Reducing Salivary Toxicity with Adaptive Radiotherapy (ReSTART): A Randomized Controlled Trial Comparing Conventional IMRT to Adaptive IMRT in Head and Neck Squamous Cell Carcinomas

BACKGROUND

The utility of Adaptive Radiotherapy (ART) in Head and Neck Squamous Cell Carcinoma (HNSCC) remains to be ascertained. While multiple retrospective and single-arm prospective studies have demonstrated its efficacy in decreasing parotid doses and reducing xerostomia, adequate randomized evidence is lacking.

METHODS AND ANALYSIS

ReSTART (Reducing Salivary Toxicity with Adaptive Radiotherapy) is an ongoing phase III randomized trial of patients with previously untreated, locally advanced HNSCC of the oropharynx, larynx, and hypopharynx. Patients are randomized in a 1:1 ratio to the standard Intensity Modulated Radiotherapy (IMRT) arm {Planning Target Volume (PTV) margin 5 mm} vs. Adaptive Radiotherapy arm (standard IMRT with a PTV margin 3 mm, two planned adaptive planning at 10th and 20th fractions). The stratification factors include the primary site and nodal stage. The RT dose prescribed is 66Gy in 30 fractions for high-risk PTV and 54Gy in 30 fractions for low-risk PTV over six weeks, along with concurrent chemotherapy. The primary endpoint is to compare salivary toxicity between arms using salivary scintigraphy 12 months' post-radiation. To detect a 25% improvement in the primary endpoint at 12 months in the ART arm with a two-sided 5% alpha value and a power of 80% (and 10% attrition ratio), a sample size of 130 patients is required (65 patients in each arm). The secondary endpoints include acute and late toxicities, locoregional control, disease-free survival, overall survival, quality of life, and xerostomia scores between the two arms.

DISCUSSION

The ReSTART trial aims to answer an important question in Radiation Therapy for HNSCC, particularly in a resource-limited setting. The uniqueness of this trial, compared to other ongoing randomized trials, includes the PTV margins and the xerostomia assessment by scintigraphy at 12 months as the primary endpoint.

Investigating Indian oil sardine aggregation events in coastal waters of the southeastern Arabian sea

The southwest coast of India experiences frequent Indian oil sardine (IOS) nearshore aggregation events, especially in the coastal waters off Kerala. These ephemeral dense IOS aggregation events are known as "Sardine Run". To investigate the reason and provide a scientific basis for these sporadic events, satellite/model-derived physical, meteorological, and biological parameters were analysed. Sea Surface Temperature during a majority of events was in the range of 26-29 °C, agreeing with the reported temperature conditions for IOS in the Arabian Sea. Additionally, a marginal lowering of SST as an effect of precipitation before most of the events might have attracted IOS towards the near-coastal waters in addition to the phytoplankton diet availability, resulting in the aggregation event. However, different scenarios also depicted coastal warming and probable hypoxic conditions in degrading IOS habitat and resulting in beach aggregation events. During most of the IOS aggregation events, the wind and surface current direction was alongshore/coastward, which complemented the propagation of live IOS shoals towards the beach.

An integrated buoy-satellite based coastal water quality nowcasting system: India's pioneering efforts towards addressing UN ocean decade challenges

The Indian coastal waters are stressed due to a multitude of factors, such as the discharge of industrial effluents, urbanization (municipal sewage), agricultural runoff, and river discharge. The coastal waters along the eastern and western seaboard of India exhibit contrasting characteristics in terms of seasonality, the magnitude of river influx, circulation pattern, and degree of anthropogenic activity. Therefore, understanding these processes and forecasting their occurrence is highly necessary to secure the health of coastal waters, habitats, marine resources, and the safety of tourists. This article introduces an integrated buoy-satellite based Water Quality Nowcasting System (WQNS) to address the unique challenges of water quality monitoring in Indian coastal waters and to boost the regional blue economy. The Indian National Centre for Ocean Information Services (INCOIS) has launched a first-of-its-kind WQNS, and positioned the buoys at two important locations along the east (Visakhapatnam) and west (Kochi) coast of India, covering a range of environmental conditions and tourist-intensive zones. These buoys are equipped with different physical-biogeochemical sensors, data telemetry systems, and integration with satellite-based observations for real-time data transmission to land. The sensors onboard these buoys continuously measure 22 water quality parameters, including surface current (speed and direction), salinity, temperature, pH, dissolved oxygen, phycocyanin, phycoerythrin, Coloured Dissolved Organic Matter, chlorophyll-a, turbidity, dissolved methane, hydrocarbon (crude and refined), scattering, pCO2 (water and air), and inorganic macronutrients (nitrite, nitrate, ammonium, phosphate, silicate). This real-time data is transmitted to a central processing facility at INCOIS, and after necessary quality control, the data is disseminated through the INCOIS website. Preliminary results from the WQNS show promising outcomes, including the short-term changes in the water column oxic and hypoxic regimes within a day in coastal waters off Kochi during the monsoon period, whereas effluxing of high levels of CO2 into the atmosphere associated with the mixing of water, driven by local depression in the coastal waters off Visakhapatnam. The system has demonstrated its ability to detect changes in the water column properties due to episodic events and mesoscale processes. Additionally, it offers valuable data for research, management, and policy development related to coastal water quality.

Physicochemical controls on the initiation of phytoplankton bloom during the winter monsoon in the Arabian Sea

Occurrence of phytoplankton bloom in the northern Arabian Sea (NAS) during the winter monsoon is perplexing. The convective mixing leads to a deeper and well-oxygenated (> 95% saturation) mixed layer. We encountered low chlorophyll conditions though the nutrient conditions were favorable for a bloom. The mean ratio of silicate (Si) to DIN (Dissolved Inorganic Nitrogen: nitrate + nitrite + ammonium) in the euphotic zone was 0.52 indicating a “silicate-stressed” condition for the proliferation of diatoms. Also, the euphotic depth was much shallower (~ 49 m) than the mixed layer (~ 110 m) suggesting the Sverdrup critical depth limitation in the NAS. We show that the bloom in this region initiates only when the mixed layer shoals towards the euphotic zone. Our observations further suggest that two primary factors, the stoichiometric ratio of nutrients, especially the Si/DIN ratio, in the mixed layer and re-stratification of the upper water column, govern the phytoplankton blooming in NAS during the later winter monsoon. The important finding of the present study is that the Sverdrup’s critical depth limitation gives rise to the observed low chl-a concentration in the NAS, despite having enough nutrients.

Limits on the Existence of sub-MeV Sterile Neutrinos from the Decay of ^{7}Be in Superconducting Quantum Sensors

Sterile neutrinos are natural extensions to the standard model of particle physics and provide a possible portal to the dark sector. We report a new search for the existence of sub-MeV sterile neutrinos using the decay-momentum reconstruction technique in the decay of ^{7}Be. The experiment measures the total energy of the ^{7}Li daughter atom from the electron capture decay of ^{7}Be implanted into sensitive superconducting tunnel junction (STJ) quantum sensors. This first experiment presents data from a single STJ operated at a low count rate for a net total of 28 days, and provides exclusion limits on sterile neutrinos in the mass range from 100 to 850 keV that improve upon previous work by up to an order of magnitude.

A baseline investigation of phytoplankton pigment composition in contrasting coastal ecosystems of north-western Bay of Bengal

A baseline investigation of the chromatographic characterization of phytoplankton pigments with complementing microscopy was conducted in Mahanadi estuary, Chilika lagoon, and coastal waters off Gopalpur along the east coast of India. Marker pigments specific to different phytoplankton groups have been discerned in these contrasting coastal ecosystems. A total of 16 phytoplankton pigments were identified. Irrespective of seasons, Chilika lagoon was characterized by a high concentration of zeaxanthin, indicating the predominance of picocyanobacteria. Zeaxanthin and fucoxanthin were the major diagnostic pigments in Mahanadi estuary during monsoon and other seasons, respectively. In coastal waters off Gopalpur, algal blooms resulted in a higher concentration of fucoxanthin during pre-monsoon and monsoon season. The pigment ratios were comparatively higher for Chilika lagoon than for Mahanadi estuary and off Gopalpur, irrespective of seasons. The present study highlights the advantages of the chromatography technique in identifying small-sized phytoplankton in coastal ecosystems in comparison to conventional microscopy.

Histone/protein deacetylase inhibitor therapy for enhancement of Foxp3+ T-regulatory cell function posttransplantation

T-regulatory (Treg) cells are like other cells present throughout the body in being subject to biochemical modifications in response to extracellular signals. An important component of these responses involves changes in posttranslational modifications (PTMs) of histones and many nonhistone proteins, including phosphorylation/dephosphorylation, ubiquitination/deubiquitination, and acetylation/deacetylation. Foxp3, the key transcription factor of Tregs, is constantly being rapidly turned over, and a number of these PTMs determine its level of expression and activity. Of interest in the transplant setting, modulation of the acetylation or deacetylation of key lysine residues in Foxp3 can promote the stability and function, leading to increased Treg production and increased Treg suppressive activity. This mini-review focuses on recent data concerning the roles that histone/protein deacetylases (HDACs) play in control of Treg function, and how small molecule HDAC inhibitors can be used to promote Treg-dependent allograft survival in experimental models. These data are discussed in the light of increasing interest in the identification and clinical evaluation of isoform-selective HDAC inhibitors, and their potential application as tools to modulate Foxp3+ Treg cell numbers and function in transplant recipients.

Extraction of effective solid-liquid interfacial free energies for full 3D solid crystallites from equilibrium MD simulations

Molecular dynamics simulations of an embedded atom copper system in the isobaric-isenthalpic ensemble are used to study the effective solid-liquid interfacial free energy of quasi-spherical solid crystals within a liquid. This is within the larger context of molecular dynamics simulations of this system undergoing solidification, where single individually prepared crystallites of different sizes grow until they reach a thermodynamically stable final state. The resulting equilibrium shapes possess the full structural details expected for solids with weakly anisotropic surface free energies (in these cases, ∼5% radial flattening and rounded [111] octahedral faces). The simplifying assumption of sphericity and perfect isotropy leads to an effective interfacial free energy as appearing in the Gibbs-Thomson equation, which we determine to be ∼177 erg/cm², roughly independent of crystal size for radii in the 50-250 Å range. This quantity may be used in atomistically informed models of solidification kinetics for this system.

Characterization of oceanic Noctiluca blooms not associated with hypoxia in the Northeastern Arabian Sea

Intense blooms of the heterotrophic dinoflagellate, green Noctiluca scintillans, have been reported annually in the Northern Arabian Sea since the early 2000s. Although not known to produce organic toxins, these blooms are still categorized as a harmful due to their association with massive fish mortalities. Recent work has attributed these blooms to the vertical expansion of the oxygen minimum zone, driven by cultural eutrophication from major coastal cities in western India. As diatoms are preferred prey of green Noctiluca scintillans, more frequent blooms of this mixotroph will likely impact the productivity of important fisheries in the region. The present study uses a satellite algorithm to determine the distribution of both diatom and green Noctiluca blooms in the Northeastern Arabian Sea from 2009 to 2016. The results from shipboard microscopy of phytoplankton community composition were used to validate the satellite estimates. The satellite algorithm showed 76% accuracy for detection of green Noctiluca and 92% for diatoms. Shipboard measurements and data from biogeochemical-Argo floats were used to assess the relationship between oxygen concentrations and green Noctiluca blooms in the Northeastern Arabian Sea. Regardless of the presence of a Noctiluca bloom, the dissolved oxygen in the photic zone was always >70% saturated, with an average oxygen saturation >90%. The variability in the relative abundance of diatoms and green Noctiluca is not correlated with changes in oxygen concentration. These findings provide no evidence that cultural eutrophication has contributed to the decadal scale shifts in plankton composition in the Northeastern Arabian Sea oceanic waters. Conversely, the climatic warming of surface waters would have intensified stratification, thereby reducing net nutrient flux to the photic zone and decreasing silicate to nitrate ratios (Si:N); both factors that could increase the competitive advantage of the mixotroph, green Noctiluca, over diatoms. If so, the decadal-scale trajectory of phytoplankton community composition in the Northeastern Arabian Sea may be a harbinger of future climate-driven change in other productive oceanic systems.

Response of phytoplankton community and size classes to green Noctiluca bloom in the northern Arabian Sea

A comprehensive analysis on the phytoplankton ecology with special reference to different phytoplankton size classes was carried out at green Noctiluca scintillans (hereafter Noctiluca) bloom and non-bloom locations in offshore waters of the northern Arabian Sea. At the bloom locations, green Noctiluca represented a dense mono-specific proliferation with average cell density of 10.16 ± 5.806 × 10⁴ cells-L^-1 and relative abundance share of 98.63%. Active photosynthesis through prasinophytic endosymbiont was depicted from net community production magnitude reaching 85.26 mgC/m³/Day under low prey abundance. Parallel swarming of Porpita porpita, a voracious copepod feeder signified the competitive advantage of Noctiluca to have the phytoplankton prey. Average concentration of picophytoplankton biomass was eleven times lower in surface waters of non-bloom stations in comparison to bloom. Higher N:P ratio in subsurface waters of non-bloom stations signified non-utilization of nitrogenous nutrients. Green Noctiluca bloom onset subsequent to diatom rich conditions was evident from spatio-temporal ocean colour satellite imageries.

Correction: Functionalised type-I collagen as a hydrogel building block for bio-orthogonal tissue engineering applications

Correction for 'Functionalised type-I collagen as a hydrogel building block for bio-orthogonal tissue engineering applications' by R. Ravichandran et al., J. Mater. Chem. B, 2016, 4, 318-326.

CO2 hydrogenation to higher hydrocarbons on K/Fe–Al–O spinel catalysts promoted with Si, Ti, Zr, Hf, Mn and Ce

Si and Zr species grafted on Fe–Al–O catalysts act as an inhibitor and promoter, respectively, in CO₂ hydrogenation.

A feasibility study of educational tools for osteomalacia

Many people in the UK, particularly people of South Asian origin, are advised to supplement their vitamin D intake, yet most do not. This suggests an unmet educational need. The osteomalacia mind map was developed to meet this need. The mind map contains culturally sensitive images, translated into Urdu and made interactive on a DVD. This study explores the feasibility of a randomised controlled study to measure the effect of education on improving vitamin D knowledge and adherence. This was a pilot and feasibility study. Cluster randomisation was used to avoid inter person contamination. Two South Asian women's groups were recruited to receive information about osteomalacia either by interactive DVD or an Arthritis Research UK leaflet. Knowledge and compliance were tested before and after the educational interventions via a knowledge questionnaire and the measurement of vitamin D and parathormone levels. The groups were found to be mismatched for knowledge, educational attainment and language at baseline. There were also organisational difficulties and possible confounding due to different tutors and translators. The DVD group had high knowledge at baseline which did not improve. The leaflet group had low knowledge at baseline that did improve. The DVD group had lower parathormone which did not change. The leaflet group had an increase in vitamin D but parathormone remained high. Performing a randomised study with this population utilising an educational intervention was difficult to execute. If cluster randomisation is used, extreme care must be taken to match the groups at baseline.

Functionalised type-I collagen as a hydrogel building block for bio-orthogonal tissue engineering applications

Modulating the hydrogel properties from injectable to implantable scaffolds using the bio-orthogonal thiol-Michael addition click reaction.

A systematic MEDLINE analysis of therapeutic approaches in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disorder involving the sacroiliac joints (SIJs), spine and less frequently the peripheral joints. Traditionally, it is well recognised that AS is a challenging disease to manage due to the lack of effective therapeutic options. Current evidence would suggest this has changed and there are now a number of therapies available that provide persistent control of inflammatory symptoms with improvement in daily function. NSAIDs remain the first step in patient treatment. Sulphasalazine may be effective in peripheral arthritis and there are emerging data to support its use in early inflammatory back pain. Studies have shown that pamidronate and steroid injection into SIJ have a symptom-modifying effect in AS. Current data suggest that anti-TNF treatment promises early benefit which is likely to continue in the longer term. Treatment with biologics should be considered sooner rather than later in the management of AS.

TEL-AML1 preleukemic activity requires the DNA binding domain of AML1 and the dimerization and corepressor binding domains of TEL

The t(12;21)(p13;q22) translocation generates the TEL-AML1 (TEL, translocation-Ets-leukemia; AML1, acute myeloid leukemia-1) (ETV6-RUNX1) fusion product and is the most common chromosomal abnormality in pediatric leukemia. Our previous studies using a murine fetal liver transplantation model demonstrated that TEL-AML1 promotes the self-renewal of B-cell precursors in vitro and enhances the expansion of hematopoietic stem cells (HSCs) in vivo. This is consistent with the hypothesis that TEL-AML1 induces expansion of a preleukemic clone. Several studies have described domains within TEL-AML1 involved in the transcriptional regulation of specific target genes. However, it is unclear which of these domains is important for the activity of TEL-AML1 in preleukemic hematopoiesis. In order to examine this, we have generated a panel of deletion mutants and expressed them in HSCs. These experiments demonstrate that TEL-AML1 requires multiple domains from both TEL and AML1 to alter hematopoiesis. Furthermore, mutation of a single amino-acid residue within the runt homology domain of AML1, required for DNA binding, was sufficient to abrogate TEL-AML1 activity. These data suggest that TEL-AML1 acts as an aberrant transcription factor to perturb multiple pathways during hematopoiesis.

Tuning the size and optical properties in molecular nano/microcrystals: manifestation of hierarchical interactions

Intermolecular interactions, such as hydrogen bonding, dipolar and van der Waals, occurring in molecular crystals cover a range of magnitudes. As the crystal evolves from a relatively softer state in the nanoscopic size regime to a harder one in the microcrystalline and bulk solid state, the impact of the hierarchy of intermolecular interactions can be expected to emerge in a progressive fashion. The strongest interactions alone would be manifested at small sizes; as the crystal grows, the effect of the weaker ones will be added on, with the bulk crystals exhibiting the cumulative impact of the different interactions. We demonstrate this phenomenon through investigations of the solution, colloid, and solid state of a novel zwitterionic molecule based on the diaminodicyanoquinodimethane framework. A reprecipitation-digestion protocol is developed for the fabrication of nano/microcrystals of varying sizes. Microscopic and spectroscopic characterizations reveal tuning of the size and optical properties of this material. The optical absorption of the colloidal particles evolves with size towards that of the bulk solid, the emission showing a steady enhancement of intensity. Crystallographic investigations coupled with semiempirical computations provide a viable model to describe the range of observations in terms of the gradual accumulation of hierarchical intermolecular interactions.

Arm-crank propelled three-wheeled chair: physiological evaluation of the propulsion using one arm and both arm patterns

Disabled people in India frequently use the arm-crank propelled three-wheeled chair (ACWC) for outdoor transportation. Two models of these chairs are commercially available: one is powered by cranking using one arm (ACWC-1) and the other uses both arms (ACWC-2). The purpose of the study was to compare the efficiency of the two types of propulsion with respect to the standard physiological responses and, consequent upon the findings, to recommend the use of a suitable one. The energetics of locomotion of the users at their freely chosen speed (FCS) were measured and compared with changes in the physiological parameters in the within-subject groups. The study was conducted in outdoor settings to simulate the actual locomotive conditions encountered by the users in their practical life. 14 males, who had been regular and proficient users of both propulsion systems for more than last six years and who had a history of paraplegia (below the 10th thoracic vertebra, n=11) and poliomyelitis (n=3) participated in the study. The subjects were required to propel the test chair (a combination of both the propulsion systems built in a single model) on an oval track of 358 m circumference at their FCS for 5 min; ambulatory data were collected during last 3 min of exercise and averaged. The FCS (m/min), heart rates (bpm) and oxygen uptake (l/min) were measured. Physiological cost index (b/m) oxygen consumption (ml/kg/min), oxygen cost (ml/kg/m) and net locomotor energy cost (kcal/kg/km) of the two sets of observations were derived and compared using a t-test for the paired observations. The FCS was significantly higher and the physiological parameters were lower with the ACWC-2 than with ACWC-1, except for heart rate and oxygen consumption, where the difference was not significant . It is concluded that two-arm use is more efficient and less physically demanding than one-arm use in the arm-crank propulsion system and that the former is more suitable for efficient ambulation.

Are evidence-based guidelines being followed for the monitoring of ocular toxicity of hydroxychloroquine? A nationwide survey of practice amongst consultant rheumatologists and implications for clinical governance

OBJECTIVE

To determine whether consultant rheumatologists monitor the ocular toxicity of hydroxychloroquine according to standards set by national guidelines.

METHOD

An observational cross-sectional questionnaire study of all consultant rheumatologists in the UK was undertaken. The main outcome measure was the proportion of rheumatologists who practise in compliance with nationally set standards.

RESULTS

A wide variation in practice was found. Nearly half the respondents did not assess either baseline visual symptoms or visual acuity, and 3% undertook infrequent visual monitoring at intervals of longer than 1 yr. At least a quarter of rheumatologists within the survey routinely referred patients to ophthalmology, either for baseline visual screening or for regular visual monitoring. Such use of ophthalmology services was outside the recommendations of the guidelines and would suggest that these referrals were unnecessary. No differences in monitoring practices were ascertained between respondents from district general and teaching hospitals.

CONCLUSION

The present study shows that nationally set guidelines for the monitoring of ocular toxicity of hydroxychloroquine are not consistently followed by rheumatologists with regard to baseline assessment, referral to ophthalmology and frequency of monitoring. Clinical guidelines aim to reduce variations in practice and to promote uniform and consistent best practice. The present study demonstrates a lack of conformity to national guidelines in respect of the monitoring of ocular toxicity of hydroxychloroquine. Clinical governance provides a framework for assuring quality in health care. The implications of this study for clinical governance would include understanding why barriers to the use of guidelines might occur and how they might be overcome, risk management, accounting for the reasonableness of a decision for positive divergence and audit.

An evidence-based approach to the management of low back pain and sciatica: how the evidence is applied in clinical cases

BACKGROUND

Low back pain and sciatica are common complaints that affect a major proportion of the population at some time in their lives. The treatment and management of this condition may vary widely.

OBJECTIVE

The present paper aims to provide an evidence-based approach to the management of low back pain and sciatica, and demonstrates how to search for the evidence and how to apply it practically in individual patients. The principles underlying evidence-based medicine are explained. The practice of evidence-based medicine requires initial formulation of the appropriate clinical question, followed by searching databases for relevant evidence. Finally evidence needs to be applied on a patient-specific basis.

METHOD

Best Evidence, the Cochrane Library, Embase and Medline were searched to obtain quality controlled information regarding the management of low back pain and sciatica.

RESULTS

Current evidence shows that an active exercise programme promotes early recovery. This may allow patients to resume an active and sportive lifestyle. Epidural corticosteroid injections may help to resolve additional troublesome symptoms of sciatica. Two clinical cases are used to show how evidence-based medicine can be individualized to specific patients.

CONCLUSIONS

A patient-focused strategy combining best evidence and clinical expertise is suggested as the mainstay for the management of low back pain.

Comparative study of bone mineral density, calcium, and vitamin D status in the Gujarati and white populations of Leicester

OBJECTIVES

To evaluate differences in bone mineral density (BMD), calcium, and vitamin D status between the Gujarati (South Asian) and white populations resident in Leicester and to determine whether this was linked to lifestyle factors.

DESIGN

An observational cross sectional study of randomly selected Gujarati and white volunteers aged from 20-40 years.

SETTING

City of Leicester.

PARTICIPANTS

Subjects were randomly selected by age (20-40 years) and ethnicity. A total of 262 individuals volunteered to participate, of which 201 (51 white females, 71 Gujarati females, 37 white males, 42 Gujarati males) were eligible for the study.

MAIN OUTCOME MEASURES

Results of questionnaire, BMD at the hip and lumbar spine, and measurement of serum calcium, albumin, alkaline phosphatase, and 25-hydroxyvitamin D.

RESULTS

Male and female white subjects were significantly taller and heavier than their Gujarati counterparts. There was a statistically significant difference in BMD both at the spine (p<0.001) and hip (p<0.001) between the white and Gujarati females with the Gujaratis having a lower BMD. There was a trend for Gujarati males to have a lower BMD at the hip and spine than their white counterparts but these figures did not reach statistical significance. The intensity of cigarette smoking and the amount of alcohol consumption were both higher in the white male and female subjects. Sunlight exposure (>4 hours per day) was significantly higher in white subjects compared with Gujaratis. There were no significant differences in the mean level of serum calcium or alkaline phosphatase between the Gujaratis and whites. A significantly higher proportion (p<0.001) of the Gujarati men and women had a vitamin D level that was not measurable (that is, below the lower limit of the laboratory range of normal). Of those who had a measurable level (that is, in the normal range) mean levels of vitamin D were lower (p<0.05) in the Gujarati men and women.

CONCLUSION

The present study is the first of its kind to note a low BMD in Gujarati subjects of South Asian origin compared with their white counterparts, living in Leicester. This study also confirms the presence of low serum vitamin D levels in Gujaratis. There is a need for more research in South Asians with regard to the collection of normal BMD values. This could provide a more meaningful reference range for identifying South Asians at risk of osteoporotic fractures and may have public health implications of relevance to this ethnic group.