TFIIIB and TFIIIC). Using a genetic screen, we isolated a mutant with a truncated 95-kDa subunit of TFIIIC (TFIIIC95) that reduced the apparent retrotransposition of Ty3 into a plasmid-borne target site between two divergently transcribed tRNA genes. Although TFIIIC95 is conserved and essential, no defect in growth or transcription of tRNAs was detected in the mutant. Steps of the Ty3 life cycle, such as protein expression, proteolytic processing, viruslike particle formation, and reverse transcription, were not affected by the mutation. However, Ty3 integration into a divergent tDNA target occurred exclusively in one orientation in the mutant strain. Investigation of this orientation bias showed that TFIIIC95 and Ty3 integrase interacted in two-hybrid and glutathione S-transferase pulldown assays and that interaction with the mutant TFIIIC95 protein was attenuated. The orientation bias observed here suggests that even for wild-type Ty3, the protein complexes associated with the long terminal repeats are not equivalent in vivo.

Risk factors in dengue shock syndrome

Despite a growing body of evidence predominantly, but not exclusively, from Thailand suggesting that the risk of developing dengue shock syndrome (DSS) is greatest following an anamnestic dengue infection, particularly if the most recent infection was with dengue 2 virus, there continues to be debate about the justification for these claims. This report describes a five-year, prospective study in two townships (suburbs) in Yangon (Rangoon) Myanmar (Burma) in which attempts were made to confirm the data from an earlier prospective study in Thailand and to address some of the criticism of earlier studies. This investigation found the incidence of anamnestic dengue infections in DSS patients to be significantly higher than in the community from which they were drawn and a significantly higher risk of developing DSS following an anamnestic infection (particularly with dengue 2 virus) than following a primary infection with any serotype.

Development of a simple indirect enzyme-linked immunosorbent assay for the detection of immunoglobulin M antibody in serum from patients following an outbreak of chikungunya virus infection in Yangon, Myanmar

During 1984, 1548 children were admitted to the Yangon [Rangoon] Children's Hospital in Myanmar [Burma] with haemorrhagic fever. No evidence of recent dengue infection was found in 577 of the 803 children from whom paired sera were obtained, raising the possibility of reappearance of Chikungunya virus infection in Myanmar. An enzyme-linked immunosorbent assay (ELISA) for the detection of anti-Chikungunya virus immunoglobulin M (IgM) antibody was prepared and standardized using only reagents which are commercially available or which could be prepared without the use of sophisticated equipment. While there was 90% agreement between haemagglutination inhibition (HI) tests and the IgM ELISA in the diagnosis of acute Chikungunya virus infections, 12 additional patients with stationary anti-Chikungunya virus HI antibody titres could be identified as having acute Chikungunya infections using the ELISA. Furthermore, the ELISA could identify twice as many patients (31/103) at the time of admission to hospital as the HI test (15/103). There was no false positive IgM reaction with the ELISA which could be attributed to the presence of rheumatoid factor. Using the test, 103 of a sample of 163 children who presented to the Yangon Children's Hospital with fever/haemorrhagic fever were diagnosed as Chikungunya patients, 4 had possible dual Chikungunya and dengue infections, 16 had dengue, 30 had neither Chikungunya nor dengue infections, and a definitive diagnosis could not be made for 10 patients. Routine use of the ELISA would alert authorities to future outbreaks of Chikungunya virus infection and avoid admission to hospital of patients with a non-life-threatening viral disease.

Hydrocortisone in the management of dengue shock syndrome

A total of 98 patients with dengue shock syndrome admitted into Children's Hospital from February 1973 to February 1974 were randomly selected into 2 groups. A double blind controlled trial of the efficacy of pharmacologic doses of hydrocortisone hemisuccinate was carried out. The 2 groups were confirmed to be completely matched by age, sex and severity of the disease. Nine deaths occurred out of 48 cases in the steroid group (Case Fatality Rate 18.75%) and 22 deaths out of 50 cases in the non-steroid group (Case Fatality Rate 44%), the difference being statistically significant. No significant difference was detected in fluid requirements and other morbidity pattern.