OPTN/SRTR 2017 Annual Data Report: Heart

In 2017, 3273 heart transplants were performed in the United States. New listings continued to increase, and 3769 new adults were listed for heart transplant in 2017. Over the past decade, posttransplant mortality has declined. The number of new pediatric listings increased over the past decade, as did the number of pediatric heart transplants, although some fluctuation has occurred more recently. New listings for pediatric heart transplants increased from 481 in 2007 to 623 in 2017. The number of pediatric heart transplants performed each year increased from 330 in 2007 to 432 in 2017, slightly fewer than in 2016. Short-term and long-term mortality improved. Among pediatric patients who underwent transplant between 2015-2016, 4.8% had died by 6 months and 6.2% by 1 year.

OPTN/SRTR 2017 Annual Data Report: Liver

Data on adult liver transplants performed in the US in 2017 are notable for (1) continued growth in numbers of new waitlist registrants (11,514) and of transplants performed (8,082); (2) continued increase in the transplant rate (51.5 per 100 waitlist-years); (3) a precipitous decrease in waitlist registrations and transplants for hepatitis C-related indications; (4) reciprocal increases in waitlist registrants and recipients with alcoholic liver disease and with clinical profiles consistent with non-alcoholic fatty liver disease; and (5) continued improvement in graft survival despite changing recipient characteristics such as older age and higher rates of obesity. Variability in transplant rates remained by candidate race, presence of hepatocellular carcinoma, urgency status (status 1A versus model for end-stage liver disease (MELD) score >35), and geography. More than half of all children listed for liver transplant in 2017 were aged younger than 5 years in 2017, and the highest rate of pretransplant mortality persisted for children aged younger than 1 year. Children underwent transplant at higher acuity than the past, as evidenced by higher MELD/pediatric end-stage liver disease scores and listings at status 1A and 1B. Higher acuity at transplant is likely due to lack of access to suitable donor organs, which has been compensated for by persistent trends toward use of partial or split liver grafts and ABO-incompatible grafts. Despite higher illness severity scores at transplant, pediatric graft and patient survival posttransplant have improved over time.

Targeting eotaxin-1 and CCR3 receptor alleviates enteric neuropathy and colonic dysfunction in TNBS-induced colitis in guinea pigs

BACKGROUND

The accumulation of eosinophils is mediated by the chemokine receptor-3 (CCR3)-eotaxin axis. Increased expression of eotaxin and its receptor is associated with inflammatory bowel disease (IBD). Activation of eosinophils causes the release of cationic proteins that are neurotoxic such as eosinophil-derived neurotoxin (EDN). Damage to enteric neurons alters neurally controlled functions of the gut correlated with intestinal inflammation. We hypothesized that inhibition of the CCR3-eotaxin axis will prevent inflammation-induced functional changes to the gastrointestinal tract.

METHODS

Hartley guinea pigs were administered with trinitrobenzene sulfonate (TNBS; 30 mg/kg in 30% ethanol) intrarectally to induce colitis. A CCR3 receptor antagonist (SB 328437 [SB3]) was injected intraperitoneally 1 hour postinduction of colitis. Animals were euthanized 7 days post-treatment and colon tissues were collected for ex vivo studies. The EDN-positive eosinophils in the colon, indicating eosinophil activation, were quantified by immunohistochemistry. Effects of SB3 treatment on gross morphological damage, enteric neuropathy, and colonic dysmotility were determined by histology, immunohistochemistry, and organ bath experiments.

KEY RESULTS

The number of EDN-positive eosinophils was significantly increased in the lamina propria in close proximity to myenteric ganglia in inflamed colon. The TNBS-induced inflammation caused significant damage to colonic architecture and inhibition of colonic motility. Treatment with SB3 antagonist attenuated inflammation-associated morphological damage in the colon, reduced infiltration of EDN-positive eosinophils and restored colonic motility to levels comparable to control and sham-treated guinea pigs.

CONCLUSION & INFERENCES

This is the first study demonstrating that inhibition of CCR3-eotaxin axis alleviates enteric neuropathy and restores functional changes in the gut associated with TNBS-induced colitis.

Measuring and monitoring equity in access to deceased donor kidney transplantation

The Organ Procurement and Transplantation Network monitors progress toward strategic goals such as increasing the number of transplants and improving waitlisted patient, living donor, and transplant recipient outcomes. However, a methodology for assessing system performance in providing equity in access to transplants was lacking. We present a novel approach for quantifying the degree of disparity in access to deceased donor kidney transplants among waitlisted patients and determine which factors are most associated with disparities. A Poisson rate regression model was built for each of 29 quarterly, period-prevalent cohorts (January 1, 2010-March 31, 2017; 5 years pre-kidney allocation system [KAS], 2 years post-KAS) of active kidney waiting list registrations. Inequity was quantified as the outlier-robust standard deviation (SD_w ) of predicted transplant rates (log scale) among registrations, after "discounting" for intentional, policy-induced disparities (eg, pediatric priority) by holding such factors constant. The overall SD_w declined by 40% after KAS implementation, suggesting substantially increased equity. Risk-adjusted, factor-specific disparities were measured with the SD_w after holding all other factors constant. Disparities associated with calculated panel-reactive antibodies decreased sharply. Donor service area was the factor most associated with access disparities post-KAS. This methodology will help the transplant community evaluate tradeoffs between equity and utility-centric goals when considering new policies and help monitor equity in access as policies change.

Long-term safety of adalimumab in clinical trials in adult patients with Crohn's disease or ulcerative colitis

BACKGROUND

Adalimumab is used to treat moderate to severe Crohn's disease (CD) and ulcerative colitis (UC) when conventional therapies fail.

AIM

To update long-term adalimumab safety from CD and UC trials; the previous report was CD only, 3160 patients/3402 patient-years (PYs).

METHODS

Treatment-emergent adverse events (AEs; first dose to 70 days after last dose/December 31, 2015) in adults in phase 2/3 and 3/3b trials and open-label extensions were coded using Medical Dictionary for Regulatory Activities (MedDRA-v18.1). Rates were assessed as events/100 (E/100 PYs).

RESULTS

The database (16 trials; CD, N = 3606; UC, N = 1739) represented 4145 and 3397 PYs of exposure, respectively. For CD, incidences of any AEs with adalimumab were 60.8%-65.1%, depending on dose, and 71.5% with placebo; for UC, the incidences were 53.5%-54.8% and 56.1%, respectively. Rates of any AEs (CD, 605 E/100 PYs; UC, 361 E/100 PYs), serious AEs (CD, 36.1 E/100 PYs; UC, 18.9 E/100 PYs), and malignancies (CD, 1.2 E/100 PYs; UC, 1.0 E/100 PYs) were similar between current and prior analyses. Apparent rate of opportunistic infections was lowered to 0.3 and 0.2 E/100 PYs for CD and UC, respectively, by recent MedDRA changes excluding oral candidiasis and tuberculosis. Standardised incidence ratios for malignancies were similar to the general population (CD, 1.45 [95% CI, 0.90-2.22]; UC, 1.36 [95% CI, 0.84-2.07]). Demyelinating disorders were uncommon (CD, 0.1 E/100 PYs; UC, <0.1 E/100 PYs).

CONCLUSIONS

Patients with moderately to severely active Crohn's disease or ulcerative colitis continued to experience acceptable safety with adalimumab, without new safety signals.

Effects of concomitant immunomodulators on the pharmacokinetics, efficacy and safety of adalimumab in patients with Crohn's disease or ulcerative colitis who had failed conventional therapy

BACKGROUND

Adalimumab is approved for use in patients with moderate to severe Crohn's disease (CD) or ulcerative colitis (UC) who have not achieved disease control with conventional therapies including corticosteroids and/or immunomodulators (IMM).

AIM

To analyse six studies that examined efficacy, pharmacokinetics and safety of combination IMM/adalimumab therapy, compared with adalimumab monotherapy in patients with inadequate disease control on conventional therapy.

METHODS

Patients with moderate to severe CD or UC from randomised, double-blind, placebo-controlled trials were analysed. Adalimumab was added to background therapy; patients were categorised as receiving adalimumab monotherapy (CD induction, n = 245, maintenance, n = 185; UC induction, n = 213, maintenance, n = 157) or combination therapy (CD induction, n = 139, maintenance, n = 139; UC induction, n = 140, maintenance, n = 100) according to baseline immunomodulator use. Efficacy was reported for the intent-to-treat populations from each study, with remission defined as CD activity index <150 for CD and Mayo score ≤2 with no subscore >1 for UC. Safety was assessed via adverse events.

RESULTS

The proportions of patients achieving remission were similar for adalimumab monotherapy and immunomodulator combination therapy in all studies. Median adalimumab concentrations at week 4 or 8 were numerically but not significantly higher with adalimumab combination therapy vs. monotherapy in the CD and UC studies respectively. Incidence and rate of adverse events was similar for adalimumab monotherapy and combination therapy.

CONCLUSIONS

Post hoc analysis of six randomised, controlled trials demonstrated no efficacy benefits with immunomodulator/adalimumab combination therapy, compared with adalimumab monotherapy in CD and UC patients with inadequate disease control on conventional therapy; the safety of the two treatment approaches was comparable.

Randomised clinical study: discrepancies between patient-reported outcomes and endoscopic appearance in moderate to severe ulcerative colitis

BACKGROUND

Associations between patient-reported outcomes and mucosal healing have not been established in ulcerative colitis (UC).

AIM

To evaluate relationships of rectal bleeding and stool frequency with mucosal healing and quality of life (QoL) in patients with UC in two Phase 3 studies (ULTRA 1 and 2).

METHODS

Associations of patient-reported rectal bleeding and stool frequency subscores with mucosal healing (Mayo endoscopy subscore = 0 or 0/1) and QoL [inflammatory bowel disease questionnaire (IBDQ)] were assessed in adalimumab-randomised patients (160/80 mg at Weeks 0/2 followed by 40 mg biweekly or weekly) at Weeks 8 (n = 433) and 52 (n = 299), and in patients with mucosal healing [endoscopy subscore = 0 (n = 17); 0/1 (n = 52)] at Weeks 8 and 52.

RESULTS

At Week 8, the positive predictive values (PPVs) of rectal bleeding subscore = 0, stool frequency subscore = 0 or both scores = 0 for endoscopy subscore = 0/1 were 69%, 84% and 90% respectively; all proportions increased at Week 52. Equivalent PPVs for these subscores in patients with endoscopy subscore = 0 were 26%, 37% and 46% respectively. Among patients with endoscopy subscore = 0 at Week 8, 87% reported no rectal bleeding, while only 29% reported normal stool frequency; these proportions had increased to 94% and 41% respectively, at Week 52. Among patients with mucosal healing, IBDQ scores trended highest for patients with both rectal bleeding and stool frequency subscores = 0.

CONCLUSIONS

Absence of rectal bleeding and normal stool frequency are often predictive of mucosal healing and QoL, but complete normalisation of stool frequency is encountered rarely in patients with mucosal healing.

Escalation to weekly dosing recaptures response in adalimumab-treated patients with moderately to severely active ulcerative colitis

BACKGROUND

Patients with moderately to severely active ulcerative colitis occasionally do not respond to or lose initial response to maintenance dosing of anti-TNF therapy.

AIM

To report the efficacy of escalation from every other week (EOW) to weekly adalimumab dosing in patients from the clinical trial ULTRA 2 (NCT00408629), by week 8 response (i.e. response after adalimumab induction therapy).

METHODS

Week 52 remission, response, and mucosal healing rates were assessed in ULTRA 2 adalimumab-randomised patients who escalated to weekly dosing. Patients were stratified by week 8 response per partial Mayo score. Kaplan-Meier and logistic regression analyses estimated time to weekly dosing and defined predictors of escalation to weekly dosing, respectively. Adverse events were reported for patients receiving open-label adalimumab.

RESULTS

The rate of escalation to weekly dosing was 16.3% (20/123) for week 8 responders and 38.4% (48/125) for week 8 nonresponders. Week 52 remission, response and mucosal healing rates with weekly dosing were 20%, 45%, and 45% for week 8 responders and 2.1%, 25% and 29.2% for nonresponders, respectively (NRI). The median time to weekly dosing was 288 days for week 8 nonresponders and not estimable for responders. Prior anti-TNF use was a significant predictor of escalation to weekly dosing. Treatment-emergent adverse event rates were similar for patients receiving open-label EOW or weekly adalimumab.

CONCLUSIONS

Escalation to weekly adalimumab dosing demonstrated clinical benefits for patients who lost response to therapy and may be beneficial for patients not initially responding to induction therapy. No new safety risks were identified with weekly dosing.

Adalimumab maintains remission of Crohn's disease after up to 4 years of treatment: data from CHARM and ADHERE

BACKGROUND

Therapies that maintain remission for patients with Crohn's disease are essential. Stable remission rates have been demonstrated for up to 2 years in adalimumab-treated patients with moderately to severely active Crohn's disease enrolled in the CHARM and ADHERE clinical trials.

AIM

To present the long-term efficacy and safety of adalimumab therapy through 4 years of treatment.

METHODS

Remission (CDAI <150), response (CR-100) and corticosteroid-free remission over 4 years, and maintenance of these endpoints beyond 1 year were assessed in CHARM early responders randomised to adalimumab. Corticosteroid-free remission was also assessed in all adalimumab-randomised patients using corticosteroids at baseline. Fistula healing was assessed in adalimumab-randomised patients with fistula at baseline. As observed, last observation carried forward and a hybrid nonresponder imputation analysis for year 4 (hNRI) were used to report efficacy. Adverse events were reported for any patient receiving at least one dose of adalimumab.

RESULTS

Of 329 early responders randomised to adalimumab induction therapy, at least 30% achieved remission (99/329) or CR-100 (116/329) at year 4 of treatment (hNRI). The majority of patients (54%) with remission at year 1 maintained this endpoint at year 4 (hNRI). At year 4, 16% of patients taking corticosteroids at baseline were in corticosteroid-free remission and 24% of patients with fistulae at baseline had healed fistulae. The incidence rates of adverse events remained stable over time.

CONCLUSIONS

Prolonged adalimumab therapy maintained clinical remission and response in patients with moderately to severely active Crohn's disease for up to 4 years. No increased risk of adverse events or new safety signals were identified with long-term maintenance therapy. (clinicaltrials.gov number: NCT00077779).

Physical exercise during pregnancy improves object recognition memory in adult offspring

Exercising during pregnancy has been shown to improve spatial learning and short-term memory, as well as increase brain-derived neurotrophic factor mRNA levels and hippocampal cell survival in juvenile offspring. However, it remains unknown if these effects endure into adulthood. In addition, few studies have considered how maternal exercise can impact cognitive functions that do not rely on the hippocampus. To address these issues, the present study tested the effects of maternal exercise during pregnancy on object recognition memory, which relies on the perirhinal cortex (PER), in adult offspring. Pregnant rats were given access to a running wheel throughout gestation and the adult male offspring were subsequently tested in an object recognition memory task at three different time points, each spaced 2-weeks apart, beginning at 60 days of age. At each time point, offspring from exercising mothers were able to successfully discriminate between novel and familiar objects in that they spent more time exploring the novel object than the familiar object. The offspring of non-exercising mothers were not able to successfully discriminate between objects and spent an equal amount of time with both objects. A subset of rats was euthanized 1h after the final object recognition test to assess c-FOS expression in the PER. The offspring of exercising mothers had more c-FOS expression in the PER than the offspring of non-exercising mothers. By comparison, c-FOS levels in the adjacent auditory cortex did not differ between groups. These results indicate that maternal exercise during pregnancy can improve object recognition memory in adult male offspring and increase c-FOS expression in the PER; suggesting that exercise during the gestational period may enhance brain function of the offspring.

Association of baseline C-reactive protein and prior anti-tumor necrosis factor therapy with need for weekly dosing during maintenance therapy with adalimumab in patients with moderate to severe Crohn's disease

OBJECTIVE

A post hoc analysis of data from the adalimumab Crohn's disease (CD) maintenance trial (CHARM, NCT00077779), examining the relationship between adalimumab dosing and maintenance of remission and response in subgroups stratified by previous anti-TNF use and baseline CRP.

METHODS

All patients received open-label induction (adalimumab: 80 mg, week [wk] 0; 40 mg, wk 2). At wk 4, all patients were randomized to double-blind maintenance adalimumab (40 mg weekly or every other week [eow]) or placebo for 52 weeks. In this analysis, clinical remission (CDAI <150) and clinical response (CR-100) at wk 26 and wk 56 by baseline CRP (high: ≥ 10 mg/L, or low: <10 mg/L) and prior anti-TNF use were determined for patients with CR-70 at wk 4.

RESULTS

Of 498 patients in this analysis, 260 (52.2%) were anti-TNF-naïve. For anti-TNF-naïve patients, the wk 56 remission rates in the adalimumab groups were significantly greater than placebo (P < 0.05) for both high and low CRP cohorts, with no statistically significant differences between remission rates with eow and weekly dosing within each CRP cohort (high: 52.8% eow, 53.5% weekly; low: 34.7% eow, 41.9% weekly). For anti-TNF-exposed patients, wk 56 remission rates were higher than placebo with both eow and weekly dosing within each cohort; weekly dosing in the high CRP cohort and eow dosing in the low CRP cohort achieved statistical significance (P < 0.05). In the high CRP cohort, remission rate with weekly dosing (46.9%) was statistically significantly greater compared with eow dosing (22.5%). There were no significant differences between eow (23.1%) and weekly (37.0%) dosing in the low CRP group. For all subgroups, clinical remission (wk 26) and clinical response (wk 26 and wk 56) patterns were similar to those observed for wk 56 remission.

CONCLUSIONS

These subgroup analyses suggest that in patients with moderately to severely active CD, weekly dosing may be most effective in the anti-TNF-experienced patients with elevated CRP at baseline.

Subgroup analysis of the placebo-controlled CHARM trial: increased remission rates through 3 years for adalimumab-treated patients with early Crohn's disease

BACKGROUND AND AIMS

We examined the impact of disease duration on clinical outcomes and safety in a post hoc analysis of a remission maintenance trial with adalimumab in patients with moderate to severe CD.

METHODS

Patients in the CHARM trial were divided into 3 disease duration categories: <2 (n=93), 2 to <5 (n=148), and ≥5 years (n=536). Clinical remission and response rates at weeks 26 and 56 were compared between adalimumab and placebo subgroups, and assessed through 3 years of adalimumab treatment in the ADHERE follow-on trial. Logistic regression assessed the effect of disease duration and other factors on remission and safety.

RESULTS

At week 56, clinical remission rates were significantly greater for adalimumab-treated versus placebo-treated patients in all 3 duration subgroups (19% versus 43% for <2 years; P=0.024; 13% versus 30% for 2 to <5 years; P=0.028; 8% versus 28% for ≥5 years, P<0.001). Logistic regression identified shorter duration as a significant predictor for higher remission rate in adalimumab-treated patients. Patients with disease duration <2 years maintained higher remission rates than patients with longer disease duration through 3 years of treatment. The incidence of serious adverse events in adalimumab-treated patients was lowest with disease duration <2 years.

CONCLUSIONS

Adalimumab was superior to placebo for maintaining clinical remission in patients with moderately to severely active CD after 1 year of treatment regardless of disease duration. Clinical remission rates through 3 years of treatment were highest in the shortest disease duration subgroup in adalimumab-treated patients, with a trend to fewer side effects.

One-year maintenance outcomes among patients with moderately-to-severely active ulcerative colitis who responded to induction therapy with adalimumab: subgroup analyses from ULTRA 2

BACKGROUND

Patients with moderately-to-severely active ulcerative colitis (UC) are unlikely to continue anti-TNF therapy in the absence of early therapeutic response.

AIM

To assess week 52 efficacy, safety and benefit/risk balance of adalimumab treatment in patients with moderately-to-severely active UC failing conventional therapy who achieved clinical response at week 8 in the 52-week ULTRA 2 trial.

METHODS

Patients randomised to adalimumab (160/80 mg, week 0/2; 40 mg, every other week thereafter) in ULTRA 2 who achieved clinical response at week 8 per partial Mayo score (Mayo score without endoscopy subscore) were assessed for week 52 clinical remission, clinical response, mucosal healing, steroid-free remission and steroid discontinuation rates, overall and by prior anti-TNF use. Benefit/risk balance for the overall ITT population (regardless of week 8 responder status) was assessed using 'net efficacy adjusted for risk' (NEAR) odds ratios. Safety was assessed using adverse event rates.

RESULTS

Of 248 adalimumab-treated patients, 123 (49.6%) achieved clinical response at week 8. Of these, 30.9%, 49.6%, and 43.1% achieved clinical remission, clinical response, and mucosal healing, respectively, at week 52. Of the week 8 responders using corticosteroids at baseline (N = 90), 21.1% achieved steroid-free remission and 37.8% were steroid-free at week 52. NEAR odds ratios indicated a positive benefit/risk balance for achievement of week 8 and week 52 response or remission without serious adverse events or serious infections. No safety concerns were identified.

CONCLUSIONS

Adalimumab treatment was associated with a positive benefit/risk balance in the overall population of patients with moderately-to-severely active ulcerative colitis in ULTRA 2; early response was predictive of a positive outcome at 1 year (NCT00408629).

Spread of cochlear excitation during stimulation with pulsed infrared radiation: inferior colliculus measurements

Infrared neural stimulation (INS) has received considerable attention over the last few years. It provides an alternative method to artificially stimulate neurons without electrical current or the introduction of exogenous chromophores. One of the primary benefits of INS could be the improved spatial selectivity when compared with electrical stimulation. In the present study, we have evaluated the spatial selectivity of INS in the acutely damaged cochlea of guinea pigs and compared it to stimulation with acoustic tone pips in normal-hearing animals. The radiation was delivered via a 200 µm diameter optical fiber, which was inserted through a cochleostomy into the scala tympani of the basal cochlear turn. The stimulated section along the cochlear spiral ganglion was estimated from the neural responses recorded from the central nucleus of the inferior colliculus (ICC). ICC responses were recorded in response to cochlear INS using a multichannel penetrating electrode array. Spatial tuning curves (STCs) were constructed from the responses. For INS, approximately 55% of the activation profiles showed a single maximum, ∼22% had two maxima and ∼13% had multiple maxima. The remaining 10% of the profiles occurred at the limits of the electrode array and could not be classified. The majority of ICC STCs indicated that the spread of activation evoked by optical stimuli is comparable to that produced by acoustic tone pips.

Adalimumab sustains steroid-free remission after 3 years of therapy for Crohn's disease

BACKGROUND

Treatments that achieve sustainable steroid-free clinical remission in Crohn's disease are needed; however, long-term steroid-sparing efficacy data are limited.

AIM

To evaluate steroid-sparing efficacy and the impact of steroid discontinuation on adverse events during treatment of Crohn's disease with adalimumab in the phase III randomised, double-blind 1-year CHARM trial and for an additional 2 years in its open-label extension ADHERE.

METHODS

Steroid-free remission and response and steroid-sparing (≥50% steroid dose reduction) remission rates were evaluated over 3 years in patients who were taking corticosteroids at CHARM baseline.

RESULTS

Of 778 patients randomised in CHARM (including those who did not achieve clinical response to open-label induction therapy), 313 patients (40%) were on corticosteroids at baseline. In the 206 patients randomised to adalimumab, rates of steroid-free remission at 1 year and 3 years were 26% and 23% respectively; corresponding rates were 29% and 25% for steroid-sparing remission and 32% and 28% for steroid-free response. Although the incidence of serious infections with adalimumab treatment during CHARM was higher in patients taking steroids at baseline than those who were not, the rates of overall adverse events, serious infections and opportunistic infections were lower in patients who were able to discontinue corticosteroids than those who remained on steroids.

CONCLUSION

Adalimumab therapy resulted in modest but clinically meaningful rates of steroid-free remission, sustained over 3 years of treatment, in a heavily pretreated population of patients with Crohn's disease receiving steroids at the start of therapy (http://www.clinicaltrials.gov number: NCT00077779).

Adalimumab sustains clinical remission and overall clinical benefit after 2 years of therapy for Crohn's disease

BACKGROUND

In the randomized, double-blind, placebo-controlled CHARM trial, adalimumab was more effective than placebo in maintaining clinical remission for patients with moderate-to-severe Crohn's disease (CD) through 56 weeks.

AIM

To substantiate the long-term safety and clinical benefits of adalimumab through 2 years of therapy in CHARM and its open-label extension (ADHERE).

METHODS

Patients entering ADHERE on blinded therapy received adalimumab 40 mg every other week (eow). Patients who had already moved to open-label adalimumab eow or weekly in CHARM continued their regimens. Data were analysed by originally randomized treatment group at CHARM baseline (adalimumab 40 mg eow, adalimumab 40 mg weekly, or placebo), regardless of whether patients entered ADHERE or received open-label adalimumab (eow or weekly).

RESULTS

After up to 2 years of therapy, 37.6%, 41.9% and 49.8% of patients originally randomized to placebo, adalimumab eow and adalimumab weekly, respectively, were in clinical remission. All groups experienced sustained improvements on the Inflammatory Bowel Disease Questionnaire. Decreasing hazard rates for both all-cause and CD-related hospitalizations were observed over time. Over a 2-year period, the rates of serious adverse events and malignancies (33.3 and 1.1 events/100-patient-years respectively) were similar to those observed during the overall adalimumab CD clinical development programme.

CONCLUSIONS

Adalimumab demonstrated sustained maintenance of clinical remission, improvements in quality of life and reductions in hospitalization during long-term treatment for CD, with no new safety concerns identified.

Does odour cross contamination alter olfactory thresholds in certain odours?

OBJECTIVES

To determine if 1) there is cross contamination between odours tested on thresholds achieved, 2) a delay period is necessary between testing different odours.

METHODS

Thirty-five subjects underwent threshold testing with phenethyl alcohol (PEA), ethylmercaptan (MER), acetic acid (ACE), and eucalyptol (EUC) using serial logarithmic dilutions. On separate occasions subjects were exposed to high concentrations of PEA, ACE and EUC in random order for two minutes, and thresholds for all four odours re-tested. Pre- and post-high concentration odour thresholds were compared.

RESULTS

Exposure to high concentrations of PEA, ACE and EUC does not alter olfactory thresholds by more than 10-2 for the other odours except in specific circumstances with ACE and EUV.

CONCLUSIONS

There is limited cross contamination with ACE and EUC, which is avoided by specifying presentation order as: PEA, MER, ACE, EUC. Odours PEA, MER, ACE and EUC are recommended for olfactory testing.

What is the short term effect of perfumes on olfactory thresholds?

OBJECTIVES

Body sprays and perfumes are commonly worn by patients attending ENT out-patients clinics. Their effect on performance in olfactory testing is unknown. The aim of this study was to determine whether olfactory thresholds are altered by the presence of such fragrances.

MATERIALS AND METHODS

One hundred and sixty healthy volunteers, aged 18 to 65 years, underwent olfactory thresholds testing. Each was then exposed to one of four strong perfumes, applied in a facemask for two minutes, and the thresholds were retested.

RESULTS AND ANALYSIS

All olfactory thresholds worsened after being exposed to the strong perfumes of Lynx and Impulse body sprays, with the strongest effect being on olfactory detection of phenylethyl alcohol (p<0.001).

CONCLUSIONS

Strong perfumes can have a negative effect on olfactory thresholds.

SIGNIFICANCE

Patients attending olfactory threshold testing need to be advised not to wear body sprays or perfumes.

Shot noise in the current of a surface acoustic-wave-driven single-electron pump

We have measured the noise at approximately 1.6 MHz in the current produced by a single-electron pump that uses an approximately 2.7 GHz surface acoustic wave (SAW). The current can be varied by altering the voltage applied to surface gates. Over the range of gate voltage where the current is close to the quantized value corresponding to one electron being transported per cycle of the SAW, the noise in the current is dominated by shot noise, whereas away from this range the noise mostly arises from switching the charge states of electron traps in the material. By combining measurements of the shot noise and the current, we determined how the error rates--the probabilities of transporting zero or two electrons in a cycle--vary with gate voltage when the current is close to the quantized value. The results obtained suggest that these two probabilities are controlled by closely linked mechanisms.

Treatment of olfactory dysfunction, II: studies with minocycline

OBJECTIVES/HYPOTHESIS

The treatment of anosmia has changed minimally since the early 1970s, despite dramatic advances in the understanding of the molecular biology of olfaction. Recent studies from the authors' laboratory have suggested that most common causes of clinical olfactory dysfunction, including rhinosinusitis, appear to be associated with increased apoptotic death of olfactory sensory neurons. This appears to result in a decline in the number of functioning mature olfactory sensory neurons, despite the capacity of the olfactory epithelium for regeneration. The current study evaluated the ability of the antibiotic minocycline to inhibit olfactory sensory neuron apoptosis. This drug is known to inhibit apoptosis separate from its anti-infective properties. Olfactory sensory neuron apoptosis was triggered by surgical deafferentation ("bulbectomy"), the standard experimental model. Earlier studies have indicated that bulbectomy and sinusitis invoke similar proteolytic enzyme cascades in olfactory sensory neurons.

STUDY DESIGN

Histological analysis of animal olfactory tissue.

METHODS

Mice underwent unilateral olfactory bulbectomy to induce apoptotic olfactory sensory neuron death, with and without 45 mg/kg intraperitoneal minocycline given 12 hours before surgery and every 12 hours until death. Mice were killed at 2 and 4 days after bulbectomy and assessed for activation of capsase-3 and olfactory sensory neuron survival by immunohistochemical analysis.

RESULTS

Minocycline resulted in partial suppression of cell death at 2 days after surgery when compared with untreated animals.

CONCLUSION

Minocycline inhibits olfactory sensory neuron death in the face of a potent pro-apoptotic stimulus. This drug is well tolerated and is currently undergoing human trials for the management of a variety of neurological disorders associated with apoptosis. The current results suggest that minocycline may be efficacious in the management of peripheral olfactory loss as well.

Pathology of the Olfactory Epithelium: Smoking and Ethanol Exposure

OBJECTIVE

To investigate the effects of tobacco smoke on the olfactory epithelium. Cigarette smoking has been associated with hyposmia; however, the pathophysiology is poorly understood. The sense of smell is mediated by olfactory sensory neurons (OSNs) exposed to the nasal airway, rendering them vulnerable to environmental injury and death. As a consequence, a baseline level of apoptotic OSN death has been demonstrated even in the absence of obvious disease. Dead OSNs are replaced by the mitosis and maturation of progenitors to maintain sufficient numbers of neurons into adult life. Disruption of this balance has been suggested as a common cause for clinical smell loss. This current study will evaluate the effects of tobacco smoke on the olfactory mucosa, with emphasis on changes in the degree of OSN apoptosis.

STUDY DESIGN

A rat model was used to assess the olfactory epithelium after exposure to tobacco smoke.

METHODS

Rats were exposed to tobacco smoke alone (for 12 weeks), smoke plus dietary ethanol (for the final 5 weeks), or to neither (control). Immunohistochemical analysis of the olfactory epithelium was performed using an antibody to the active form of caspase-3. Positive staining for this form of the caspase-3 enzyme indicates a cell undergoing apoptotic proteolysis.

RESULTS

Control rats demonstrated a low baseline level of caspase-3 activity in the olfactory epithelium. In contrast, tobacco smoke exposure triggered a dramatic increase in the degree of OSN apoptosis that affected all stages of the neuronal lineage.

CONCLUSIONS

These results support the following hypothesis: smell loss in smokers is triggered by increased OSN death, which eventually overwhelms the regenerative capacity of the epithelium.

Sleep problems in children with an intellectual disability: parental perceptions of sleep problems, and views of treatment effectiveness

BACKGROUND

Sleep problems are common in children with an intellectual disability (ID), often lasting for many years. Many parents do not perceive their child to have a sleep problem, do not believe treatment is possible and do not seek treatment. This paper examined prevalence and duration of sleep problems in children with an ID and considered parental perceptions of sleep problems and views towards treatment.

METHOD

The paper reports on two studies (n = 149 and 243 respectively) of children between 3 and 18 years, with a range of disabilities. Parents in each study completed a questionnaire about their child's sleep problems, and the type and effectiveness of any treatment used to address their child's sleep problems.

RESULTS

Prevalence rates ranged between 25.5% and 36.2% for sleep problems with an average duration of between 6 and 9 years. Around half of parents had sought treatment for their child's sleep problem in Study 1, while 76% had done so in Study 2. Parental ratings regarding treatment effectiveness were higher in Study 1 than in Study 2. Contrary to expectations, behavioural treatment was not rated as significantly more effective than other treatments in either study.

CONCLUSIONS

While sleep problems are common and chronic in children with an ID, parents may not recognize a sleep problem as present, often do not seek treatment for their child's sleep problems, and treatment advice and effectiveness is very variable. Thus, further research and parent and professional education regarding the identification and treatment of sleep problems in these children is required.

Sleep problems in children with an intellectual disability: parental perceptions of sleep problems, and views of treatment effectiveness

BACKGROUND

Sleep problems are common in children with an intellectual disability (ID), often lasting for many years. Many parents do not perceive their child to have a sleep problem, do not believe treatment is possible and do not seek treatment. This paper examined prevalence and duration of sleep problems in children with an ID and considered parental perceptions of sleep problems and views towards treatment.

METHOD

The paper reports on two studies (n = 149 and 243 respectively) of children between 3 and 18 years, with a range of disabilities. Parents in each study completed a questionnaire about their child's sleep problems, and the type and effectiveness of any treatment used to address their child's sleep problems.

RESULTS

Prevalence rates ranged between 25.5% and 36.2% for sleep problems with an average duration of between 6 and 9 years. Around half of parents had sought treatment for their child's sleep problem in Study 1, while 76% had done so in Study 2. Parental ratings regarding treatment effectiveness were higher in Study 1 than in Study 2. Contrary to expectations, behavioural treatment was not rated as significantly more effective than other treatments in either study.

CONCLUSIONS

While sleep problems are common and chronic in children with an ID, parents may not recognize a sleep problem as present, often do not seek treatment for their child's sleep problems, and treatment advice and effectiveness is very variable. Thus, further research and parent and professional education regarding the identification and treatment of sleep problems in these children is required.

Pathology of the Olfactory Mucosa: Implications for the Treatment of Olfactory Dysfunction

OBJECTIVE

The pathology of the olfactory mucosa is poorly understood; however, most cases of hyposmia and anosmia appear to be associated with a decline in the number of functioning mature olfactory sensory neurons (OSNs). Under normal conditions, OSNs undergo apoptotic cell death at a baseline rate likely secondary to their exposed location in the nose. Regeneration of mature OSNs from precursors in the epithelium allows the animal to maintain an adequate number of neurons necessary for olfactory sensation. In many cases of olfactory dysfunction, this balance is apparently disturbed, with a net loss of OSNs. The current study will examine normal and diseased olfactory tissue for the presence of data demonstrating that the preferred mechanism of OSN cell death is apoptotic in both health and disease. The potential therapeutic implications will be discussed.

STUDY DESIGN

Histologic analysis of human and animal olfactory tissue.

METHODS

Normal and diseased human and animal olfactory mucosa were assessed for immunohistochemical evidence of apoptosis.

RESULTS

Increased activity of the apoptotic effector enzyme caspase-3 was demonstrated in diseased olfactory mucosa in comparison with normal controls.

CONCLUSION

These results indicate that a common pathway may mediate OSN cell death from a diverse set of pathologic insults including aging, trauma, and sinusitis. Interference with this pathway of cell death is currently the subject of intense pharmacotherapeutic research for the management of stroke and meningitis. These drugs may ultimately prove useful in the treatment of clinical olfactory dysfunction.

Screening for diabetes in general practice: cross sectional population study

OBJECTIVE

To assess the policy proposed by the American Diabetes Association of universal screening in general practice of all patients aged over 45 years for diabetes.

DESIGN

Cross sectional population study.

SETTING

Local general practice in the United Kingdom.

PARTICIPANTS

All patients aged over 45 not known to have diabetes.

MAIN OUTCOME MEASURES

Prevalence of diabetes in the screened population, cardiovascular risk profile of patients diagnosed as having diabetes after screening.

RESULTS

Of 2481 patients aged over 45 and not known to have diabetes, 876 attended for screening. There were no significant demographic differences between the screened and unscreened patients. Prevalence of diabetes in patients with age as a sole risk factor was 0.2% (95% confidence interval 0% to 1.4%). Prevalence of diabetes in patients with age and one or more other risk factors (hypertension, obesity, or a family history of diabetes) was 2.8% (1.6% to 4.7%). Four hours a week for a year would be needed to screen all people over 45 in the practice's population; about half this time would be needed to screen patients with risk factors other than age. More than 80% of patients newly diagnosed as having diabetes had a 10 year risk of coronary heart disease >15%, 73% (45% to 92%) were hypertensive, and 73% (45% to 92%) had a cholesterol concentration >5 mmol/l.

CONCLUSIONS

Screening for diabetes in general practice by measuring fasting blood glucose is feasible but has a very low yield in patients whose sole risk factor for diabetes is age over 45. Screening in a low risk population would best be targeted at patients with multiple risk factors.

The use of immunoliposomes for specific delivery of antimicrobial agents to oral bacteria immobilized on polystyrene

Antibacterial immunoliposomes have been prepared using covalently bound antibody, raised to the cell surface of the bacterium Streptococcus oralis (S. oralis), and incorporating the bactericides chlorhexidine and Triclosan. A regrowth assay, in which the ability of a bacterial biofilm immobilised on polystyrene to grow after exposure to a test solution, was undertaken to study the action of the antibacterial immunoliposomes. The antibacterial anti-oralis immunoliposomes show enhanced growth inhibition of S. oralis, compared to free bactericide, using low bactericide concentrations. For short exposure times to the biofilms, antibacterial anti-oralis immunoliposomes can show several times enhanced growth inhibition of S. oralis compared to free bactericide. Antibacterial anti-oralis immunoliposomes inhibit the growth of S. oralis more than that of other oral bacteria. The extent of growth inhibition by antibacterial anti-oralis immunoliposomes is linearly related to the number of immunoliposomes targeted to the biofilm surface.

Expression of nitric oxide synthase type 3 in reflux-induced esophageal lesions

BACKGROUND

The expression of endothelial constitutive nitric oxide synthase (NOS3) by squamous dysplasia and carcinomas of the head and neck has previously been described. We sought to compare NOS3 expression in squamous mucosa, glandular metaplasia, and adenocarcinoma of the esophagus.

METHODS

Forty paraffin-embedded specimens from 20 patients with adenocarcinoma were stained with anti-NOS3 monoclonal antibody. The percentage of cells stained and the intensity of staining were determined for squamous epithelium, metaplasia, and adenocarcinoma. Staining characteristics were statistically analyzed according to clinical variables.

RESULTS

NOS3 expression was significantly higher in adenocarcinoma and squamous epithelium compared with glandular metaplasia. Among the carcinomas, larger tumor size (T3/4), nodal positivity, and advanced TNM stage (III/IV) significantly correlated with increased NOS3 expression.

CONCLUSIONS

NOS3 is expressed in reflux-induced lesions of the esophagus. Glandular metaplasia shows basal levels of NOS3 that significantly increase with malignant transformation and tumor progression. The role of free radicals in carcinogenesis is being actively studied.

Mineralocorticoid receptors in the mammalian olfactory mucosa

Mineralocorticoid hormones regulate secretion and absorption in a wide variety of epithelial tissues, although specific mechanisms in the olfactory mucosa are currently unknown. Utilizing reverse transcription-polymerase chain reaction (RT-PCR) analysis, we have demonstrated the expression of mineralocorticoid (type I) receptor messenger RNA in the rodent olfactory mucosa. Amplification products of predicted size were obtained with nucleotide sequences corresponding to respective mineralocorticoid receptor (MR) kidney transcripts. Immunocytochemistry, using an antibody with known specificity for MRs, was then utilized in order to localize the cellular site(s) of MR protein expression in the olfactory mucosa. The highest levels of MR immunoreactivity were localized to the supranuclear region of sustentacular cells, as well as the acinar cells of the Bowman's glands. The respiratory regions of the nasal cavity were devoid of appreciable MR immunoreactivity. This study demonstrates both MR transcript and protein expression in the olfactory mucosa. We hypothesize that the mineralocorticoid hormones may have a role in modulation of olfactory secretion and/or sensory transduction in the peripheral olfactory system.

Expression of gamma-aminobutyric acid(A) receptor subunits in the vestibular system

OBJECTIVES

Profile the expression of genes encoding GABAA receptor subunits in the vestibular end organs of a rat.

MATERIALS AND METHODS

Using a combination of reverse transcription followed by polymerase chain reaction (PCR) with gene-specific primers, expression of mRNAs encoding 13 individual GABA(A) receptor subunits was examined.

RESULTS

PCR amplification products representing subunit gene expression for alpha1-6, beta1-3, and gamma1-3, but not for delta, subunits were amplified, suggesting multiple molecular levels of regulation of vestibular GABA(A) receptor expression. Nucleotide sequencing confirmed the identity of rat vestibular end-organs subunit cDNAs.

CONCLUSION

These results give the most direct evidence to date that GABAA receptors composed of the detected subunits are expressed in the mammalian vestibular system, giving new support to previous investigations implicating GABA as a vestibular neurotransmitter.

Expression of glucocorticoid receptor mRNA and protein in the olfactory mucosa: physiologic and pathophysiologic implications

OBJECTIVES

Define the presence and distribution of glucocorticoid receptors (GRs) within the olfactory mucosa in order to assess potential physiologic and pathophysiologic effects of these hormones on olfaction.

STUDY DESIGN

The olfactory mucosa was harvested from adult male rats and guinea pigs. Kidney tissue was utilized as a known positive control.

METHODS

The techniques of reverse transcriptase-polymerase chain reaction (RT-PCR) and immunocytochemistry were utilized to examine the expression of GR mRNA and protein. To assure the presence of olfactory mucosa in the nasal tissue samples, RT-PCR was utilized to identify the olfactory marker protein (OMP).

RESULTS

The presence of GR mRNA was confirmed in both the olfactory mucosa and kidney. GR-like immunoreactivity associated with the olfactory epithelium was greatest at the apical surface, a position corresponding to the dendrites, knobs, and cilia of olfactory receptor neurons, as well as the supranuclear region of sustentacular cells. Weaker GR-like immunoreactivity was associated with the region of the cell bodies of the olfactory receptor neurons. Within the lamina propria, acinar cells of the Bowman's glands and olfactory nerve bundles were intensely immunoreactive.

CONCLUSIONS

The presence of GR mRNA and protein within the olfactory mucosa is consistent with a functional role for glucocorticoid hormones in the systemic regulation of olfaction. Furthermore, these studies suggest that corticosteroid medications may have direct effects on the cells of the olfactory mucosa in the pathologic state. The potential mechanisms whereby these hormones may act are discussed.

The specificity and affinity of immunoliposome targeting to oral bacteria

Immunoliposomes have been prepared using antibodies raised to an antigenic determinant on the cell surface of the oral bacterium Streptococcus oralis (S. oralis) in an investigation of their potential to reduce dental plaque. The N-succinimidyl-S-acetylthioacetate (SATA) derivative of the antibodies were conjugated through the reactive m-maleimidobenzoyl-N-hydroxysuccinimide (MBS) derivative of dipalmitoyl-phosphatidylethanolamine (DPPE) incorporated into liposomes. The degree of antibody conjugation to the liposomes was controlled by the percentage of DPPEMBS incorporated into the liposomes. The chemical modification of the antibodies did not affect the ability of the antibodies to bind to a S. oralis biofilm. However, the affinity of the immunoliposomes for S. oralis was much lower than that of the free antibody. The anti-oralis antibodies were highly specific for S. oralis. The anti-oralis immunoliposomes showed the greatest affinity for S. oralis, when targeted to a range of different oral bacterial biofilms. The immunoliposome targeting affinity for S. oralis was largely unaffected by the number of antibodies conjugated to the liposomal surface or by the net charge of the liposomal lipid bilayer. The immunoliposomes showed a greater affinity for S. oralis than 'naked' (bearing no antibody) liposomes. However, positively charged liposomes, incorporating stearylamine, adsorbed to S. oralis with greater affinities than the immunoliposomes. The immunoliposomes appeared to be physically stable over a period of 18 months, as judged by particle-size measurements.

Impotence in diabetes

Impotence is more common in diabetic patients than in the normal population. This is due to the complications of diabetes, which damage the neurovascular bundle required for normal penile function. Minimally invasive methods of treatment have improved the outcome; however, the methods are still suboptimal. Recent advances in our understanding of the underlying mechanisms may lead to more non-invasive, targeted forms of treatment. (Trends Endocrinol Metab 1997;8:98-101). (c) 1997, Elsevier Science Inc.

Glucocorticoid replacement therapy: are patients over treated and does it matter?

BACKGROUND AND OBJECTIVES

Adequate assessment of patients on glucocorticoid replacement therapy is of great importance to avoid the consequences of under or over treatment, but no simple test is available for this. The aims of this study were (1) to assess adequacy of glucocorticoid replacement in hypoadrenal patients, (2) to correlate serum cortisol levels (cortisol day curve) with 24-hour urine free cortisol excretion and (3) to assess the impact of glucocorticoid dose optimization on markers of bone formation and bone resorption.

DESIGN

Cross-sectional study of current replacement therapy and a prospective study of the effect of dose alteration on bone turnover markers.

PATIENTS

Thirty-two consecutive patients on replacement glucocorticoid therapy (12 Addison's disease, 20 hypopituitarism) from a University teaching hospital out-patient department.

MEASUREMENTS

Serum and urinary cortisol, osteocalcin, N-telopeptide of type I collagen (NTX) and bone mineral density.

RESULTS

28/32 (88%) patients required a change of therapy; 24/32 (75%) a total reduction in dose, 18/32 (56%) a change in replacement therapy regimen or drug and 14/32 (44%) both changes. The mean daily dose of hydrocortisone was reduced from 29.5 +/- 1.2 to 20.8 +/- 1.0 mg. A significant correlation was found between peak cortisol and 24-hour urine free cortisol/ creatinine (Spearman correlation r = 0.60, P < 0.0001; n = 51). Following hydrocortisone dose reduction, median osteocalcin increased from 16.7 micrograms/l (range 8.2-65.7) to 19.9 micrograms/l (8.2-56.3); P < 0.01, with no change in the NTX/creatinine ratio.

CONCLUSIONS

A high proportion of patients on conventional corticosteroid replacement therapy are over treated or on inappropriate replacement regimens. To reduce the long term risk of osteoporosis, corticosteroid replacement therapy should be individually assessed and over replacement avoided.

Diverticulitis. A comprehensive follow-up

PURPOSE

This study was undertaken to examine the longterm results of medical and surgical management for diverticulitis.

METHODS

A retrospective review of all patients admitted to Naval Medical Center Portsmouth, Virginia, between January 1991 and February 1994, was conducted. Of 78 patients included in the study, 65 were able to be contacted for follow-up.

RESULTS

The surgically treated group consisted of 33 patients, and medically treated group had 32 patients. Of the medically treated group, 62.5 percent were found to have continuing symptoms. Medically treated patients with a long history and infrequent flares tended to be less symptomatic after hospitalization. Conversely, those medical patients with a short intense history were more likely to have symptoms. The frequency of symptoms in the surgical group was surprising, because 27.2 percent of this group reported continuing symptoms.

CONCLUSIONS

Close follow-up of medically treated patients for objective evidence of diverticulitis is indicated. When surgical therapy is undertaken, patients should be counseled that symptoms may be largely unchanged following operation.

Antecedent hypoglycaemia in non-diabetic subjects reduces the adrenaline response for 6 days but does not affect the catecholamine response to other stimuli

1. Recent hypoglycaemia reduces the counter-regulatory and symptomatic response to the next episode of hypoglycaemia. This study was designed to determine whether antecedent hypoglycaemia (a) affected the sympathoadrenal response to other stimuli (postural change and a mathematical stress test, (b) was associated with adaptation of cognitive function and (c) if avoided for 6 days led to the restoration of the counter-regulatory response to hypoglycaemia. 2. On the morning of day 1, 10 healthy men had their response to the sympathoadrenal stimuli assessed before an episode of hypoglycaemia (2.5 mmol/l). A further hyperinsulinaemia clamp was performed for 2h (blood glucose 3.0 mmol/l or 5.0 mmol/l) in the afternoon and the assessments repeated the next day and 6 days later. Cognitive function using the four-choice reaction time test was assessed before and during the episodes of morning hypoglycaemia. The whole study was repeated 4 weeks later with the other afternoon glucose level. 3. Adrenaline levels and sweat rates were reduced (P < 0.05) on day 2 during hypoglycaemia on both occasions and had not returned to normal after 6 days. Symptom scores were lower (P < 0.05) only on day 2 after the afternoon of hypoglycaemia. The responses to the sympathoadrenal stimuli and cognitive function were unaffected by antecedent hypoglycaemia. 4. The adaptation of the counter-regulatory response to antecedent hypoglycaemia appears to be specific to hypoglycaemia. The response takes longer than 6 days but less than 4 weeks to return to normal. Antecedent hypoglycaemia does not lead to cerebral adaptation.

Physiological response to postural change during mild hypoglycaemia in patients with IDDM

It has been suggested that patients with insulin-dependent diabetes mellitus may be less aware of impending hypoglycaemia when lying than standing. We have studied the effect of posture and duration of hypoglycaemia on symptoms and physiological responses in 10 men with insulin-dependent diabetes. A standard tilting protocol was used (supine, 50 degrees, 90 degrees headup, and return to supine, 5 min at each position). At one visit patients were tilted before, 10 min after and 40 min after achieving hypoglycaemia (blood glucose 2.5 mmol/l), and at another visit were tilted after euglycaemia (5.0 mmol/l) using a hyperinsulinaemic clamp. At each position, hormonal and physiological responses and symptoms (using visual analogue scales) were recorded. After 10 min of hypoglycaemia, adrenaline was significantly higher when 90 degrees headup compared with supine (mean [+/- SEM] 6.26 [+/- 1.88] vs 1.68 [+/- 0.4] nmol/l; p < 0.05), and fell significantly (to 2.46 [+/- 0.65] nmol/l; p < 0.05) when returned to supine; sweating, symptom score and blood pressure followed a similar pattern. After 40 min of hypoglycaemia a similar effect of standing was seen on sweating, adrenaline and blood pressure but symptoms did not increase. Five patients underwent two further periods of hypoglycaemia, remaining supine or standing throughout. Face skin blood flow (p < 0.05) and temperature (p = 0.05) decreased when standing was maintained compared with lying. In conclusion, standing increases awareness of early hypoglycaemia and modifies many of the physiological changes. This increase in awareness is lost if hypoglycaemia is prolonged.

Investigating the capillary circulation of the foot with 99mTc-macroaggregated albumin: a prospective study in patients with diabetes and foot ulceration

Macroaggregated albumin has been used to assess capillary circulation for over 20 years. The aim of the present study was to use 99mTc-macroaggregated albumin (99mTc-MAA) perfusion scanning to assess capillary circulation in feet with ischaemic ulcers in patients with diabetes, and relate the appearances to outcome. Twenty-three patients with diabetes presented with a total of 41 neuroischaemic foot ulcers. Perfusion scanning was performed by direct femoral artery injection of approximately 400,000 particles of 99mTc-MAA and imaging with a gamma camera. Patients were followed prospectively for 3 months. Scans were graded independently by a radiologist who was unaware of the site of the ulcers. Significant associations were detected between a radiologist's assessment of increased tissue perfusion and complete healing after 3 months (p = 0.047) and poor tissue perfusion on the image and failure to heal (p = 0.0005). This technique may be useful in deciding whether to persist with conservative treatment in patients with diabetes and foot ulceration.

Subcutaneous versus intravenous administration of heparin in the treatment of deep vein thrombosis; which do patients prefer? A randomized cross-over study

Patient preference for intravenous or subcutaneous heparin in the treatment of deep venous thrombosis was assessed in a randomized cross-over study. Twenty patients with venographically proven deep venous thrombosis were randomized to receive subcutaneous or intravenous heparin for 3 days followed by 3 days of the other treatment. Discomfort at the injection site, assessed by visual analogue scale, was significantly less for the subcutaneous than the intravenous administration route (P < 0.001), mobility was thought to be better when receiving subcutaneous heparin (P < 0.005) and patients' overall preference was for subcutaneous treatment (P < 0.001).