Brain complications of diabetes mellitus: a cross-sectional study of awareness among individuals with diabetes and the general population in Ireland

AIMS

To identify awareness of potential brain complications of diabetes among individuals with diabetes and the public.

METHODS

For this observational, cross-sectional survey study, we recruited consecutive adult attendees of a specialist diabetes clinic and two primary care practices. Primary care attendees represented members of the general population of Ireland. An interviewer-administered questionnaire was used to gather data on respondents' awareness of brain complications of diabetes and modifiable risk factors for dementia. Multivariable logistic regression was undertaken to identify variables independently associated with awareness.

RESULTS

Respondents included a total of 502 adults: 250 in the diabetes group (37% women, mean age 63 ± 14 years, 88% with Type 2 diabetes) and 252 in the general population group (51% women, mean age 47 ± 17 years, 7% with Type 2 diabetes). The diabetes group had significantly greater awareness of diabetes complications, except for depression, compared with the general population group. In the group as a whole, respondent awareness of dementia (35%) and memory problems (47%) as potential complications of diabetes was poor compared with awareness of kidney (84%) and eye damage (84%). Respondents were 1.5 times more likely to identify that individuals can modify their risk of developing Type 2 diabetes than their risk of dementia.

CONCLUSIONS

This study shows that there is poor awareness of brain complications of diabetes among individuals with diabetes and the general population in Ireland. The results suggest a need for expansion of public awareness campaigns and diabetes education programmes to promote awareness of the brain complications of diabetes and of the modifiable risk factors for dementia, as part of a life-course approach to dementia prevention.

Transanal irrigation in the management of neurogenic bowel dysfunction

Many patients with a spinal cord injury (SCI) or spina bifida suffer from neurogenic bowel dysfunction which causes significant physical and psychological morbidity. For the last four years at the National Rehabilitation Hospital, transanal irrigation (TAI) has been offered to patients who were dissatisfied with a conservative bowel management programme. This is an observational study of eleven patients who were offered TAI. Three questionnaires, scoring bowel symptoms at baseline and follow-up (3-28 months) were completed by patients. Nine patients had a SCl and two had spina bifida, mean age was 44 years. A reduction in mean scores for all three questionnaires occurred post TAI (39.5-42.1%) indicating fewer bowel symptoms. Statistically significant reductions in faecal incontinence (p < 0.05), abdominal pain (p < 0.05) and lifestyle alterations secondary to bowel management (p < 0.05) occurred. No serious adverse events occurred during the study. TAI is an effective treatment option for the management of neurogenic bowel dysfunction.

Design characteristics and clinical implementation of a newly designed indwelling carotid artery shunt

The author has developed a new silicone carotid artery shunt (Loftus carotid endarterectomy shunt, Integra NeuroCare, Plainsboro, New Jersey) which offers several advantages over previously available commercial products. It is designed as an indwelling 15 cm (short) shunt, without an external loop. The silicone material makes for simple insertion and the ends are beveled and tapered to minimize dislodgement of any atheromatous material. At its proximal end a built-up bulb has been placed to facilitate securing by a Rummel tourniquet. At the distal end of the shunt no bulb is necessary. A broad black band has been applied to its center to allow for immediate visual inspection of shunt migration or misplacement. In contrast to previous designs, no metal reinforcement is necessary in this shunt. It is supplied in two sizes in a kit which also includes a pair of disposable scissors hooked on the end for easy shunt transection at the time of removal. The shunt is best accompanied by a specialized shunt clamp (Loftus shunt clamp, Scanlan Medical Instruments, St. Paul, Minnesota) which has been designed with atraumatic jaws to secure it with minimal closing force in the internal carotid artery and to prevent back-bleeding around it. Clinical experience with the shunt has been extensive and satisfactory. Both the shunt kit and the shunt clamps are now available for commercial distribution.

Highly cross-reactive T cell responses to myelin basic protein epitopes reveal a nonpredictable form of TCR degeneracy

We identified two nonoverlapping epitopes in myelin basic protein presented by I-Au that are responsible for mediating tolerance induction to this self-Ag. A large number of T cells expressing diverse TCRs are strongly cross-reactive to both epitopes. Surprisingly, the TCR contact residues in each peptide are highly dissimilar. Furthermore, functional TCR contacts cannot be interchanged between the two epitopes, indicating that the TCR contacts in each peptide can only be recognized within the context of the other amino acids present in that peptide's sequence. This observation indicates that both buried and exposed residues of each peptide contribute to the sculpting of completely distinct antigenic surfaces. We propose that the cross-reactive TCRs adopt mutually exclusive conformations to recognize these dissimilar epitopes, adding a new dimension to TCR degeneracy. This unpredictable TCR plasticity indicates that using just the TCR contacts on a single epitope to define other cross-reactive peptides will identify only a subset of the complete repertoire of cross-reactive epitopes.

Is duplex follow-up cost-effective in the first year after carotid endarterectomy?

Recent reports have suggested that duplex scanning is an ideal method to noninvasively assess the incidence of recurrent carotid stenosis. However, the timing and frequency of the follow-up studies are controversial. In the present study, 150 patients underwent 173 carotid endarterectomy procedures over a 2 year period. In the postoperative period, a total of 210 duplex studies were carried out on 117 carotid arteries. 21.4 percent of the 117 arteries studied had recurrent stenosis of 16 percent or greater at a mean postoperative follow-up of 15.2 +/- 3 months. Recurrent stenoses were detected early after operation; 96 percent were detected at or before 15 months postoperatively. Patients with recurrent stenoses remained stable and had infrequent symptoms. Several risk factors placed the patient at increased risk for recurrent carotid stenosis: presence of contralateral disease (defined as stenosis of 50 percent or greater), use of tacking sutures, and continued smoking in the postoperative period. Although it remains important for researchers to thoroughly investigate the natural history of atherosclerosis of the extracranial carotid artery, including those changes that occur after carotid endarterectomy, our results indicate that frequent duplex scanning in the first postoperative year is unnecessary and is not cost-effective. Duplex follow-up studies 1 and 12 months after carotid endarterectomy are sufficient for assessing the problem of recurrent stenosis in the first postoperative year.