A-02 Concussion at One-Year Post-Injury and Anxiety Do Not Predict Head Protective and Jump Landing Functional Reaction Time

Purpose: Individuals with a concussion history are more likely to sustain subsequent concussions and/or musculoskeletal injuries. Underlying mechanisms are unclear; reaction time (RT) deficits associated with anxiety may play an important role. The primary aim of this study was to determine if anxiety and recent concussion history predict functional RT (i.e., head protective, jump landing) under single and dual-task conditions. Methods: 40 participants (concussion:healthy = 20:20; time since concussion = 11.8 months) completed the State–Trait Anxiety Inventory, anxiety ratings before and after each task, and performed RT tasks. We used a virtual reality environment and motion capture laboratory to collect RTs for head protective and jump landing, respectively. Participants completed assessments under both single-task (i.e., “Focus solely on completing the task as quickly as possible”) and dual-task (i.e., “Subtract as quickly and accurately as possible as you await your visual stimulus”) conditions. Instructions gave equal weight to speed and accuracy. All RTs were calculated (ms) as the time from visual onset of stimuli to first movement ≥3 cm of hands (head protective) or sacral body (jump landing). A series of linear regression models determined if the independent variables predicted RTs. Results: Regression models did not explain a significant proportion of the variance in head protective (single- R2 = 0.05; p = 0.78; dual- R2 = 0.09; p = 0.49), or jump landing (single- R2 = 0.21; p = 0.08; dual- R2 = 0.12; p = 0.32) RTs. Conclusions: In a low anxiety sample, recent concussion history and anxiety do not predict clinical or functional reaction times at twelve-months post-concussion. If these differences exist, they are likely resolved by this time.

Developing a standardized approach to virtual clinic follow-up of hip and knee arthroplasty

AIMS

This study aimed to develop a virtual clinic for the purpose of reducing face-to-face orthopaedic consultations.

PATIENTS AND METHODS

Anonymized experts (hip and knee arthroplasty patients, surgeons, physiotherapists, radiologists, and arthroplasty practitioners) gave feedback via a Delphi Consensus Technique. This consisted of an iterative sequence of online surveys, during which virtual documents, made up of a patient-reported questionnaire, standardized radiology report, and decision-guiding algorithm, were modified until consensus was achieved. We tested the patient-reported questionnaire on seven patients in orthopaedic clinics using a 'think-aloud' process to capture difficulties with its completion.

RESULTS

A patient-reported 13-item questionnaire was developed covering pain, mobility, and activity. The radiology report included up to ten items (e.g. progressive periprosthetic bone loss) depending on the type of arthroplasty. The algorithm concludes in one of three outcomes: review at surgeon's discretion (three to 12 months); see at next available clinic; or long-term follow-up/discharge.

CONCLUSION

The virtual clinic approach with attendant documents achieved consensus by orthopaedic experts, radiologists, and patients. The robust development and testing of this standardized virtual clinic provided a sound platform for organizations in the United Kingdom to adopt a virtual clinic approach for follow-up of hip and knee arthroplasty patients. Cite this article: Bone Joint J 2019;101-B:951-959.

The role of bracken fern illudanes in bracken fern-induced toxicities

Bracken fern is carcinogenic when fed to domestic and laboratory animals inducing bladder and ileal tumours and is currently classified as a possible human carcinogen by IARC. The carcinogenic illudane, ptaquiloside (PTQ) was isolated from bracken fern and is widely assumed to be the major bracken carcinogen. However, several other structurally similar illudanes are found in bracken fern, in some cases at higher levels than PTQ and so may contribute to the overall toxicity and carcinogenicity of bracken fern. In this review, we critically evaluate the role of illudanes in bracken fern induced toxicity and carcinogenicity, the mechanistic basis of these effects including the role of DNA damage, and the potential for human exposure in order to highlight deficiencies in the current literature. Critical gaps remain in our understanding of bracken fern induced carcinogenesis, a better understanding of these processes is essential to establish whether bracken fern is also a human carcinogen.

A substudy evaluating treatment intensification on medication adherence among hypertensive patients receiving home blood pressure telemonitoring and pharmacist management

WHAT IS KNOWN AND OBJECTIVE

Hypertension is a leading cause of death and major contributor to heart attacks, strokes, heart and kidney failure. Antihypertensive (HTN medication) non-adherence contributes to uncontrolled hypertension. Effective initiatives to improve uncontrolled hypertension include a team-based approach with home blood pressure (BP) monitoring. Our study objective was to evaluate whether objectively measured medication adherence was influenced by home BP telemonitoring and pharmacist management.

METHODS

We analysed HTN medication adherence in 240 patients who received home BP telemonitoring and pharmacist intervention (TI). Adherence was measured based on prescription fills and the proportion of days covered (PDC). HTN medications continued pre- to post-baseline were similar for telemonitoring intervention (TI) and usual care (UC) patients (rate ratio = 1·00, P = 0·90).

RESULTS AND DISCUSSION

More HTN medications were discontinued pre- to post-baseline in TI patients (rate ratio = 1·38, P = 0·04). Similarly, more HTN medications were added in TI patients (rate ratio = 2·46, P < 0·001). The proportion with a mean PDC ≥ 0·8 for HTN medications added after baseline and overall adherence did not differ between groups.

WHAT IS NEW AND CONCLUSION

Medication adherence was high in both groups; however, medication adherence was not significantly altered by the intervention. There were more medication modifications and greater medication intensification among TI patients.

Outpatient diabetes clinical decision support: current status and future directions

Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment-relevant information to patients, using such systems for care coordination and case management and integrating patient-reported information and data from remote devices into clinical decision algorithms and interfaces.

First Report of Septoria apocyni Causing Spot Blight on the Species of Apocynum venetum and Poacynum pictum in China

The species of Apocynum venetum and Poacynum pictum grow widely from the middle to northwestern regions of China. During the summers of 2011 to 2013, a spot blight was found in wild and cultivated both species in Altay Prefecture of the Xinjiang Uygur Autonomous Region, China. The spot blight caused leaf yellowing and leaf drop, and serious damage to plant phloem. Lesions were circular to irregular, and the diameter of lesions on A. venetum and P. pictum was 1.84 to 6.84 × 1.23 to 4.24 mm and 2.05 to 7.09 × 1.46 to 5.65 mm, respectively. Pycnidia were 70 to 115 × 52 to 120 μm, scattered, spherical, buried, and had a brown hard shell with a prominent ostiole. Conidia were colorless, needle-shaped, or linear. The conidia base was obtuse, containing 3 to 5 indistinct septa, 46.3 to 110.3 × 2 to 2.5 μm. Fungal cultures were obtained by cutting 1-cm-long infected leaf pieces from the margins of the lesions following routine surface sterilizing procedures. The sections were placed on potato dextrose agar (PDA) in petri dishes and incubated at 23°C for 4 weeks (4). Hyphae had septa, the aerial and base mycelium was white and rufous, and the back of the colony was sunken and cracked after 2 weeks, but no spore was observed. To verify the identity, total DNA was extracted directly from fungal mycelium with a UNIQ-10 fungal genomic DNA extraction kit (Sangon Biotech, Shanghai, China) and PCR amplification performed with primers ITS1/ITS4 (3). A 512-bp PCR product was sequenced and contrasted with GenBank sequences using BLAST, which revealed 99% identity with Septoria sp. (GenBank Accession No. KC134322.1). To confirm pathogenicity, A. venetum and P. pictum were planted in pots and grown in a greenhouse. After 6 weeks of growth, plants were inoculated by spraying a mycelial suspension onto the foliage while control plants received a similar application of sterilized distilled water. Five pots (3 plants per pot) were used for each treatment. The pots were then placed on plates filled with tap water and covered with Plexiglas hoods in the greenhouse at 20 to 25°C. Lesions began to appear 6 to 7 days after inoculation with the mycelial suspension, whereas control plants remained healthy. The average disease incidence was 19.3%. The symptoms and morphology were similar to Septoria apocyni in Teterevnikova (2). It was determined that spot blight of A. venetum and P. pictum was caused by S. apocyni based on morphological comparison. There is one relevant literature report of spot blight on A. venetum and P. pictum in China, but without any details of the pathogenicity or morphology of the pathogen (1). We believe that this is the first report of S. apocyni occurring on the species of A. venetum and P. pictum in China. References: (1) W. Sun et al. Special Economic Animal and Plant 8:23, 2005. (2) D. N. Teterevnikova. Page 79 in: Septoria sp. Fungus of USSR. Armenian Academy of Sciences Publishing, Armenia, USSR, 1987. (3) G. J. M. Verkley et al. Mycologia 96:558, 2004. (4) W. Zhang et al. Plant Dis. 96:1374, 2012.

The Dublin SURGE Project: geochemical baseline for heavy metals in topsoils and spatial correlation with historical industry in Dublin, Ireland

The Dublin SURGE (Soil Urban Geochemistry) Project is Dublin's first baseline survey of heavy metals and persistent organic pollutants in topsoils and is part of a Europe-wide initiative to map urban geochemical baselines in ten cities. 1,058 samples were collected as part of a stratified random sampling programme in the greater Dublin area to give an overview of baseline conditions in the city. Samples were analysed for 31 inorganic elements including heavy metals. Analysis of results indicates that the concentrations of lead, copper, zinc and mercury are strongly influenced by human activities, with elevated concentrations in the city docklands, inner city and heavy industry areas. Sources of heavy metals in these areas may include historical industry, coal burning, re-use of contaminated soil, modern traffic and leaded paint and petrol. Concentrations of other inorganic elements in topsoil show patterns which are strongly related to regional bedrock parent material. The spatial distributions of heavy metals, in particular Pb and As, are explored in detail with respect to regional geology and the influence of historical industry on soil quality. Exploratory data, geostatistical and correlation analyses suggest that the concentrations of heavy metals tend to increase as the intensity of historical industrial activity increases. In particular, drinks production, power generation, oil/gas/coal, metals and textile historical industries appear to be the contamination source for several heavy metals. The data provide a geochemical baseline relevant to the protection of human health, compliance with environmental legislation, land use planning and urban regeneration.

Contrast-enhanced MRI of the subdeltoid, subacromial bursa in painful and painless rotator cuff tears

OBJECTIVE

Although shoulder pain is often associated with rotator cuff tears, many tears are asymptomatic and are not the cause of the patient's pain. This may explain the persistence of symptoms in some patients despite technically successful rotator cuff repair. It has been proposed that rotator cuff tears cause pain through subdeltoid/subacromial bursal inflammation. The aim of this study was to determine whether bursal inflammation seen on MRI is associated with pain in patients with rotator cuff tears of the shoulder.

METHODS

The shoulders of 255 patients were screened with ultrasound. 33 full-thickness rotator cuff tears (18 with shoulder pain and 15 without pain) were identified and subsequently studied using contrast-enhanced MRI of the shoulder. Enhancement of the subacromial bursa was scored independently by two musculoskeletal radiologists. Logistic regression was used to determine whether bursal enhancement was independently associated with pain.

RESULTS

There was a significant association between pain and age, with greater likelihood of pain in younger patients. Bursal enhancement was common in both painful and painless tears. No statistically significant link between pain and bursal enhancement was seen, even after accounting for age.

CONCLUSION

Although enhancement of the subdeltoid/subacromial bursa was common, no evidence was found to support the hypothesis that bursal enhancement is associated with pain in rotator cuff tears. It is therefore unlikely to determine reliably which patients would benefit from rotator cuff repair. Advances in knowledge Bursal enhancement and thickening does not reliably correlate with symptoms or presence of rotator cuff tear.

Quantitative MRI measurements of the Achilles tendon in spondyloarthritis using ultrashort echo times

OBJECTIVES

Tendon involvement is common in spondyloarthritis. The MRI signal from the Achilles tendon has been used to quantify mechanical tendinopathy; however, conventional MRI is limited by the short T(2) of normal tendon. Short and ultrashort echo time (UTE) MRI have the potential to better measure signal intensity reflecting changes in T(2) or gadolinium enhancement. Furthermore, UTE images could be used for normalisation to reduce variability. The aim of this work was to investigate such techniques in patients with spondyloarthritis (SpA).

METHODS

The Achilles tendons of 14 healthy volunteers and 24 patients with symptomatic spondyloarthritis were studied. Combined UTE (TE=0.07 ms) and gradient echo (TE=4.9 ms) images were acquired before and after intravenous gadolinium together with pre-contrast gradient echo images (TE=2 ms). The signal intensity from a region of interest in the Achilles tendon above the calcaneus was measured. The relative enhancement at echo times of 0.07 ms (RE(0.1)) and 4.9 ms (RE(5)) were calculated. The ratios of the signal intensities from both 4.9 ms and 2 ms gradient echo images to the signal intensity from the UTE image were calculated (RTE(5) and RTE(2) respectively).

RESULTS

Interobserver intraclass correlation coefficients were excellent (≥0.97). The contrast-to-noise ratio was higher for enhancement on UTE images than on gradient echo images. RE(0.1), RTE(5) and RTE(2) were significantly higher in SpA patients than controls.

CONCLUSION

Signal intensity ratios using UTE images allow quantitative measurements to be made which are sensitive to tendon T(2) or contrast enhancement and which are increased in spondyloarthritis. They therefore have the potential for use as measures of tendon disease in spondyloarthritis.

Glycaemia and correlates of patient-reported outcomes in ACCORD trial participants

AIMS

Post-hoc evaluation of relationships between first-year change in glycaemic control (HbA(1c) ) and change in patient-reported outcomes among ACCORD health-related quality of life (HRQoL) substudy participants.

METHODS

Data from 2053 glycaemia-trial subjects were analysed. We assessed physical and mental health status (36-Item Short Form Health Survey, Version-2), symptom count and severity (Diabetes Symptoms Distress Checklist) and treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire). Linear mixed models were used to test relationships between 1-year changes in HbA(1c) and patient reported outcomes sequentially adjusting for correlates (baseline characteristics, baseline patient reported outcomes, treatment assignment, frequency of clinical contact and post-randomization weight change plus new complications).

RESULTS

Poorer baseline control of HbA(1c) and cardiovascular disease risk factors predicted greater one-year improvements in treatment satisfaction. Similarly, poorer baseline patient reported outcome scores all individually predicted greater 1-year improvement in that same outcome. Accounting for baseline and post-randomization characteristics and treatment arm, 1-year change in HbA(1c) was unrelated to changes in overall physical or mental health; however, every one percentage-point (10.9 mmol/mol) reduction in HbA(1c) was associated with lower symptom count (β = 0.599; P = 0.012), lower symptom distress (β = 0.051; P = 0.001), and higher treatment satisfaction (β = -2.514; P < 0.001).

CONCLUSIONS

Independent of all relevant covariates, better glycaemic control over 1 year was associated with reduced patient-reported diabetes symptoms and symptom distress, and increased treatment satisfaction, but not overall physical and mental health. Further investigation is required to understand the specific psychosocial mechanisms that affect how patients value health and treatments.

Fenofibrate-associated changes in renal function and relationship to clinical outcomes among individuals with type 2 diabetes: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) experience

AIMS/HYPOTHESIS

Fenofibrate has been noted to cause an elevation in serum creatinine in some individuals. Participants in the Action to Control Cardiovascular Risk in Diabetes Lipid Study were studied to better characterise who is at risk of an increase in creatinine level and to determine whether those with creatinine elevation have a differential risk of adverse renal or cardiovascular outcomes.

METHODS

A fenofibrate-associated creatinine increase (FACI) was defined as an increase in serum creatinine of at least 20% from baseline to month 4 in participants assigned to fenofibrate. Baseline patient characteristics, and baseline and 4-month drug, clinical, laboratory characteristics and study outcomes were examined by FACI status.

RESULTS

Of the sample, 48% of those randomised to receive fenofibrate had at least a 20% increase in serum creatinine within 4 months. In multivariable analysis, participants who were older, male, used an ACE inhibitor at baseline, used a thiazolidinedione (TZD) at 4 months post-randomisation, had baseline CVD, and had lower baseline serum creatinine and LDL-cholesterol levels were all more likely to meet the criteria for FACI. Participants in the FACI group were also more likely to have a decrease in their serum triacylglycerol level from baseline to 4 months. No differences in study outcomes were seen by FACI criteria.

CONCLUSIONS/INTERPRETATION

Several characteristics predict a rapid rise in serum creatinine upon starting fenofibrate. Participants who met the criteria for FACI also had a greater change in triacylglycerol levels. In the setting of careful renal function surveillance and reduction of fenofibrate dose as indicated, no increase in renal disease or cardiovascular outcome was seen in those individuals demonstrating FACI.

TRIAL REGISTRATION

ClincalTrials.gov: NCT00000620.

FUNDING

The ACCORD Trial was supported by grants (N01-HC-95178, N01-HC-95179, N01-HC-95180, N01-HC-95181, N01-HC-95182, N01-HC-95183, N01-HC-95184, IAA-Y1-HC-9035 and IAA-Y1-HC-1010) from the National Heart, Lung, and Blood Institute; by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute on Aging, and the National Eye Institute; by the Centers for Disease Control and Prevention; by General Clinical Research Centers and by the Clinical and Translational Science Awards. Abbott Laboratories, Amylin Pharmaceutical, AstraZeneca Pharmaceuticals LP, Bayer HealthCare LLC, Closer Healthcare, GlaxoSmithKline Pharmaceuticals, King Pharmaceuticals, Merck, Novartis Pharmaceuticals, Novo Nordisk, Omron Healthcare, sanofi-aventis US and Takeda Pharmaceuticals provided study medications, equipment or supplies.

Tendon and ligament imaging

MRI and ultrasound are now widely used for the assessment of tendon and ligament abnormalities. Healthy tendons and ligaments contain high levels of collagen with a structured orientation, which gives rise to their characteristic normal imaging appearances as well as causing particular imaging artefacts. Changes to ligaments and tendons as a result of disease and injury can be demonstrated using both ultrasound and MRI. These have been validated against surgical and histological findings. Novel imaging techniques are being developed that may improve the ability of MRI and ultrasound to assess tendon and ligament disease.

Imaging of the Achilles tendon in spondyloarthritis: a comparison of ultrasound and conventional, short and ultrashort echo time MRI with and without intravenous contrast

OBJECTIVES

To compare conventional MRI, ultrashort echo time MRI and ultrasound for assessing the extent of tendon abnormalities in spondyloarthritis.

METHODS

25 patients with spondyloarthritis and Achilles symptoms were studied with MRI and ultrasound. MR images of the Achilles tendon were acquired using T1-weighted spin echo, gradient echo and ultrashort echo time (UTE) sequences with echo times (TE) between 0.07 and 16 ms, before and after intravenous contrast medium. Greyscale and power Doppler ultrasound were also performed. The craniocaudal extent of imaging abnormalities measured by a consultant musculoskeletal radiologist was compared between the different techniques.

RESULTS

Abnormalities were most extensive on spoiled gradient echo images with TE = 2 ms. Contrast enhancement after intravenous gadolinium was greatest on the UTE images (TE = 0.07 ms). Fewer abnormalities were demonstrated using unenhanced UTE. Abnormalities were more extensive on MRI than ultrasound. Contrast enhancement was more extensive than power Doppler signal.

CONCLUSIONS

3D spoiled gradient echo images with an echo time of 2 ms demonstrate more extensive tendon abnormalities than the other techniques in spondyloarthritis. Abnormalities of vascularity are best demonstrated on enhanced ultrashort echo time images.

Measurement of joint effusion and haematoma formation by ultrasound in assessing the effectiveness of drains after total knee replacement: A prospective randomised study

We prospectively randomised 78 patients into two groups, 'drains' or 'no drains' to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.

MR imaging of erosions in interphalangeal joint osteoarthritis: is all osteoarthritis erosive?

OBJECTIVE

Erosive osteoarthritis is usually considered as an inflammatory subset of osteoarthritis (OA). However, an inflammatory component is now recognised in all subsets of OA, so this subgroup of erosive or inflammatory OA is more difficult to conceptualise. The aim of this study was to compare routine CR and MRI to investigate erosion numbers and morphology to determine whether hand OA in general is a more erosive disease than previously recognised.

DESIGN AND METHODS

Fifteen patients with clinical (OA) of the small joints of the hand underwent MRI of one of the affected proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Conventional radiographs (CR) of the hand were also obtained. The MR images were reviewed by two observers for the presence of central and marginal erosions. The site and morphology of any erosions was recorded. CR images of the same hand joint were scored independently for central and marginal erosions by the same observers.

RESULTS

There was 100% agreement between the observers for scoring erosions on CR. Agreement for the MRI scores was also excellent (kappa = 0.84). MRI detected 37 erosions, of which only 9 were seen on CR. The increase in sensitivity using MRI was much greater for marginal erosions (1 detected on CR, 19 on MRI) than for central erosions (8 on CR, 18 on MRI). Using MRI 80% of joints examined showed 1 or more erosions compared with 40% using CR. If only marginal erosions were considered 80% of joints were still considered erosive by MRI criteria, but only 1 showed evidence of erosion on CR. Morphologically central erosions appeared to represent areas of subchondral collapse and pressure atrophy. In contrast, marginal erosions resembled those seen in inflammatory arthritides.

CONCLUSION

Erosions, and particularly marginal erosions typical of those seen in inflammatory arthritis, are a more common feature of small joint OA than conventional radiographs have previously indicated.

Advanced imaging in rheumatoid arthritis: part 2: erosions

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium. We now recognise that conventional radiographic images show changes of rheumatoid arthritis late after irreversible joint damage has occured. With the advent of powerful disease-modifying drugs there is a need for early demonstration of rheumatoid arthritis and to monitor progress of the disease and response to therapy. Advanced imaging techniques such as ultrasound and MRI have focussed on the demonstration and quantification of synovitis and erosions and allow early diagnosis of RA. The technology to quantify synovitis and erosions is developing rapidly and now allows change in disease activity to be assessed. However, problems undoubtedly exist in quantification techniques and this review serves to highlight them. Much of the literature on advanced imaging in RA appears in rheumatological journals and may not be familiar to radiologists. This review article aims to increase the awareness of radiologists to this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. This first part addresses synovitis imaging. The second part will look at advanced imaging of erosions in RA.

Advanced imaging in rheumatoid arthritis. Part 1: synovitis

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium. We now recognise that conventional radiographic images show changes of rheumatoid arthritis long after irreversible joint damage has occured. With the advent of powerful disease-modifying drugs, there is a need for early demonstration of rheumatoid arthritis and a need to monitor progress of the disease and response to therapy. Advanced imaging techniques such as ultrasound and MRI have focussed on the demonstration and quantification of synovitis and erosions and allow early diagnosis of RA. The technology to quantify synovitis and erosions is developing rapidly and now allows change in disease activity to be assessed. However, problems undoubtedly exist in quantification techniques, and this review serves to highlight them. Much of the literature on advanced imaging in RA appears in rheumatological journals and may not be familiar to radiologists. This review article aims to increase the awareness of radiologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses synovitis imaging. The second part will look at advanced imaging of erosions in RA.

Finger tendon disease in untreated early rheumatoid arthritis: A comparison of ultrasound and magnetic resonance imaging

OBJECTIVE

To investigate the frequency and distribution of finger tenosynovitis in patients with early, untreated rheumatoid arthritis (RA) using gray-scale ultrasound (US) and magnetic resonance imaging (MRI).

METHODS

Fifty patients underwent US and MRI of metacarpophalangeal (MCP) joints 2-5. Twenty healthy controls underwent US only. Flexor and extensor involvement was documented for each joint. Intrareader reliability (IRR) was calculated by rereading static images.

RESULTS

Flexor tenosynovitis was found in 57 (28.5%) of 200 joints in 24 (48%) of 50 patients on US compared with 128 (64%) of 200 joints in 41 (82%) of 50 patients on MRI. Periextensor tenosynovitis was found in 14 (7%) joints in 9 (18%) patients on US compared with 80 (40%) joints in 36 (72%) patients on MRI. No controls had imaging tenosynovitis. Using MRI as the gold standard, the sensitivity, specificity, and negative and positive predictive values for US were 0.44, 0.99, 0.49, and 0.98, respectively, for flexor tenosynovitis and 0.15, 0.98, 0.63, and 0.86 for extensor tenosynovitis, respectively. The IRR was 0.85 and 0.8 for US and MRI, respectively. The most frequently involved joints on US and MRI were the second and third MCP joints.

CONCLUSION

This is the first study to compare US and MRI for the detection of tenosynovitis in the fingers of patients with early untreated RA. Tenosynovitis was found to be common using both modalities, with MRI being more sensitive. A negative US scan does not exclude inflammation and an MRI should be considered. Further work is recommended to standardize definitions and image acquisition for both US and MRI images.

Ultrasonography for rheumatologists: the development of specific competency based educational outcomes

BACKGROUND

A competency based approach to the education of rheumatologists in musculoskeletal ultrasonography (MSK US) ensures standards are documented, transparent, accountable, and defensible, with clear benefit to all stakeholders. Specific competency outcomes will facilitate informed development of a common curriculum and structured programme of training and assessment.

OBJECTIVE

To determine explicit competency based learning outcomes for rheumatologists undertaking MSK US.

METHODS

International experts in MSK US, satisfying specific selection criteria, were asked to define the minimum standards required by a rheumatologist to be judged competent in MSK US. They reviewed 115 MSK US skills, comprising bone and soft tissue pathology, in seven joints regions of the upper and lower limbs, and rated their relative importance according to specific criteria. These data are presented as specific educational outcomes within designated competency categories.

RESULTS

57 expert MSK US practitioners were identified and 35 took part in this study. Ten generic core competency outcomes were recognised including physics, anatomy, technique, and interpretation. Regarding specific regional competencies, 53% (61/115) were considered "must know" core learning outcomes, largely comprising inflammatory joint/tendon/bone pathology and guided procedures; 45% (52/115) were required at an intermediate/advanced level (18/115 "should know", 34/115 "could know"), and 2% (2/115) were deemed inappropriate/unnecessary for rheumatologist ultrasonographers.

CONCLUSIONS

This is the first study to developing a competency model for the education of rheumatologists in MSK US based on the evidence of international experts. A specific set of learning outcomes has been defined, which will facilitate future informed education and practice development and provide a blueprint for a structured rheumatology MSK US curriculum and assessment process.

Differentials in poisoning rates of young Australian children according to residential location and geographical remoteness

OBJECTIVES

To assess differentials in the poisoning rates of children aged 0-4 years according to residential location and geographical remoteness.

DESIGN

Cross sectional study based on hospitalizations.

SETTING

Australia.

SUBJECTS

Children aged 0-4 years admitted to hospital due to poisoning during the financial year 1996-97.

MAIN OUTCOME MEASURES

Crude rates of hospitalization.

RESULTS

The rate of hospitalization due to poisoning peaked in the third year and second year of life for medicinal and non-medicinal substances respectively. Rates were significantly higher among children aged 0-4 years residing in rural and remote areas when compared with those residing in metropolitan areas, and rate differentials increased with geographical remoteness.

CONCLUSIONS

The observed differentials suggest the need for targeted research and prevention efforts aimed at rural and remote area communities. A detailed empirical study is recommended, involving the assessment of risk factors and an in-home hazard checklist, as a precursor to any intervention program.

Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug–induced clinical remission: Evidence from an imaging study may explain structural progression

OBJECTIVE

More timely and effective therapy for rheumatoid arthritis (RA) has contributed to increasing rates of clinical remission. However, progression of structural damage may still occur in patients who have satisfied remission criteria, which suggests that there is ongoing disease activity. This questions the validity of current methods of assessing remission in RA. The purpose of this study was to test the hypothesis that modern joint imaging improves the accuracy of remission measurement in RA.

METHODS

We studied 107 RA patients receiving disease-modifying antirheumatic drug therapy who were judged by their consultant rheumatologist to be in remission and 17 normal control subjects. Patients underwent clinical, laboratory, functional, and quality of life assessments. The Disease Activity Score 28-joint assessment and the American College of Rheumatology remission criteria, together with strict clinical definitions of remission, were applied. Imaging of the hands and wrists using standardized acquisition and scoring techniques with conventional 1.5T magnetic resonance imaging (MRI) and ultrasonography (US) were performed.

RESULTS

Irrespective of which clinical criteria were applied to determine remission, the majority of patients continued to have evidence of active inflammation, as shown by findings on the imaging assessments. Even in asymptomatic patients with clinically normal joints, MRI showed that 96% had synovitis and 46% had bone marrow edema, and US showed that 73% had gray-scale synovial hypertrophy and 43% had increased power Doppler signal. Only mild synovial thickening was seen in 3 of the control subjects (18%), but no bone marrow edema.

CONCLUSION

Most RA patients who satisfied the remission criteria with normal findings on clinical and laboratory studies had imaging-detected synovitis. This subclinical inflammation may explain the observed discrepancy between disease activity and outcome in RA. Imaging assessment may be necessary for the accurate evaluation of disease status and, in particular, for the definition of true remission.

Former college artistic gymnasts maintain higher BMD: a nine-year follow-up

INTRODUCTION

If higher bone gains acquired from weight-bearing sports during growth persist into old age, the residual benefits could delay or even prevent osteoporotic fractures. The purpose of this study was to determine if the higher areal bone mineral density (aBMD) observed 15 years after competitive training and competition in former female college artistic gymnasts (GYM) compared with controls (CON) is maintained nine years later in this same cohort approaching menopause. In this 9-year follow-up, aBMD changes were also compared between GYM (n=16; aged 45.3+/-3.3 years) and CON (n=13; aged 45.4+/-3.8 years).

METHODS

Total body, lumbar spine, proximal femur, femoral neck, leg, and arm aBMD were assessed at baseline and follow-up using dual-energy X-ray absorptiometry (DXA), (Hologic QDR-1000W). GYM had higher aBMD at all sites at follow-up (P<0.05; eta (2)>0.14).

RESULTS

While there were no significant differences between groups for percent changes in aBMD at the total body, lumbar spine, total proximal femur, femoral neck, and arm, the change in leg aBMD was significantly different between GYM and CON (P=0.05; eta (2)=0.14).

CONCLUSIONS

Former female college artistic gymnasts maintained significantly higher aBMD than controls 24 years after retirement from gymnastics training and competition. This study provides greater insight into the effects of past athletic participation on skeletal health in women approaching menopause.

Prevalence of spinal cord injury in Australia

STUDY DESIGN

Cohort study, based on cases of spinal cord injury (SCI) that occurred between 1986 and 1997 (n=2959).

OBJECTIVES

To estimate prevalence historically, currently and into the future.

SETTING

Australia.

METHODS

Prevalence was estimated on the basis of (1) historical data concerning survival and the relationship between the incidence of fatalities and SCI, (2) information on SCI incidence and survival 1986-1997, and (3) forecasts of incidence and population growth from 1997 to 2021 and consideration of survival.

RESULTS

It was estimated that the prevalence of SCI in Australia was in the range 8096-9614 cases by 1985. By 1997, this had increased to nearly 10,000 and the prevalence rate was more than 681 per million of population. By 2021, this could increase to nearly 12,000 if age-specific SCI incidence rates continued at average values evident over the period 1986-1997 and national population projections applied. In addition, there would be more elderly SCI cases due to the ageing of the national population. The prevalent population could be reduced to less than 7000 if the incidence rate was reduced by -3% p.a.

CONCLUSION

The prevalence of SCI in Australia has increased and it will continue to increase unless measures are taken to control incidence. The case mix will change due to the ageing of the population, and treatment services will need to be prepared for a larger and more elderly prevalent population. It was suggested that consideration should be given to a national health and welfare goal to reduce the SCI incidence rate by -3% p.a., focusing in particular on the prevention of transport crashes and falls.

Glutathione S-transferase M1, T1 and P1 polymorphisms and bladder cancer risk in Egyptians

Previous studies suggest that bladder cancer risk may vary with GST genotype but these results are inconsistent. The aim of this study was to explore whether GSTM1, GSTT1 and GSTP polymorphisms were associated with increased bladder cancer risk in an Egyptian population. GSTM1, GSTT1 and GSTP1 genotype frequencies were determined in bladder cancer cases (n=72) and healthy controls with no history of malignancies (n=82) using PCR-based techniques. The GSTT1*2 genotype was particularly associated with increased risk (OR 2.71, 95%CI 1.27-5.73) and the GSTM1*2 genotype to a lesser extent (OR 1.63, 95%CI 0.85-3.10). 18.1% of cases but only 7.3% of controls were GSTP1*B*B homozygotes (OR 2.38, 95%CI 0.83-6.87). The presence of two or more a priori at-risk genotypes was associated with increased bladder cancer risk (OR 2.42; 95%CI 1.47-3.97). These results suggest that polymorphisms in the GST genes are associated with increased risk of bladder cancer among Egyptians.

Improving the efficiency of wildlife monitoring by estimating detectability: a case study of foxes (Vulpes vulpes) on the Eyre Peninsula, South Australia

Demonstrating the existence of trends in monitoring data is of increasing practical importance to conservation managers wishing to preserve threatened species or reduce the impact of pest species. However, the ability to do so can be compromised if the species in question has low detectability and the true occupancy level or abundance of the species is thus obscured. Zero-inflated models that explicitly model detectability improve the ability to make sound ecological inference in such situations. In this paper we apply an occupancy model including detectability to data from the initial stages of a fox-monitoring program on the Eyre Peninsula, South Australia. We find that detectability is extremely low (<18%) and varies according to season and the presence or absence of roadside vegetation. We show that simple methods of using monitoring data to inform management, such as plotting the raw data or performing logistic regression, fail to accurately diagnose either the status of the fox population or its trajectory over time. We use the results of the detectability model to consider how future monitoring could be redesigned to achieve efficiency gains. A wide range of monitoring programs could benefit from similar analyses, as part of an active adaptive approach to improving monitoring and management.

New approaches to imaging early inflammatory arthritis

Imaging techniques such as musculoskeletal ultrasonography (MUS) and magnetic resonance imaging (MRI) are playing an increasingly important role in the assessment of patients with inflammatory arthritis. Such modalities are now used routinely in the evaluation of joint, tendon and soft tissue inflammation and bone damage in many early arthritis clinics. They have the ability to directly visualise, characterise and quantify the earliest inflammatory changes and have proved not only to be useful additional complimentary clinical tools to improve the speed and accuracy of diagnosis, direct appropriate treatment, monitor response to therapy, measure disease progression and outcome but also continue to contribute to our understanding of disease pathogenesis. These imaging methods may therefore offer a significant advantage as they endorse the principles of early diagnosis and optimal targeted therapy essential to providing the most favourable long term outcome for patients with inflammatory arthritis. This article reviews the current evidence supporting the role of MUS and MRI in the assessment of patients with inflammatory arthritis.

Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings

OBJECTIVE

To evaluate gadolinium-enhanced MR imaging in athletes with chronic groin pain and correlate with the clinical features.

DESIGN AND PATIENTS

MR examinations performed in 52 athletes (51 male, 1 female; median age 26 years) with chronic groin pain and 6 asymptomatic control athletes (6 male; median age 29 years) were independently reviewed by two radiologists masked to the clinical details. Symptom duration (median 6 months) and clinical side of severity were recorded. Anatomical areas in the pelvis were scored for abnormality (as normal, mildly abnormal or abnormal) and an overall assessment for side distribution of abnormality was recorded, initially without post-gadolinium sequences and then, 3 weeks later (median 29 days), the post-gadolinium sequences only. Correlation between radiological and clinical abnormality was calculated by Spearman's correlation.

RESULTS

Abnormal anterior pubis and enthesis enhancement significantly correlated with clinical side for both radiologists (both P=0.008). Abnormal anterior pubis and adductor longus enthesis oedema was significant for one radiologist ( P=0.009). All other features showed no significant correlation ( P>0.05). In the control cases there was no soft tissue abnormality but symphyseal irregularity was present ( n=2). For both radiologists assessment of imaging side severity significantly correlated with clinical side for post-gadolinium ( P=0.048 and P=0.023) but not non-gadolinium sequences ( P>0.05).

CONCLUSION

The extent and side of anterior pubis and adductor longus enthesis abnormality on MR imaging significantly and reproducibly correlates with the athletes' current symptoms in chronic adductor-related groin pain.

Trait Anxiety Predicts Panic Behavior in Beginning Scuba Students

Recreational scuba diving is associated with a significant number of fatalities and decompression illnesses each year, and there is evidence that permanent neuropsychological injury can occur in divers. There is also evidence that the principal cause of decompression illness and fatalities in divers is rapid ascent, and it appears that the primary stimulus for rapid ascent is panic. The primary purpose of this investigation was to evaluate the extent to which an objective measure of trait anxiety could be effective in predicting panic behavior in students undergoing scuba training. Trait anxiety was assessed at the outset of scuba instruction in 42 students, and the instructor recorded instances of panic behavior during the 4-month course. It was predicted that individuals scoring 39 or greater on the trait anxiety sub-scale of the State-Trait Anxiety Inventory would be more likely to experience panic behavior than individuals with scores below this cut-off. Predictions and actual recordings of panic behavior were performed independently using a blinded paradigm. Eleven of the students exhibited panic behavior on two or more occasions during the instruction, and 35 of 42 (83 %) predictions were accurate (p < 0.001). It is concluded that an objective measure of trait anxiety can be employed a priori for prediction of panic behavior in beginning scuba students.

Effects of Schistosoma haematobium infection on drug-metabolizing enzymes in human bladder cancer tissues

The mixed function oxidase system includes the phase I drug oxidation proteins e.g. aryl hydrocarbon hydroxylase (AHH), N-nitrosodimethylamine-N-demethylase I (NDMA-dI) and cytochrome b5 which metabolize most carcinogens and xenobiotics into less and/or more active intermediates. These were determined in human bladder tissues diagnosed as bladder cancer only (10 samples) and bladder cancer associated with Schistosoma haematobium (12 samples) and normal bladder tissues (12 samples). In addition to the above enzymes, agents involved in Phase II drug metabolism e.g. glutathione and glutathione S-transferase as well as free radicals (detected as thiobarbituric acid-reactive substances, TBARS) were also determined in these tissues samples. AAH and NDMA-dI, cytochrome b5, and glutathione S-transferase activity decreased by 42, 28, 47 and 32%, respectively, in human bladder cancer tissues. In bladder cancer tissues associated with S. haematobium infection NDMA-dI and GST activity decreased further by 65 and 56%, respectively, whereas AHH activity increased by 50% and levels of reduced glutathione also increased by 43% in cancer tissue and by 29% in schistocome infected bladder cancer tissue. The level of free radicals also increased significantly (by 57%) in infected bladder cancer tissue but not at all in non-infected cancer tissue. Alterations in the activity of phase I and II of drug-metabolizing enzymes in human bladder tissues as a result of S. haematobium infection may therefore change the bladder's capacity to detoxify many endogenous compounds and may also potentiate the deleterious effects of bladder carcinogens, (e.g. N-nitrosamines) which are known to be present in relatively large quantities in the bladder of patients with schistosomiasis. The present study thus provides new insights into mechanisms for the genesis of bladder cancer initiated in association with schistosomiasis.

The role of ultrasonography and magnetic resonance imaging in early rheumatoid arthritis

Advances in ultrasound (US) and magnetic resonance imaging (MRI) techniques have provided new methods for evaluating early rheumatoid arthritis (RA). Their diagnostic properties in terms of detecting primary pathology of RA (i.e., erosions, bone changes, synovitis, tenosynovitis, and effusion) are reviewed. High-resolution US plays a significant role in therapeutic and diagnostic procedures. MRI also assists in the understanding of RA pathogenesis and joint mechanics.

Cerebrovascular reactivity to carbon dioxide in sepsis syndrome

Cerebral dysfunction in sepsis is common in critically ill adults. However, little is known of the effects of sepsis on cerebral haemodynamics. We studied 12 sedated and ventilated patients in whom sepsis had been established for > 24 h. Transcranial Doppler measurements of the middle cerebral artery flow velocity were made at normocapnia, then hypocapnia (-1 kPa) and hypercapnia (+1 kPa). From these data, cerebrovascular reactivity to carbon dioxide was calculated. Variables indicating disease severity, systemic cardiovascular status and outcome were also recorded. We found significant changes in cerebrovascular reactivity to carbon dioxide. Only three of 12 patients had a cerebrovascular reactivity to carbon dioxide in the normal range; seven patients had a reduced cerebrovascular reactivity to carbon dioxide, whereas in two patients it was raised. In this smaD sample, we could not find any trend of association between altered cerebrovascular reactivity to carbon dioxide and severity of illness, cardiovascular status or outcome. This study suggests that established sepsis profoundly affects the vascular tone and reactivity, not only of the systemic circulation, but also of the cerebral vasculature.

Changes in the expression of cytochrome P450 isozymes and related carcinogen metabolizing enzyme activities in Schistosoma mansoni-infected mice

Mixed-function oxidase enzymes metabolize most xenobiotic agents. Western blotting was used to investigate the effect of Schistosoma mansoni infection on the expression of various cytochrome P450 (CYP) isozymes and specific enzyme assays to study related metabolic functions in mouse liver microsomes. Male BK-TO mice were infected with 200 cercariae per mouse and their livers were assayed at 6, 15, 30 and 45 days post-infection (p.i.) and compared with appropriately matched controls. The expression of each of the CYP isozymes (1A1, 2B1/2, 2C6, and 4A) was either unaffected or transiently increased up to 30 days post-infection. By 45 days, a significant loss of signal was observed, particularly for CYP 1A1 and 2B1 /2 where no signal could be detected. Evidence supporting these findings was obtained from enzyme assays specific for particular CYP isozymes. The activity of ethoxyresorufin O-deethylase (CYP 1A1) was reduced by 97% and that of pentoxyresorufin O-depentylase (CYP 2B1 /2) by 96% at 45 days p.i. Similarly, the activity of ethoxycoumarin hydroxylase was progressively reduced over the period under study. It is believed that N-nitrosamines are activated principally by N-nitrosodimethylamine N-demethylase I which was significantly increased at both 30 and 45 days p.i. To further investigate metabolic competency following S. mansoni infection, the in vitro binding of benzo(a)pyrene metabolites to DNA was measured, using isolated liver microsomes to activate benzo(a)pyrene. Benzo(a)-pyrene-DNA adduct formation was markedly increased at 6,15 and 30 days with a maximum at 15 days, but decreased at 45 days p.i. It was concluded that S. mansoni infection changes the expression of different CYP isozymes and also the activity of phase I drug-metabolizing enzymes at different periods of infection and may thus change the liver's capacity to activate or detoxify many endogenous and exogenous compounds. Such alterations may also change the therapeutic actions of drugs that are primarily metabolized by the P450 system, when administered to patients with schistosomiasis.

Increased pathology incidence in the forestomach of rats maintained on a diet containing ivermectin and given a single dose of N-methyl-N1-nitro-N-nitrosoguanidine

Ivermectin is widely used against parasitic infections in veterinary and human medicine and was found to promote the growth of lesions leading to neoplasia when given continuously in the diet to Wistar rats receiving a single low dose of N-methyl-N1-nitro-N-nitrosoguanidine (MNNG). No tumors or pathological lesions were observed in the forestomach of the control animals or those given ivermectin alone. However, compared to animals receiving MNNG alone, rats maintained on a diet containing ivermectin (2 ppm) and given MNNG (12.5 mg/kg) by gavage showed an increased number of neoplasms (9/26 vs 3/18; p = 0.30) and a statistically significant fourfold increase in the number of pathological lesions (18/26 vs 3/18; p = 0.002), which include preneoplasia in the forestomach. In all cases, the pathological lesions were more severe in the animals receiving ivermectin and MNNG, compared to those receiving MNNG alone.

Comparative assessment of leflunomide and methotrexate for the treatment of rheumatoid arthritis, by dynamic enhanced magnetic resonance imaging

OBJECTIVE

Ethical constraints on the conduct of placebo-controlled trials evaluating new therapies for serious chronic diseases, such as rheumatoid arthritis (RA), indicate the need for discerning methods to assess treatment effect in active-controlled clinical trials. Dynamic gadolinium-enhanced magnetic resonance imaging (DEMRI) is a sensitive technique for the detection of synovial inflammation in RA. Therefore, this investigation was undertaken to evaluate DEMRI as an efficacy assessment tool for differentiating treatment effect in a randomized, active-controlled trial comparing leflunomide and methotrexate.

METHODS

Patients with active RA (n = 39) were randomized in a 2-center, prospective, double-blind clinical trial to receive either leflunomide (n = 18) or methotrexate (n = 21) therapy for 4 months. DEMRI scans were obtained at baseline and at 4 months, and the initial rate of enhancement (IRE) and the maximal signal intensity (SI) enhancement (ME) were calculated from the SI curves. Clinical improvement was assessed by conventional outcome measures.

RESULTS

Thirty-four patients (17 treated with leflunomide and 17 with methotrexate) had usable baseline and end point DEMRI scans. Leflunomide treatment was associated with a significantly greater improvement in IRE compared with methotrexate treatment (P < 0.05). Average values of ME indicated reduction of inflammation with both leflunomide and methotrexate. The improvement in clinical signs and symptoms, as measured by traditional assessments, was comparable for both active treatments.

CONCLUSION

Results of this study validate the sensitivity of DEMRI in detecting inflammatory changes in active RA in response to treatment. Improvement in synovial inflammation as measured by IRE was significantly better with leflunomide than with methotrexate over 4 months of therapy.

Developments in digital radiography: an equipment update

Digital X-ray imaging technology has advanced rapidly over the past few years. This review, particularly aimed at those involved in using and purchasing such technology, is an attempt to unravel some of the complexities of this potentially confusing subject. The main groups of X-ray imaging devices that are considered are digitisers of conventional radiographs, image-intensifier-based fluorography systems, photostimulable phosphor computed radiography, amorphous selenium-based technology for thorax imaging and flat-panel systems. As well as describing these different systems, we look at ways of objectively assessing their image quality. Concepts that are used and explained include spatial resolution, grey-scale bit resolution, signal-to-noise ratio and detective quantum efficiency. An understanding of these basic parameters is vital in making a scientific assessment of a system's performance. Image processing and techniques are also briefly discussed, particularly with reference to their potential effects on image quality. This review aims to provide a basic understanding of digital X-ray imaging technology and enables the reader to make an independent and educated assessment of the relative merits of each system.

Screening for diabetes mellitus in high-risk patients: cost, yield, and acceptability

CONTEXT

Although universal screening for diabetes mellitus is generally not recommended, recent reports suggest that screening individuals with multiple diabetes risk factors may be worthwhile. Little is known about the cost, yield, or acceptability of this kind of screening.

PRACTICE PATTERN EXAMINED

Screening of high-risk patients for diabetes mellitus using a two-step, glucose-based screening protocol: Patients were initially screened with a random glucose test; those with abnormal results received a follow-up fasting, 2-hour, 75-gram oral glucose tolerance test. CLINIC SELECTION: Three volunteer clinics from a large medical group in Minnesota.

PATIENT SELECTION

Of 38,989 adults receiving care at the three clinics, we identified 1548 high-risk patients with evidence of both dyslipidemia and hypertension in laboratory and administrative databases. Many of these 1548 patients were not eligible for screening: Twenty-five percent already had diagnosed diabetes; 41% had been screened for diabetes in the past year; and 3% had died, disenrolled, or changed clinics before screening commenced. The remaining 30% (n = 469) were invited for diabetes screening.

RESULTS

Of the 469 high-risk patients invited, 206 (44%) initiated screening; 176 (38%) completed diabetes screening. Five new patients with diabetes were identified in this high-risk group (one from the random glucose test and four from the glucose tolerance test). One new patient with diabetes was identified for every 40 high-risk patients screened. The program cost $4064 per new case of diabetes identified (screening costs alone).

CONCLUSION

In this high-risk managed care population, the yield and acceptability of systematic diabetes screening were low, and the costs were relatively high. The acceptability of office-based diabetes screening may be improved by using a one-step screening test, such as glycosylated hemoglobin, during routine visits.

Ethanol modulates rat hepatic DNA repair functions

To further explore how ethanol may act at the DNA level, studies have been made of DNA repair mechanisms in male Wistar rats given ethanol either as an acute intragastric dose (5 g/kg) or continuously in a liquid diet (5% w/v) to provide 36% of the caloric intake. These treatments generate significant levels of free radicals with evidence of damage to DNA. The acute ethanol dose significantly inhibited O(6)-alkylguanine-DNA alkyltransferase (ATase) activity by 21-32% throughout the 24-h post-treatment period and this was confirmed by immunohistochemical detection of the ATase protein in hepatic nuclei. Twelve hours after the ethanol treatment, the activities of the DNA glycosylases, alkylpurine-DNA-N-glycosylase (APNG) and 8-oxoguanine-DNA glycosylase (OXOG glycosylase) were each increased by approximately 44%. In contrast, when given chronically via the liquid diet, ethanol initially had no effect on ATase activity, but after 4 weeks ATase activity was increased by 40%. Following ethanol withdrawal, ATase activity remained elevated for at least 12 h, but, by 24 h, the activity had fallen to the uninduced control level. DNA glycosylase activities were again affected differently. After 1 week of dietary ethanol exposure, there was no effect on APNG activity but it was inhibited by 19% at 4 weeks. OXOG glycosylase activity, on the other hand, was increased by 53% after 1 week, but decreased by 40% after 4 weeks. Although some of these changes in DNA repair capacity were relatively small, over time, their potential impact on the repair of endogenous or exogenous alkylation and/or oxidation damage in DNA would be substantial. These studies indicate possible mechanisms for the co-carcinogenic effects of ethanol.

Host determinants of DNA alkylation and DNA repair activity in human colorectal tissue: O(6)-methylguanine levels are associated with GSTT1 genotype and O(6)-alkylguanine-DNA alkyltransferase activity with CYP2D6 genotype

There is increasing evidence that alkylating agent exposure may increase large bowel cancer risk and factors which either alter such exposure or its effects may modify risk. Hence, in a cross-sectional study of 78 patients with colorectal disease, we have examined whether (i) metabolic genotypes (GSTT1, GSTM1, CYP2D6, CYP2E1) are associated with O(6)-methyldeoxyguanosine (O(6)-MedG) levels, O(6)-alkylguanine-DNA alkyltransferase (ATase) activity or K-ras mutations, and (ii) there was an association between ATase activity and O(6)-MedG levels. Patients with colon tumours and who were homozygous GSTT1(*)2 genotype carriers were more likely than patients who expressed GSTT1 to have their DNA alkylated (83 versus 32%, P=0.03) and to have higher O(6)-MedG levels (0.178+/-0.374 versus 0.016+/-0.023 micromol O(6)-MedG/mol dG, P=0.04) in normal, but not tumour, DNA. No such association was observed between the GSTT1 genotype and the frequency of DNA alkylation or O(6)-MedG levels in patients with benign colon disease or rectal tumours. Patients with colon tumours or benign colon disease who were CYP2D6-poor metabolisers had higher ATase activity in normal tissue than patients who were CYP2D6 extensive metabolisers or CYP2D6 heterozygotes. Patients with the CYP2E1 Dra cd genotype were less likely to have a K-ras mutation: of 55 patients with the wild-type CYP2E1 genotype (dd), 23 had K-ras mutations, whereas none of the 7 individuals with cd genotype had a K-ras mutation (P=0.04). No other associations were observed between GSTT1, GSTM1, CYP2D6 and CYP2E1 Pst genotypes and adduct levels, ATase activity or mutational status. O(6)-MedG levels were not associated with ATase activity in either normal or tumour tissue. However, in 15 patients for whom both normal and tumour DNA contained detectable O(6)-MedG levels, there was a strong positive association between the normal DNA/tumour DNA adduct ratio and the normal tissue/tumour tissue ATase ratio (r(2)=0.66, P=0.001). These results indicate that host factors can affect levels both of the biologically effective dose arising from methylating agent exposure and of a susceptibility factor, the DNA repair phenotype.

Ethanol enhances the formation of endogenously and exogenously derived adducts in rat hepatic DNA

To investigate the role of ethanol in chemically-induced carcinogenesis, we exposed Wistar rats to ethanol, either as an acute dose or for prolonged periods in a liquid diet and looked for effects on endogenously and exogenously derived DNA adducts. Changes in the cytochrome P450 protein (CYP 2E1) and its catalytic demethylase activity were also followed in order to provide a sequence of relatively well understood changes that are associated with free radical production and, therefore, potentially capable of affecting DNA. The exocyclic DNA adducts, ethenodeoxyadenosine (varepsilondA) and ethenodeoxycytidine (varepsilondC), known to arise from oxidative stress and lipid peroxidation (LPO) sources, were detected in the liver DNA of Wistar rats at background concentrations of 4-6 (varepsilondA) and 25-35 (varepsilondC) adducts per 10(9) parent bases. When rats were given either an acute dose of ethanol (5g/kg, i.g.) or exposed for 1 week to ethanol in a liquid diet (5%, w/v), etheno adduct levels were increased approximately 2-fold and this was statistically significant for varepsilondC (P<0.05 and P<0.02, respectively) for the two separate treatments.In N-nitrosodimethylamine (NDMA)-treated rats, acute ethanol treatment significantly increased the level of O(6)-methylguanine (O(6)-MeG) in hepatic DNA and this was paralleled by a decrease in O(6)-alkylguanine DNA alkyltransferase (ATase) activity; immunohistochemistry confirmed this increase of O(6)-MeG in both hepatic and renal nuclei. When rats were given ethanol in the diet and treated with NDMA, O(6)-MeG levels in hepatic DNA increased at 1 week which coincided with the peak of CYP 2E1-dependent NDMA-demethylase activity. Single cell gel electrophoresis of liver cells showed that after 1 week of exposure to ethanol, there was a small but significant increase in the frequency of DNA strand breaks induced by NDMA (P<0.05); after 4 weeks the increase was 1.4-fold (P<0.01). Our results indicate that exposures to ethanol, which resulted in blood ethanol concentrations similar to those seen in chronic alcoholics and increased levels of expression of the CYP 2E1 protein can exacerbate the DNA damaging effects of endogenous and exogenous alkylating agents. These observations provide indications of possible mechanisms for the carcinogenic or co-carcinogenic action of ethanol.