Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine

Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.

Barriers and facilitators to the implementation of lifestyle management in polycystic ovary syndrome: Endocrinologists' and obstetricians and gynaecologists' perspectives

OBJECTIVE

To study the barriers and facilitators to lifestyle management in PCOS from the perspectives of endocrinologists and obstetricians and gynecologists (Ob/Gyns) to inform the translation and implementation of the international evidence-based guideline on lifestyle management in PCOS.

METHODS

11 endocrinologists and ten Ob/Gyns participated in semi-structured interviews and transcripts were thematically analyzed on NVIVO software.

RESULTS

Both endocrinologists and Ob/Gyns supported lifestyle as key to PCOS management but faced systemic barriers of lack of access to allied health services and had limited capacity for in-depth lifestyle discussions. They suggested team-based approach to address these barriers. Endocrinologists reported lifestyle could be a less effective treatment option and most of their patients had challenges with past failed lifestyle attempts while Ob/Gyns perceived the desire to conceive among patients a facilitator. The importance of credible, individualised and PCOS-specific lifestyle advice was highlighted.

CONCLUSION

Endocrinologists and Ob/Gyns perceived lifestyle management as integral to PCOS management but experience barriers to lifestyle management related to specialist care.

PRACTICE IMPLICATIONS

Resources that provide credible, individualized and PCOS-specific lifestyle advice, team care approach and professional development on motivating patients for lifestyle modification may address these barriers.

Optimising Cardiometabolic Risk Factors in Pregnancy: A Review of Risk Prediction Models Targeting Gestational Diabetes and Hypertensive Disorders

Cardiovascular disease, especially coronary heart disease and cerebrovascular disease, is a leading cause of mortality and morbidity in women globally. The development of cardiometabolic conditions in pregnancy, such as gestational diabetes mellitus and hypertensive disorders of pregnancy, portend an increased risk of future cardiovascular disease in women. Pregnancy therefore represents a unique opportunity to detect and manage risk factors, prior to the development of cardiovascular sequelae. Risk prediction models for gestational diabetes mellitus and hypertensive disorders of pregnancy can help identify at-risk women in early pregnancy, allowing timely intervention to mitigate both short- and long-term adverse outcomes. In this narrative review, we outline the shared pathophysiological pathways for gestational diabetes mellitus and hypertensive disorders of pregnancy, summarise contemporary risk prediction models and candidate predictors for these conditions, and discuss the utility of these models in clinical application.

Relationships between self-management strategies and physical activity and diet quality in women with polycystic ovary syndrome

OBJECTIVE

To determine the relationships of self-management strategies and physical activity (PA) and diet quality in women with PCOS.

METHODS

An online cross-sectional study involving women (n = 501), 18-45 years in the general Australian community with a self-reported PCOS diagnosis. The self-management and lifestyle behaviour questionnaires were completed between August 2017 and March 2018.

RESULTS

Implementation of PA related self-management strategies increased the odds of meeting PA recommendations [Odds ratio (OR): 2.929 (95%CI: 2.172, 3.951), p < 0.001] but had no association with body mass index (BMI) [OR: 0.-0.984 (95%CI: -1.010, 0.959), p = 0.217] nor perception of self weight [OR: 1.382 (95% CI: 0.700, 2.725), p = 0.352]. Nutrition related self-management strategies were inversely associated with BMI [OR: - 0.115 (95%CI: -7.159, -0.980), p = 0.010] but had no association with diet quality [OR: 0.183 (95%CI: -2.328, 2.800), p = 0.855], energy intake [OR: - 0.092 (95%CI: -1204.443, 527.496) p = 0.438] or weight [OR: - 0.034 (95%CI: -4.020, 1.930), p = 0.491].

CONCLUSIONS

PA self-management strategies were associated with meeting PA recommendations. Nutrition strategies were associated with lower BMI but not diet quality, energy intake or weight in women with PCOS.

PRACTICE IMPLICATIONS

Other behaviour change determinants (e.g. education, skills and self-efficacy) should be considered when designing a PCOS lifestyle programme in conjunction with self-management strategies.

Perspectives of Allied Health Professionals on Implementation of the Lifestyle Polycystic Ovary Syndrome Guidelines: A Qualitative Study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common condition affecting up to 13% of reproductive-aged women. Weight and lifestyle management are key initial treatment strategies for individuals with PCOS, as recommended in international evidence-based guidelines. Allied health professionals, including dietitians, exercise physiologists, and psychologists, are crucial in delivering support for lifestyle and weight management.

OBJECTIVE

Our aim was to explore the barriers and enablers to lifestyle and weight management for individuals with PCOS from the perspectives of allied health professionals.

DESIGN

This was a qualitative study using a phenomenology approach to understand the allied health professionals lived experiences managing the lifestyles of individuals with PCOS. Semi-structured interviews were conducted with allied health professionals (ie, dietitians, exercise physiologists, and psychologist). Interviews were audio-recorded and professionally transcribed. Transcripts were coded inductively and analyzed thematically.

PARTICIPANTS/SETTING

Participants were 15 allied health professionals (ie, 9 dietitians, 5 exercise physiologists, and 1 psychologist) involved in the management of PCOS in Australia (n = 10 in Victoria, n = 5 in other states) and interviewed between June and September 2019.

MAIN OUTCOME MEASURES

Barriers and enablers of allied health professionals relating to the provision of lifestyle and weight management in individuals with PCOS were analyzed.

RESULTS

Barriers relating to individuals with PCOS included insufficient knowledge on lifestyle management; lack of time; socioeconomic disadvantage preventing access to lifestyle support; and psychological issues, such as eating disorders or depression. Barriers relating to health professionals included insufficient knowledge about PCOS and insufficient time during consultation. Barriers relating to the health system included lifestyle recommendations in the PCOS guidelines that are too general and weight-focused, funding system that does not facilitate long-term care, and low integration of care among health professionals.

CONCLUSIONS

Barriers for the individual, health professional, and health system all need to be addressed to improve the implementation of lifestyle management in PCOS care to optimize consistency with the PCOS international evidence-based guidelines.

Informing a PCOS Lifestyle Program: Mapping Behavior Change Techniques to Barriers and Enablers to Behavior Change Using the Theoretical Domains Framework

This article aimed to identify the behavior change techniques (BCTs) based on facilitators and barriers to lifestyle management in women with polycystic ovary syndrome (PCOS) according to the behavior change wheel (BCW). This qualitative study design using inductive thematic analysis following semistructured interviews (n = 20) identified barriers and enablers to lifestyle management. These were then mapped to Capability, Opportunity, Motivation-Behavioral Model (COM-B) constructs and the corresponding Theoretical Domains Framework (TDF) domains. This study included women with PCOS residing in Australia. Main outcome measures include intervention functions, policy categories, and BCTs described in the BCW. Twenty-three BCTs were recognized to influence behavior change in women with PCOS. Factors were categorized into the subcomponents of the COM-B: psychological capability (e.g., lack of credible information), physical capability (e.g., managing multiple health conditions), physical opportunity (e.g., limited access to resources), social opportunity (e.g., adequate social support), reflective motivation (e.g., positive health expectancies following behavior change), and automatic motivation (e.g., emotional eating). Future research should use this work to guide PCOS lifestyle intervention development and then test intervention effectiveness through an experimental phase to provide empirical evidence for wider use and implementation of tailored, theory-informed PCOS lifestyle programs as part of evidence-based PCOS management.

Implementation of evidence-based PCOS lifestyle management guidelines: Perceived barriers and facilitators by consumers using the Theoretical Domains Framework and COM-B Model

BACKGROUND

The 2018 Evidence-Based Polycystic Ovary Syndrome (PCOS) Clinical Guidelines recommend lifestyle management as first-line treatment for PCOS, yet implementation of PCOS lifestyle programs into practice is not well understood.

OBJECTIVE

To complete systematic intervention mapping by identifying the facilitators and barriers to lifestyle management in women with PCOS using the theoretical domains framework (TDF) and the Capacity, Opportunity, Motivation and Behaviour model (COM-B).

PATIENT INVOLVEMENT

Women (N = 20) in Australian with PCOS were interviewed.

METHODS

Telephone semi-structured interviews.

RESULTS

Nine themes mapped onto seven TDF domains and the COM-B. Capability: psychological co-morbidities, knowledge and awareness of lifestyle change and ability to identify and resolve barriers. Opportunity: presence of other medical conditions, access to practical resources and availability of social support.

MOTIVATION

outcomes expectancies of lifestyle behaviour, personal values, enjoyment and readiness to change and the impact of stress on lifestyle choices.

DISCUSSION

This is the first study to explore barriers and facilitators to lifestyle change from the perspectives of women with PCOS using the TDF and COM-B. Addressing these themes will facilitate patient-centred care and long-term behaviour change.

PRACTICAL IMPLICATIONS

May increase the efficacy and effectiveness of PCOS lifestyle programs and reduce the risk of PCOS-associated disease in this population.

Polycystic Ovary Syndrome Models of Care: A Review and Qualitative Evaluation of a Guideline-Recommended Integrated Care

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder and many women are dissatisfied with their healthcare under the current fragmented health services. Here, we review existing literature on PCOS healthcare services and qualitatively evaluate an integrated PCOS service based on experiences of women with PCOS. Limited prior PCOS-dedicated services have been studied and their quantitative and efficacy-focused evaluations are summarized. Here, we also provide a broader PCOS service evaluation via semistructured interviews and surveys, with thematic analysis based on a predetermined evaluation framework. Fifteen women completed interviews and surveys. Overall the integrated, evidence-based PCOS service was well-received and women were generally satisfied with appropriateness, effectiveness, and reported positive health impact resulting from the service. Integrated care, tailored treatments, education, lifestyle support, and laser therapy were highly valued. Patients reported improvements on symptoms, understanding and confidence in managing PCOS, and emotional well-being. Elements of efficiency in the initial stages, awareness and communication, and the need for service expansion and tensions between evidence-based treatments and patient preferences were also captured to guide improvement. Further research into models of care is recommended to meet the needs of women with PCOS.

Implementation of the polycystic ovary syndrome guidelines: A mixed method study to inform the design and delivery of a lifestyle management program for women with polycystic ovary syndrome

AIM

The 2018 evidence-based polycystic ovary syndrome (PCOS) guidelines recommend lifestyle management as first-line treatment. This study aims to understand the preferred intervention characteristics of a PCOS lifestyle program from the perspectives of women with PCOS to inform the translation of the guidelines into practice.

METHODS

Women with self-reported PCOS residing in Australia took part in semi-structured interviews (n = 20) and an online survey (n = 286). The survey and interview schedule were developed using the template for intervention description and replication checklist.

RESULTS

Women want to take part in a lifestyle program (94.6%) and use government-subsidised sessions to attend (83%). Sessions of 45 to 60 minutes (75%) costing less than AUD$50 are preferred (60%). Topics of most interest related to sustainable daily physical activity (58%), overcoming non-hungry eating (54%), PCOS-specific diets (51%) and how to overcome barriers to behaviour change (45%). A delivery mode that combines online and in-person support is preferred (53%). Women are in need of long-term professional lifestyle support (6-12 months) that provides evidence-based, PCOS-specific, personalised prescription. Multidisciplinary support from a range of PCOS-trained professions is also preferred to address women's physical, psychological and emotional needs.

CONCLUSION

Women with PCOS are willing to take part in lifestyle programs that are low cost, long term, evidence based, PCOS-specific and provide practical strategies for nutrition and physical activity changes. Future online and in-person PCOS programs are strongly recommended to incorporate these findings to improve program engagement and patient satisfaction.

Obesity and the Risk of Infertility, Gestational Diabetes, and Type 2 Diabetes in Polycystic Ovary Syndrome

This review describes the relationship between obesity and the most common reproductive (infertility) and metabolic (gestational diabetes mellitus [GDM] and type 2 diabetes mellitus [T2DM]) consequences in polycystic ovary syndrome (PCOS). It also describes the vital role of lifestyle management for PCOS. PCOS is a heterogeneous endocrine disorder common in reproductive-age women. Consensus on the exact etiological mechanisms of PCOS is unreached. Overweight or obesity is present in at least 60% of the PCOS population, but the condition occurs irrespective of BMI, with excess BMI increasing both the prevalence and severity of clinical features. Use of lifestyle therapies (nutrition, physical activity, and/or behavioral) for the prevention and management of excess weight gain, infertility, GDM, and T2DM is a vital component of best-practice PCOS care. Lifestyle management is recommended for all women with PCOS as the first-line treatment with or without medications. Due to a lack of high-quality trials demonstrating the efficacy of specific lifestyle approaches, PCOS lifestyle recommendations are as those for the general population. This review summarizes current knowledge relating to obesity and its impact on fertility, GDM, and T2DM. It also summarizes the lifestyle recommendations to best manage these conditions in women with PCOS and obesity.

P252 Identifying predictors for all-cause mortality at admission, 1 and 3 years after admission for acute decompensated heart failure amongst patients with atrial fibrillation

Background

Heart failure (HF) and atrial fibrillation (AF) commonly co-exist, each, predisposing the other. AF may inflict haemodynamic disturbances, leading to reduced cardiac output and hence acute decompensation. Ultimately mortality risk is further increased. Identifying contributing factors is thus vital lest increasing risk of poor outcome.

Purpose

Identify predictors of all-cause mortality in AF patients after admission for acute decompensation HF (ADHF) at admission, 1 and 3 years. 

Methods

A retrospective observational study of 810 AF patients" first admission from 2009 to 2018, analysed using descriptive, ROC curve and Cox regression.

Results

Mortality at admission, 1 and 3 years following ADHF were 5.1%, 14.4% and 40.5% respectively. Majority of AF patients were male (64.7%) but there was no significant statistical difference between gender with associated mortality during those timelines. Using multivariate analysis, predictors associated with increased in-hospital mortality were Hyponatraemia, Na &lt; 135mmol/L (adjusted Odds Ratio, aOR 2.49; 95% Confidence Interval, CI 1.91-5.20; p0.015), Uric Acid ≥ 675 (aOR 2.75; CI 1.31-5.79; p0.008), Ejection Fraction, EF &lt; 40% (aOR 3.93; CI 1.63-9.49; p0.002). Medications on admission associated with reduced inpatient mortality were Angiotensin Converting Enzyme inhibitor (ACEi) / Angiotensin Receptor Blocker (ARB) + Beta Blocker (BB) + Mineralocorticoid Receptor Antagonist (MRA) (aOR 0.07; CI 0.02-0.30; p &lt; 0.001). At 1 year, multivariate analysis showed an associated increase in mortality when NTProBNP ≥ 7500pg/ml (adjusted Hazard Ratio, aHR 1.64; CI 1.02-2.65; p0.042) and Urea &gt; 7mmol/L (aHR 1.86; CI 1.04-3.32, p0.036). Medications on discharge comprising ACEi/ARB + BB + MRA were the only combination that showed a reduction in mortality (aHR 0.23; CI 0.09-0.60; p0.003). At 3 years, background coronary artery disease (aHR 1.72; CI 1.09-2.71; p0.02), hypernatraemia, Na &gt; 145mmol/L (aHR 14.89; CI 3.17-69.86; p0.001), EF &lt; 40% (aHR 2.00; CI 1.28-3.12; p0.002) were associated with increased mortality. Medications on discharge namely ACEi/ARB (aHR 0.14; CI 0.03-0.70; p0.013), BB (aHR 0.23; CI 0.10-0.51; p &lt; 0.001), ACEi/ARB + BB (aHR 0.16; CI0.06-0.41; p &lt; 0.001), ACEi/ARB + MRA (aHR 0.34; CI 0.14-0.85; p0.021), BB + MRA (aHR 0.38; CI 0.17-0.83; p0.016), ACEi/ARB + BB + MRA (aHR 0.193; CI 0.09-0.43; p &lt; 0.001) showed an associated reduction in mortality.

Conclusions

In this single centre study, patients with AF who presented with ADHF had a variety of mortality predictors that influence at different timelines. They had higher risk of inpatient mortality with hyponatraemia, hyperuricaemia and EF &lt; 40%. Elevated NTProBNP and Urea levels seemed to have more effect on mortality at 1 year compared to 3 years. Having 3 disease-modifying heart failure medications at discharge exerted the most benefit up to 3 years of follow up.

Abstract P252 Figure.

Disordered Eating Behaviours and Eating Disorders in Women in Australia with and without Polycystic Ovary Syndrome: A Cross-Sectional Study

Psychological co-morbidities common in polycystic ovary syndrome (PCOS) may contribute to disordered eating and subsequent weight gain. This cross-sectional study aimed to determine the prevalence of disordered eating and a range of eating disorders and demographic risk factors associated with these behaviours within an Australian group of women with and without PCOS. Data from 899 women with (n = 501) and without (n = 398) PCOS were analysed as possibly indicative of disordered eating or eating disorders using the Eating Disorder Examination Questionnaire (EDE-Q) and The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria. Disordered eating (p = 0.012) but not eating disorders (p = 0.076) were more prevalent in women with PCOS compared to controls. Increased body mass index (BMI) [Odds Ratio (OR): 1.03; 95%; Confidence Interval (CI): 1.01, 1.05, p = 0.012] and older age [OR: 1.05; 95%CI: 1.02, 1.08, p = 0.002] but not PCOS diagnosis [OR: 1.43; 95%CI: 0.96, 2.13 p = 0.078] increased the odds of disordered eating. Increased BMI [OR: 1.04; 95%CI: 1.02, 1.06, p < 0.001] and younger age [OR: -0.95; 95%CI: 0.93–0.95, p < 0.001] but not PCOS diagnosis [OR: 1.38; 95%CI: 0.97, 1.95, p = 0.076] increased the odds of an eating disorder. Clinicians are recommended to screen all women with PCOS for possible disordered eating behaviours, with particular attention to women with elevated BMI.

Barriers and Facilitators to the Implementation of Evidence-Based Lifestyle Management in Polycystic Ovary Syndrome: A Narrative Review

Polycystic ovary syndrome (PCOS) is a complex condition that involves metabolic, psychological and reproductive complications. Insulin resistance underlies much of the pathophysiology and symptomatology of the condition and contributes to long term complications including cardiovascular disease and diabetes. Women with PCOS are at increased risk of obesity which further compounds metabolic, reproductive and psychological risks. Lifestyle interventions including diet, exercise and behavioural management have been shown to improve PCOS presentations across the reproductive, metabolic and psychological spectrum and are recommended as first line treatment for any presentation of PCOS in women with excess weight by the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. However, there is a paucity of research on the implementation lifestyle management in women with PCOS by healthcare providers. Limited existing evidence indicates lifestyle management is not consistently provided and not meeting the needs of the patients. In this review, barriers and facilitators to the implementation of evidence-based lifestyle management in reference to PCOS are discussed in the context of a federally-funded health system. This review highlights the need for targeted research on the knowledge and practice of PCOS healthcare providers to best inform implementation strategies for the translation of the PCOS guidelines on lifestyle management in PCOS.

Lifestyle changes in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 8% to 13% of reproductive-aged women and is associated with reproductive and metabolic dysfunction. Obesity worsens the presentation of PCOS and weight management (weight loss, maintenance or prevention of excess weight gain) is proposed as an initial treatment strategy, best achieved through lifestyle changes incorporating diet, exercise and behavioural interventions.

OBJECTIVES

To assess the effectiveness of lifestyle treatment in improving reproductive, anthropometric (weight and body composition), metabolic and quality of life factors in PCOS.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL and AMED (date of last search March 2018). We also searched controlled trials registries, conference abstracts, relevant journals, reference lists of relevant papers and reviews, and grey literature databases, with no language restrictions applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing lifestyle treatment (diet, exercise, behavioural or combined treatments) to minimal or no treatment in women with PCOS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed evidence quality and risk of bias, and extracted data. Our primary outcomes were live birth, miscarriage and pregnancy. We used inverse variance and fixed-effect models in the meta-analyses. We reported dichotomous outcomes as an odds ratio and continuous outcomes as a mean difference (MD) or standardised mean difference (SMD).

MAIN RESULTS

We included 15 studies with 498 participants. Ten studies compared physical activity to minimal dietary and behavioural intervention or no intervention. Five studies compared combined dietary, exercise and behavioural intervention to minimal intervention. One study compared behavioural intervention to minimal intervention. Risk of bias varied: eight studies had adequate sequence generation, seven had adequate clinician or outcome assessor blinding, seven had adequate allocation concealment, six had complete outcome data and six were free of selective reporting. No studies assessed the fertility primary outcomes of live birth or miscarriage. No studies reported the secondary reproductive outcome of menstrual regularity, as defined in this review.Lifestyle intervention may improve a secondary (endocrine) reproductive outcome, the free androgen index (FAI) (MD -1.11, 95% confidence interval (CI) -1.96 to -0.26, 6 RCTs, N = 204, I2 = 71%, low-quality evidence). Lifestyle intervention may reduce weight (kg) (MD -1.68 kg, 95% CI -2.66 to -0.70, 9 RCTs, N = 353, I2 = 47%, low-quality evidence). Lifestyle intervention may reduce body mass index (BMI) (kg/m2) (-0.34 kg/m2, 95% CI -0.68 to -0.01, 12 RCTs, N = 434, I2= 0%, low-quality evidence). We are uncertain of the effect of lifestyle intervention on glucose tolerance (glucose outcomes in oral glucose tolerance test) (mmol/L/minute) (SMD -0.02, 95% CI -0.38 to 0.33, 3 RCTs, N = 121, I2 = 0%, low-quality evidence).

AUTHORS' CONCLUSIONS

Lifestyle intervention may improve the free androgen index (FAI), weight and BMI in women with PCOS. We are uncertain of the effect of lifestyle intervention on glucose tolerance. There were no studies that looked at the effect of lifestyle intervention on live birth, miscarriage or menstrual regularity. Most studies in this review were of low quality mainly due to high or unclear risk of bias across most domains and high heterogeneity for the FAI outcome.

Metabolic syndrome in polycystic ovary syndrome: a systematic review, meta-analysis and meta-regression

Women with polycystic ovary syndrome (PCOS) have increased risk of metabolic syndrome. The relative contribution of clinical, demographic or biochemical factors to metabolic syndrome in PCOS is not known. A literature search was conducted in MEDLINE, CINAHL, EMBASE and clinical trial registries. Of 4530 studies reviewed, 59 were included in the systematic review and 27 in the meta-analysis and meta-regression. In good and fair quality studies, women with PCOS had an overall increased prevalence of metabolic syndrome (odds ratio, OR 3.35, 95% confidence interval, CI 2.44, 4.59). Increased prevalence of metabolic syndrome occurred in overweight or obese women with PCOS (OR 1.88, 95% 1.16, 3.04) but not in lean women (OR 1.45, 95% CI 0.35, 6.12). In meta-regression analyses, the markers of metabolic syndrome diagnostic criteria (waist circumference, high-density lipoprotein cholesterol, triglyceride, blood pressure), BMI, glucose tolerance (2-hr oral glucose tolerance test) and surrogate markers of insulin resistance (HOMA-IR) but not markers of reproductive dysfunction (sex hormone binding globulin, testosterone, PCOS phenotypes) contributed significantly to the heterogeneity in the prevalence of metabolic syndrome. Women with PCOS have increased risk of metabolic syndrome which was associated with obesity and metabolic features but not with indices of hyperandrogenism.

Large falcine meningioma presented as treatment-resistant depression: A case report

Large intracranial tumour may present only with psychiatric symptoms without any neurological deficits. Delay in surgical treatment may significantly affect the quality of life in these patients. We report a case of a young engineering student who was diagnosed as treatment-resistant depression without initial neuroimaging study. Further neuroimaging studies revealed he has a large falcine meningioma. His psychiatric symptoms resolved following surgical resection of the tumour. We emphasized the importance of initial neuroimaging study in young patients presenting with psychiatric symptoms.

Differences in the diagnosis and management of systemic lupus erythematosus by primary care and specialist providers in the American Indian/Alaska Native population

Objectives The objective of this study is to investigate differences in the diagnosis and management of systemic lupus erythematosus (SLE) by primary care and specialist physicians in a population-based registry. Methods This study includes individuals from the 2009 Indian Health Service lupus registry population with a diagnosis of SLE documented by either a primary care provider or specialist. SLE classification criteria, laboratory testing, and medication use at any time during the course of disease were determined by medical record abstraction. Results Of the 320 individuals with a diagnosis of SLE, 249 had the diagnosis documented by a specialist, with 71 documented by primary care. Individuals with a specialist diagnosis of SLE were more likely to have medical record documentation of meeting criteria for SLE by all criteria sets (American College of Rheumatology, 79% vs 22%; Boston Weighted, 82% vs 32%; and Systemic Lupus International Collaborating Clinics, 83% vs 35%; p < 0.001 for all comparisons). In addition, specialist diagnosis was associated with documentation of ever having been tested for anti-double-stranded DNA antibody and complement 3 and complement 4 ( p < 0.001). Documentation of ever receiving hydroxychloroquine was also more common with specialist diagnosis (86% vs 64%, p < 0.001). Conclusions Within the population studied, specialist diagnosis of SLE was associated with a higher likelihood of having SLE classification criteria documented, being tested for biomarkers of disease, and ever receiving treatment with hydroxychloroquine. These data support efforts both to increase specialist access for patients with suspected SLE and to provide lupus education to primary care providers.

Anti-C1q antibodies in systemic lupus erythematosus

OBJECTIVE

Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study.

METHODS

Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA.

RESULTS

Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% (49/389) in controls (OR = 2.7, 95% CI: 1.8-4, p < 0.001). Anti-C1q was associated with proteinuria (OR = 3.0, 95% CI: 1.7-5.1, p < 0.001), red cell casts (OR = 2.6, 95% CI: 1.2-5.4, p = 0.015), anti-dsDNA (OR = 3.4, 95% CI: 1.9-6.1, p < 0.001) and anti-Smith (OR = 2.8, 95% CI: 1.5-5.0, p = 0.01). Anti-C1q was independently associated with renal involvement after adjustment for demographics, ANA, anti-dsDNA and low complement (OR = 2.3, 95% CI: 1.3-4.2, p < 0.01). Simultaneously positive anti-C1q, anti-dsDNA and low complement was strongly associated with renal involvement (OR = 14.9, 95% CI: 5.8-38.4, p < 0.01).

CONCLUSIONS

Anti-C1q was more common in patients with SLE and those of Asian race/ethnicity. We confirmed a significant association of anti-C1q with renal involvement, independent of demographics and other serologies. Anti-C1q in combination with anti-dsDNA and low complement was the strongest serological association with renal involvement. These data support the usefulness of anti-C1q in SLE, especially in lupus nephritis.

Validity of a self-administered version of the brief index of lupus damage in a predominantly African American systemic lupus erythematosus cohort

OBJECTIVE

To assess the reliability and criterion and construct validity of the self-administered Brief Index of Lupus Damage (SA-BILD), a patient-reported measure of organ damage in systemic lupus erythematosus (SLE).

METHODS

The validity of the SA-BILD was assessed using data from the Georgians Organized Against Lupus (GOAL) survey. GOAL is a longitudinal cohort of SLE patients predominantly derived from the Georgia Lupus Registry, a population-based registry established in Atlanta, Georgia. In total, 711 participants with documented SLE completed the SA-BILD. To test reliability, the SA-BILD was readministered to 32 patients. Criterion validity was examined in 150 respondents for whom the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) was also completed. Construct validity was assessed among 711 GOAL participants by dividing the SA-BILD scores into quartiles and examining the association with demographics, health status, and health care utilization.

RESULTS

The test-retest correlation score was 0.93 (P < 0.0001), the item-by-item agreement with the SDI was >80% for most SA-BILD items, and the Spearman's rho correlation coefficient for the SDI and SA-BILD was moderately high (ρ = 0.59, P < 0.0001). SA-BILD scores showed significant associations in the expected directions with age, disease duration, disease activity, overall health, comorbidity index, and physician visits.

CONCLUSION

The SA-BILD was reliable and had very good or good criterion validity compared with the SDI when tested in a predominantly African American cohort of US SLE patients. Associations of SA-BILD scores with sociodemographics and health status were consistent with previous studies. These findings support the use of the SA-BILD as a valid measure of patient-reported damage in SLE.

The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis

While many women with polycystic ovary syndrome (PCOS) are overweight, obese or centrally obese, the effect of excess weight on the outcomes of PCOS is inconsistent. The review aimed to assess the effects of overweight, obesity and central obesity on the reproductive, metabolic and psychological features of PCOS. MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting outcomes according to body mass index categories or body fat distribution. Data were presented as mean difference or risk ratio (95% confidence interval). This review included 30 eligible studies. Overweight or obese women with PCOS had decreased sex hormone-binding globulin (SHBG), increased total testosterone, free androgen index, hirsutism, fasting glucose, fasting insulin, homeostatic model assessment-insulin resistance index and worsened lipid profile. Obesity significantly worsened all metabolic and reproductive outcomes measured except for hirsutism when compared to normal weight women with PCOS. Overweight women had no differences in total testosterone, hirsutism, total-cholesterol and low-density lipoprotein-cholesterol compared to normal weight women and no differences in SHBG and total testosterone compared to obese women. Central obesity was associated with higher fasting insulin levels. These results suggest that prevention and treatment of obesity is important for the management of PCOS.

Thyroid Incidentalomas on Fluorine-18-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography: Incidence, Malignancy Risk, and Comparison of Standardized Uptake Values

Introduction

To determine the incidence of fluorine-18-fluorodeoxyglucose (FDG) avid thyroid incidentalomas detected on positron emission tomography (PET) with integrated computed tomography (CT), and correlate the FDG–PET-CT findings to cytology.

Methods

A total of 942 FDG–PET-CT reports were retrospectively reviewed. Patients with FDG-avid thyroid incidentalomas were further reviewed for correlative cytology.

Results

The incidence of FDG-avid thyroid incidentalomas is 2.2%. Thyroid malignancies were identified in 3 of 6 patients who underwent cytologic correlation, with a positive predictive value of 50% (95% confidence interval, 14%-86%). The mean maximum standardized uptake values of benign and malignant FDG-avid thyroid incidentalomas were 5.6 and 6.6, respectively.

Conclusion

A FDG-avid thyroid incidentaloma may predict underlying malignancy. Cytologic assessment should be considered for FDG-avid thyroid incidentalomas.

Obesity management in women with polycystic ovary syndrome

Obesity and insulin resistance play an important role in initiating or maintaining ill health in polycystic ovary syndrome (PCOS). This implies that treatment that reduces body weight and insulin resistance would alleviate the symptoms of PCOS. Lifestyle modification has been found to be effective in restoring reproductive function in up to 80% of individuals who achieve at least 5% weight loss. However, long-term weight maintenance is a challenge. This article provides a review of reduced glycemic load diets, including low glycemic index, very low carbohydrate, high-protein and high monounsaturated fat diets, on metabolic and reproductive health in PCOS and non-PCOS populations. Dietary trials in non-PCOS women suggest that higher-protein, reduced glycemic load diets were probably more beneficial than the conventional low-fat, high-carbohydrate diet but further studies are required to confirm this in PCOS women. Similarly, the optimal exercise regime for PCOS women remains to be investigated.

Benefits of a self-management program in low-income African-American women with systemic lupus erythematosus: results of a pilot test

Minorities with systemic lupus erythematosus (SLE) are at high risk of poor disease outcomes and may face challenges in effectively self-managing multiple health problems. The Chronic Disease Self-Management Program (CDSMP) is an evidence-based intervention that improves the health of people with chronic illnesses. Although the CDSMP is offered by organizations throughout the United States and many countries around the world, it has not been tested among SLE patients. We pilot tested the benefits of the CDSMP in low-income African American patients with SLE. CDSMP workshops were delivered to 49 African American women with SLE who received medical care at a public lupus clinic in Atlanta, Georgia, US. We compared pre-post CDSMP changes (from baseline to 4 months after the start of the intervention) in health status, self-efficacy and self-management behaviors using self-reported measures. Additionally, we assessed health care utilization changes using electronic administrative records in the 6-month periods before and after the intervention. We observed significant improvements post-intervention in the SF-36 physical health component summary (mean change = 2.4, p = 0.032); self-efficacy (mean change = 0.5, p = 0.035); and several self-management behaviors: cognitive symptoms management (mean change = 0.3, p = 0.036); communication with physicians (mean change = 0.4, p = 0.01); and treatment adherence (mean change = 0.4, p = 0.01). The median number of outpatient visits decreased from 3 to 1 (p < .0001). The CDSMP is a promising intervention for low-income African Americans with SLE. It is an inexpensive program with growing availability around the world that should be further evaluated as a resource to improve patient-centered outcomes and decrease health service utilization among SLE patients.

Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND Polycystic ovary syndrome (PCOS) is closely associated with obesity but the prevalence of obesity varies between published studies. The objective of this research was to describe the prevalence of overweight, obesity and central obesity in women with and without PCOS and to assess the confounding effect of ethnicity, geographic regions and the diagnostic criteria of PCOS on the prevalence. METHODS MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting the prevalence of overweight, obesity or central obesity in women with and without PCOS. Data were presented as prevalence (%) and risk ratio (RR) [95% confidence interval (CI)]. Random-effect models were used to calculate pooled RR. RESULTS This systematic review included 106 studies while the meta-analysis included 35 studies (15129 women). Women with PCOS had increased prevalence of overweight [RR (95% CI): 1.95 (1.52, 2.50)], obesity [2.77 (1.88, 4.10)] and central obesity [1.73 (1.31, 2.30)] compared with women without PCOS. The Caucasian women with PCOS had a greater increase in obesity prevalence than the Asian women with PCOS compared with women without PCOS [10.79 (5.36, 21.70) versus 2.31 (1.33, 4.00), P < 0.001 between subgroups). CONCLUSIONS Women with PCOS had a greater risk of overweight, obesity and central obesity. Although our findings support a positive association between obesity and PCOS, our conclusions are limited by the significant heterogeneity between studies and further studies are now required to determine the source of this heterogeneity. Clinical management of PCOS should include the prevention and management of overweight and obesity.

Developmental immunolocalization of heat shock protein 70 (HSP70) in epithelial cell of rat kidney

During renal development the cells in the medulla are exposed to elevated and variable interstitial osmolality. Heat shock protein 70 (HSP70) is a major molecular chaperone and plays an important role in the protection of cells in the renal medulla from high osmolality. The purpose of this study was to establish the time of immunolocalization and distribution of HSP70 in developing and adult rat kidney. In addition, changes in HSP70 immunolocalization following the infusion of furosemide were investigated. In adult animals, the HSP70 was expressed in the medullary thin ascending limb of Henle's loop (ATL) and inner medullary collecting duct (IMCD). In developing kidney, HSP70 immunoreactivity was first detected in the IMCD of the papillary tip on postnatal day 1. From four to 14 days of age, HSP70 was detected in the ATL after transformation from thick ascending limb, beginning at the papillary tip and ascending to the border between the outer and inner medulla. The immunolocalization of HSP70 in both the ATL and IMCD gradually increased during two weeks. The gradual increase in HSP70 was associated with an increase in its mRNA abundance. However, furosemide infusion resulted in significantly reduced HSP70 immunolocalization in the IMCD and ATL. These data demonstrated that the expression of HSP70 was closely correlated with changes in interstitial osmolality during the development of the kidney. We suggest that HSP70 protects ATL and IMCD cells in the inner medulla from the stress of high osmolality and may be involved in the transformation of the ATL of the long loop of Henle during renal development.

Fabrication and characterization of graphene hydrogel via hydrothermal approach as a scaffold for preliminary study of cell growth

BACKGROUND

Three-dimensional assembly of graphene hydrogel is rapidly attracting the interest of researchers because of its wide range of applications in energy storage, electronics, electrochemistry, and waste water treatment. Information on the use of graphene hydrogel for biological purposes is lacking, so we conducted a preliminary study to determine the suitability of graphene hydrogel as a substrate for cell growth, which could potentially be used as building blocks for biomolecules and tissue engineering applications.

METHODS

A three-dimensional structure of graphene hydrogel was prepared via a simple hydrothermal method using two-dimensional large-area graphene oxide nanosheets as a precursor.

RESULTS

The concentration and lateral size of the graphene oxide nanosheets influenced the structure of the hydrogel. With larger-area graphene oxide nanosheets, the graphene hydrogel could be formed at a lower concentration. X-ray diffraction patterns revealed that the oxide functional groups on the graphene oxide nanosheets were reduced after hydrothermal treatment. The three-dimensional graphene hydrogel matrix was used as a scaffold for proliferation of a MG63 cell line.

CONCLUSION

Guided filopodia protrusions of MG63 on the hydrogel were observed on the third day of cell culture, demonstrating compatibility of the graphene hydrogel structure for bioapplications.

The effect of comprehensive lifestyle intervention or metformin on obesity in young women

BACKGROUND AND AIM

Young women are at high risk of weight gain but few weight management interventions have been investigated in this group. This study aimed to determine the effect of metformin on body weight, body composition, metabolic risk factors and reproductive hormone levels in overweight or obese young women compared to placebo and comprehensive lifestyle intervention.

METHODS AND RESULTS

203 overweight or obese young women (BMI 33.2+/-0.3 kg/m², age 28+/-0.3 years) were randomised to 1500 mg/day metformin (M) plus general lifestyle advice, placebo (P) plus general lifestyle advice or comprehensive lifestyle intervention including structured diet, exercise and behavioural therapy (L) for 12-weeks. At 12-weeks, linear mixed models found that L group had greater weight loss (-4.2+/-0.4 kg) compared to M (-1.0+/-0.4 kg) and P groups (-0.2+/-0.3 kg) (P < 0.0001). Weight loss between M and P groups were not significantly different. Attrition rate was 48% for L, 34% for M and 29% for P (P = 0.08). Intention-to-treat analysis showed that 10% (8/79) of the subjects in P group had gained weight (>3%), compared to 3% (2/65) from M group and none (0/59) from L group (P < 0.001). The L group had the greatest decrease in waist circumference (-5.2+/-0.7 cm) and fat mass (-5.4+/-0.7 kg) compared to the other groups (P < 0.05). No significant time-by-group effects were seen in plasma lipids, SHBG, testosterone, blood pressure, serum folate, serum ferritin and serum vitamin B12.

CONCLUSION

Lifestyle intervention was more effective in reducing body weight and improving body composition compared to metformin among healthy overweight or obese young women.

Long-term effects of a low carbohydrate, low fat or high unsaturated fat diet compared to a no-intervention control

BACKGROUND AND AIM

Very low carbohydrate ad libitum diets have been shown to enhance weight loss without increasing cardiometabolic risk factors but no kilojoule-controlled trials have been conducted relative to no intervention. The aim of this study was to compare the changes in weight and other cardiovascular risk factors in 3 isocaloric energy-restricted diets to no-intervention control after 1 year.

METHODS AND RESULTS

One hundred and thirteen subjects (age 47 ± 10 years, BMI 32 ± 6 kg/m(2) with one additional cardiovascular risk factor) were randomly allocated to one of three isocaloric diets (VLC-very low carbohydrate, 60% fat, 4% carbohydrate, n=30; VLF-very low fat, 10% fat, n = 30; HUF-high unsaturated fat, 30% fat, n = 30) with intensive support for 3 months followed by minimal support for 12 months compared to a control group (no intervention, n = 23). The estimated weight change was -3.0 ± 0.2 kg for VLC, -2.0 ± 0.1 kg for VLF, -3.7 ± 0.01 kg for HUF and 0.8 ± 0.5 kg for controls (P=0.065). After correcting for baseline values, decreases in body weight and diastolic blood pressure in the diet groups (-2.9 ± 5.2) were significantly different to the increase in the control group (0.8 ± 5.0) (P<0.05). No differences in cardiovascular risk factors were observed between the diet groups.

CONCLUSION

Significant cardiometabolic risk factor reduction was observed equally with VLC, VLF and HUF diets after 15 months, compared to an exacerbation of risk factors in the control group. At a modest level of adherence, 3 months of intensive support on these dietary patterns confer an improvement in cardiometabolic profile compared to no dietary intervention after 15 months.

Roasted licorice extracts dampen high glucose-induced mesangial hyperplasia and matrix deposition through blocking Akt activation and TGF-beta signaling

Diabetic nephropathy (DN) characterized as nephrotic syndrome and diffuse glomerulosclerosis can cause renal failure and end-stage kidney disease. Expansion of mesangial matrix around capillaries in the kidney glomeruli is a prominent feature of DN. This study investigated whether licorice extracts inhibited mesangial cell (MC) proliferation and matrix accumulation induced by high glucose (HG). Human renal MC were cultured in media containing 5.5 mM glucose plus 27.5 mM mannitol as an osmotic control or 33 mM glucose for 3 d in the presence of water or ethanol extracts from raw licorice (LW, LE) or roasted licorice (RLW, RLE). Non-polar components including glycyrrhetic acid were elevated during licorice roasting, whereas polar components soluble in water extracts were diminished. Exposure of cells to HG caused significant increases in collagen IV secretion and connective tissue growth factor (CTGF) expression, which was appeased by RLW and RLE at transcriptional levels. The inhibitory potency was high in the order of RLE > or = RLW > or = LE > > LW. Non-polar glycyrrhetic acid but not glycyrrhizin retarded HG-stimulated mesangial matrix deposition through diminishing CTGF expression. In addition, RLW and RLE but not LW modulated membrane type matrix metalloproteinase-1 (MT-1 MMP) expression, MMP-2 activity and tissue inhibitor of MMP-2 (TIMP-2), which facilitated the degradation of mesangial matrix. Furthermore, the augmented expression of CTGF and TIMP-2 in HG-exposed cells was mediated by Akt activation and TGF-beta/Smad signaling through PKCbeta2-responsive signaling pathways. However, HG-down-regulated MT-1 MMP expression was independent of activation of ERK1/2 and Akt when using their inhibitors of DB98059 (ERK1/2) and LY294002 (Akt) alone or in combination. These results demonstrate that extracts from roasted licorice may be highly potent therapeutic agents for the prevention and treatment of mesangial fibrosis and glomerulosclerosis leading to diabetes nephropathy due to longstanding diabetes mellitus.

VIPoma syndrome: challenges in management

Vasoactive intestinal peptide-producing tumour (VIPoma) or Verner-Morrison syndrome is a very rare neuroendocrine tumour. It occurs in less than ten percent of all pancreatic islet cell tumours, and about 70 percent to 80 percent of these tumours originate from the pancreas. Diagnosis is characteristically delayed. The first-line treatment is surgical. It may be curative in forty percent of patients with benign and non-metastatic disease. Palliative surgery is indicated in extensive disease, followed by conventional somatostatin analogue (octreotide) therapy. Somatostatin analogues improve hormone-mediated symptoms, reduce tumour bulk and prevent local and systemic effects. We present a female patient with VIPoma syndrome, which had metastasised to the liver at diagnosis. The patient underwent palliative Whipple procedure and subsequent cytoreductive radiofrequency ablations to her liver metastases. Unfortunately, after symptomatic improvement for three years, her disease progressed. Currently, she is on daily octreotide, achieving partial control of her symptoms.

Assessing the cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary care

AIMS/HYPOTHESIS

This study aims to evaluate the cost-effectiveness of a screening programme for pre-diabetes, which was followed up by treatment with pharmaceutical interventions (acarbose, metformin, orlistat) or lifestyle interventions (diet, exercise, diet and exercise) in order to prevent or slow the onset of diabetes in those at high risk.

METHODS

To approximate the experience of individuals with pre-diabetes in the Australian population, we used a microsimulation approach, following patient progression through diabetes, cardiovascular disease and renal failure. The model compares costs and disability-adjusted life years lived in people identified through an opportunistic screening programme for each intervention compared with a 'do nothing' scenario, which is representative of current practice. It is assumed that the effect of a lifestyle change will decay by 10% per year, while the effect of a pharmaceutical intervention remains constant throughout use.

RESULTS

The most cost-effective intervention options are diet and exercise combined, with a cost-effectiveness ratio of AUD 22,500 per disability-adjusted life year (DALY) averted, and metformin with a cost-effectiveness ratio of AUD 21,500 per DALY averted. The incremental addition of one intervention to the other is not cost-effective.

CONCLUSIONS/INTERPRETATION

Screening for pre-diabetes followed by diet and exercise, or metformin treatment is cost-effective and should be considered for incorporation into current practice. The number of dietitians and exercise physiologists needed to deliver such lifestyle change interventions will need to be increased to appropriately support the intervention.

Psychological effects of prescriptive vs general lifestyle advice for weight loss in young women

This study aimed to investigate the effects of prescriptive lifestyle advice with quantifiable dietary and physical goals compared to general lifestyle advice on weight and psychological outcomes in young women with overweight or obesity. A total of 203 women (body mass index 33.3+/-0.3, age 28+/-0.3 years) received either prescriptive or general lifestyle advice for weight loss over 12 weeks. Linear mixed models found that the prescriptive lifestyle advice group had significantly greater weight loss (4.2+/-0.4 kg vs 0.6+/-0.2 kg, P<0.001) compared to the general lifestyle advice group. However, the prescriptive lifestyle advice group also had greater attrition (48% vs 31%, P<0.05) compared to the general lifestyle advice group. Linear mixed models found that the prescriptive lifestyle advice group had greater improvement in psychological distress (-3.0+/-0.04 vs -1.1+/-0.01, P<0.05) and in self-esteem (3.2+/-0.8 vs -0.04+/-0.04, P<0.001) compared to the general lifestyle advice group. Changes in psychological distress and self-esteem remained significantly different between groups after correcting for weight loss. Food cravings decreased significantly over time without group differences (P<0.001 for time). Weight locus of control remained unchanged in either group (P>0.05). Drop-outs had greater baseline psychological distress (15.1+/-0.7 vs 12.5+/-0.4, P<0.01) and higher food cravings (2.42+/-0.07 vs 2.24+/-0.05, P=0.049) compared to completers. In conclusion, a prescriptive approach is associated with greater weight loss and greater improvements in psychological outcomes in young women compared to general lifestyle advice. However, these quantitative targets should be accompanied with qualitative advice on how they could be met in a variety of circumstances.

Synthesis of flavonoids and their effects on aldose reductase and sorbitol accumulation in streptozotocin-induced diabetic rat tissues

Aldose reductase, the key enzyme of the polyol pathway, and oxidative stress are known to play important roles in the complications of diabetes. A drug with potent inhibition of aldose reductase and oxidative stress, therefore, would be a most promising drug for the prevention of diabetic complications. The purpose of this study was to develop new compounds with these dual-effects through synthesis of chalcone derivatives and by examining the structure-activity relationships on the inhibition of rat lens aldose reductase as well as on antioxidant effects. A series of 35 flavonoid derivatives were synthesized by Winget's condensation, oxidation, and reduction of appropriate acetophenones with appropriate benzaldehydes. The inhibitory activity of these derivatives on rat lens aldose reductase and their antioxidant effects, measured using Cu2+ chelation and radical scavenging activities on 1,1-diphenyl-picrylhydrazyl in-vitro, were evaluated. Their effect on sorbitol accumulation in the red blood cells, lenses and sciatic nerves of streptozotocin-induced diabetic rats was also estimated. Among the new flavonoid derivatives synthesized, those with the 2′,4′-dihydroxyl groups in the A ring such as 2,4,2′,4′-tetrahydroxychalcone (22), 2,2′,4′-trihydroxychalcone (11), 2′,4′-dihydroxy-2,4-dimethylchalcone (21) and 3,4,2′,4′-tetrahydroxychalcone (18) were found to possess the highest rat lens aldose reductase inhibitory activity in-vitro, their IC50 values (concentration of inhibitors giving 50% inhibition of enzyme activity) being 1.6 times 10−7, 3.8 times 10−7, 4.0 times 10−7 and 4.6 times 10−7 M, respectively. All of the chalcones tested except 3, 18, 23 with o-dihydroxy or hydroquinone moiety showed a weak free radical scavenging activity. In the in-vivo experiments, however, compound 18 with o-dihydroxy moiety in the B ring showed the strongest inhibitory activity in the accumulation of sorbitol in the tissues. It also showed the strongest activity in transition metal chelation and free radical scavenging activity. Of the 35 4,2′-dihydroxyl and 2′,4′-dihydroxyl derivatives of flavonoid synthesized, including chalcone, flavone, flavanone, flavonol and dihydrochalcone, some chalcone derivatives synthesized were found to possess aldose reductase inhibition and antioxidant activities in-vitro as well as inhibition in the accumulation of sorbitol in the tissues in-vivo. 3,4,2′,4′-Tetrahydroxychalcone (18, butein) was the most promising compound for the prevention or treatment of diabetic complications.

Dietary effects on fertility treatment and pregnancy outcomes

PURPOSE OF REVIEW

We summarize the dietary modifications that optimize fertility treatment outcomes.

RECENT FINDINGS

Body weight and nutritional status are closely related to reproductive function. However, few studies have investigated the direct effects of dietary modification on fertility treatment outcomes. Research on nutrition in pregnancy suggests that reduction in glycemic load and micronutrient supplementation may improve pregnancy outcomes.

SUMMARY

Body weight and specific dietary factors may affect fertility but evidence regarding dietary effects on fertility treatment outcomes is lacking. Research suggests that diets with a low glycemic load during pregnancy may reduce the risk of gestational diabetes or large-for-gestational-age births after adjusting for body mass index and total energy intake, but the effect of protein modification remains controversial. There is also lack of information on the impact of energy restriction during pregnancy on maternal and infant outcomes. Folate supplementation is recommended for prevention of birth defects but further research is required to determine the optimal dose to reduce the risks of multiple gestations. Further information on the upper limits of caffeine and alcohol intake during pregnancy would also be useful.

QF-PCR-based prenatal detection of aneuploidy in a southeast Asian population

OBJECTIVES

We have investigated the efficacy of using quantitative fluorescent polymerase chain reaction (QF-PCR) for the prenatal recognition of aneuploidy in chromosomes 13, 18, 21, X and Y. A total of 1115 samples, from mainly southeast Asian patients, were analysed and compared in a blind trial to the results previously obtained cytogenetically.

METHODS

A multiplex PCR involving 15 short tandem repeat (STR) sequences was used. The probability of two or more of these markers being informative was calculated, and this required the multiplex PCR to be modified.

RESULTS

The QF-PCR and previous cytogenetic results concurred, except for two products of conception (POC). One of these may be a case of complete uniparental disomy that was not recognized cytogenetically. The other was tetraploid, and as such appeared normal using QF-PCR. A mosaic trisomy 18 was correctly identified. The population sample was of a mainly Chinese, ethnic origin, and the allele frequency, size and heterozygosity appeared more restricted than the population groups analysed hitherto.

CONCLUSION

The QF-PCR methodology is an efficient cost-effective method of screening for major chromosome aneuploidy, and, for certain referral categories, could be used alone. It also appears to be applicable to patients of different ethnic origins.

The use of low-dose prednisone in the management of rheumatoid arthritis

Low doses of prednisone are safe and effective in the management of RA. Yet, some clinicians continue to manage their RA patients with glucocorticoid doses that are too high or avoid them altogether. Glucocorticoids in low doses have proven to be very effective in suppressing the inflammation associated with RA. In addition, there is good evidence that low doses of prednisolone retard bony erosions of RA. Potential side effects of low doses of glucocorticoids can be anticipated and avoided with prudent preventative measures and appropriate management. Therefore, prednisone should be initiated as early as possible in the treatment of RA usually with another DMARD. Treatment of the inflammation in RA should not exceed 10 mg/day and often may need to be given in daily divided doses (5 mg BID). Supplemental daily calcium at 800-1,000 mg/day and vitamin D at 400-800 units/day should always be initiated with treatment. Tapering of prednisone should be done slowly using 1 mg decrements every couple weeks to a month. One should not deem it a failure to hold the patient on the lowest effective dose of prednisone.

Cost-effectiveness of prescribing statins according to pharmaceutical benefits scheme criteria

OBJECTIVES

(i) To analyse how well Pharmaceutical Benefits Scheme (PBS) criteria for prescribing lipid-lowering therapy identify people most at risk of coronary heart disease (CHD); and (ii) to determine the cost-effectiveness of primary prevention therapy with pravastatin according to these criteria in Australia.

DESIGN

(i) Analysis of targeting of CHD risk according to PBS criteria; (ii) cost-effectiveness analysis for pravastatin as primary preventive therapy (40 mg/day), with a 20-year projection from 1999.

PARTICIPANTS

(i) Men and women aged 25-69 years from the 1989 National Heart Foundation Risk Factor Prevalence Survey; (ii) Australian men and women, aged 25-85 years, excluding those with diabetes and existing CHD.

MAIN OUTCOME MEASURES

(i) Proportion eligible for lipid lowering treatment according to PBS criteria within 15-year risk of CHD mortality groups; (ii) average net cost in Australian dollars ($) per year of life saved (YOLS), with 80% uncertainty ranges (UR).

RESULTS

(i) PBS criteria do not adequately identify those most at risk of CHD, as only 61% of Australians (aged 25-69 years) with a greater than 10% 15-year risk of CHD mortality were eligible for treatment; and 11% of those at low risk of CHD mortality (< 2.5% over 15 years) were eligible for treatment. (ii) Cost-effectiveness of treatment according to PBS criteria was estimated at $110,000 (80% UR, $96,000-$150,000) per YOLS for men and $87,000 (80% UR, $80,000-$130,000) per YOLS for women. As an indicator of the likely recurrent annual costs, total first-year treatment costs (excluding the costs of non-compliers) were estimated at $940 million. Assuming compliance of 50%, cost-effectiveness of treatment was markedly improved using 32.5% 15-year risk of CHD mortality as a cut-off, with ratios of $31,000 (80% UR, $27,000-$40,000) per YOLS for men and $39,000 (80% UR, $33,000-$53,000) per YOLS for women. First-year treatment costs of $940 million were the same as treating according to PBS criteria, but absolute health impact in terms of deaths averted and years of life saved was more than doubled.

CONCLUSIONS

While PBS criteria do target patients at risk of CHD, there is room for improvement in identifying those most at risk of CHD, and treatment according to PBS criteria is not likely to be the most cost-effective. For optimal cost-effectiveness, targeting of therapy for primary CHD prevention needs to be based on population-specific, multivariable risk.

Inhibition of prostalglandin E2 production by 2'-hydoxychalcone derivatives and the mechanism of action

The effects of 14 synthetic 2'-hydroxychalcone derivatives on prostaglandin E2 (PGE2) production in rat peritoneal macrophages stimulated by the protein kinase C activator, 12-O-tetradecanoylphorbol 13-acetate (TPA), were examined to clarify the structure-activity relationship. 2',4-Dihydroxy-4'-methoxychalcone (compound 3), 2',4-dihydroxy-6'-methoxychalcone (compound 8) and 2'-hydroxy-4'-methoxychalcone (compound 9) suppressed PGE2 production more potently than the other compounds. The IC50 (50% Inhibitory concentration) value for compounds 3, 8 and 9 was calculated to be 3 microM. The activity of cyclooxygenase (COX)-1 was inhibited slightly by compound 9, but that of COX-2 was not inhibited. At concentrations that inhibited the production of PGE2, compound 9 had no effect on the release of radioactivity from [3H]arachidonic acid-labelled macrophages stimulated by TPA. Western-blot analysis revealed that the induction of COX-2 protein by TPA was inhibited by compound 9 in parallel with the inhibition of PGE2 production. Compounds 3 and 8 had similar effects. These findings suggest that 4'-methoxyl and 6'-methoxyl groups are required for the expression of more potent inhibitory activity against PGE2 production, and that the inhibition of PGE2 production by these 2'-hydroxychalcone derivatives is due to the inhibition of TPA-induced COX-2 protein expression.

Inhibition of prostaglandin E2 production by platycodin D isolated from the root of Platycodon grandiflorum

Platycodin D, isolated from the root of Platycodon grandiflorum A. DC. (Campanulaceae) suppressed prostaglandin E2 production at 10 and 30 microM in rat peritoneal macrophages stimulated by the protein kinase C activator 12-O-tetradecanoylphorbol 13-acetate (TPA). Platycodin D3 and oleanolic acid showed no effect at these concentrations. Western blot analysis revealed that the induction of COX-2 protein by TPA was inhibited by platycodin D in parallel with the inhibition of prostaglandin E2 production. Platycodin D showed no direct effect on COX-1 and COX-2 activities. TPA-induced release of [3H]arachidonic acid from pre-labeled macrophages was also not inhibited by platycodin D.

Cost-effectiveness of screening x-rays at admission to acute rehabilitation after joint replacement surgery: a retrospective chart review

OBJECTIVE

To investigate the cost-effectiveness of performing routine screening x-rays for patients on admission to an acute rehabilitation facility, after hip or knee replacement surgery, by reviewing the overall incidence of abnormal radiographic findings and determining their impact on patient care and outcome.

DESIGN

A retrospective chart review study, in which 592 patients were admitted, after hip or knee replacement surgery, to three acute inpatient rehabilitation facilities under one system.

RESULTS

Eight of 592 admissions revealed abnormal screening x-rays, for an overall incidence of 1.35%. All of the eight abnormal radiologic cases remained medically stable throughout their acute rehabilitation stay. The abnormalities did not alter the patients' medical management or length of stay. One case, which had demonstrated normal admission films, revealed a dislocated hip prosthesis on a follow-up x-ray, which was obtained as a result of new onset hip pain. The patient was subsequently transferred back to the acute care hospital for surgical correction.

CONCLUSIONS

The authors found a relatively low incidence of abnormal admission x-ray findings; furthermore, the detection of abnormal admission films did not alter patient care or outcome. The results suggested that performing routine admission radiologic studies on all patients after joint replacement surgery or hemiarthroplasty may not be a cost-effective screening tool in rehabilitation.

Antioxidant and immunostimulating activities of the fruiting bodies of Paecilomyces japonica, a new type of Cordyceps sp

Cordyceps is negative for its many biological activities and a tonic for restoring vital functions in traditional Chinese medicine. In an effort to evaluate the pharmacological effects, including the antiaging effect of the fruiting bodies of the cultivated Paecilomyces japonica fungus, a new type of Cordyceps sp. was investigated. This investigation was focused on ultimately revealing its biologically active principles, its effects on free-radical scavenging enzymes, lipid peroxidation, as well as its immunological functions. As a result, both water and methanol extracts were found to cause not only significant increases in rat liver cytosolic SOD, catalase, and GSEH-px activities, but also a significant decrease in MDA production in TBA reactant assay in rats. The extracts also showed immunostimulating activity as measured by carbon clearance, weight-loaded forced swimming performances, and immobilizing stress in mice. Using bioassay-guided systematic fractionation of the extracts, two pure compounds were isolated as active principles from low molecular-weight fraction, a protein-bound polysaccharide was isolated that showed a marked increase in the liver enzyme activities, as well as a significant inhibition of lipid peroxidation.

An unusual case of groin discomfort

Groin complications after cardiac catheterizations are common. With the increasing use of mechanical hemostatic devices, cardiologists must be alert to a wide array of potential problems. We report an unusual complication after the use of a closure device.