Retinopathy develops at similar glucose levels but higher HbA1c levels in people with black African ancestry compared to white European ancestry: evidence for the need to individualize HbA1c interpretation

AIMS

To examine the association of HbA_1c and glucose levels with incident diabetic retinopathy according to black African or white European ancestry.

METHODS

In this retrospective cohort study of 202 500 US Veterans with diabetes (2000-2014), measures included HbA_1c , outpatient random serum/plasma glucose, and incident retinopathy [conversion from negative to ≥2 positive evaluations (ICD-9 codes), without a subsequent negative].

RESULTS

At baseline, the study population had a mean age of 59.3 years, their mean BMI was 31.9 kg/m² , HbA_1c level was 57 mmol/mol (7.4%) and glucose level was 8.8 mmol/l, and 77% were of white European ancestry (white individuals) and 21% of black African ancestry (black individuals). HbA_1c was 0.3% higher in black vs white individuals (P < 0.001), adjusting for baseline age, sex, BMI, estimated glomerular filtration rate (eGFR), haemoglobin, and average systolic blood pressure and glucose. Over 11 years, incident retinopathy occurred in 9% of black and 7% of white individuals, but black individuals had higher HbA_1c , glucose, and systolic blood pressure (all P < 0.001); adjusted for these factors, incident retinopathy was reduced in black vs white individuals (P < 0.001). The population incidence of retinopathy (7%) was associated with higher mean baseline HbA_1c in individuals with black vs white ancestry [63 mmol/mol (7.9%) vs 58 mmol/mol (7.5%); P < 0.001)], but with similar baseline glucose levels (9.0 vs 9.0 mmol/l; P = 0.660, all adjusted for baseline age, sex and BMI).

CONCLUSIONS

Since retinopathy occurs at higher HbA_1c levels in black people for a given level of average plasma glucose, strategies may be needed to individualize the interpretation of HbA_1c measurements.

Racial differences in performance of HbA1c for the classification of diabetes and prediabetes among US adults of non-Hispanic black and white race

AIM

To characterize differences between black and white people in optimal HbA_1c thresholds for diagnoses of diabetes and prediabetes.

METHODS

Data were included from the National Health and Nutrition Examination Survey, 2005-2014. Black and white adults (age 18-70 years) who underwent an oral glucose tolerance test and had available fasting plasma glucose, 2-h plasma glucose and HbA_1c measurements were eligible for inclusion. Diabetes or prediabetes status was defined by fasting plasma glucose and 2-h plasma glucose using American Diabetes Association criteria. Classification of diabetes, prediabetes and dysglycaemia by HbA_1c was evaluated for a range of HbA_1c thresholds, with optimal thresholds defined as those values that maximized the sum of sensitivity and specificity (Youden's index).

RESULTS

In 5324 black (32.3%) and white (67.7%) individuals, Youden's index (optimal) thresholds for HbA_1c were ≥42 mmol/mol (6.0%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs non-diabetes, ≥ 44 mmol/mol (6.2%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs prediabetes (excluding normoglycaemia), ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating dysglycaemia vs normoglycaemia, and ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating prediabetes vs normoglycaemia (excluding diabetes), in black and white people, respectively.

CONCLUSIONS

Consistently higher optimal HbA_1c thresholds in black people than in white people suggest a need to individualize HbA_1c relative to glucose levels if HbA_1c is used to diagnose diabetes and prediabetes.

Organic Compounds in a Sub-Antarctic Ice Core: A Potential Suite of Sea Ice Markers

Investigation of organic compounds in ice cores can potentially unlock a wealth of new information in these climate archives. We present results from the first ever ice core drilled on sub-Antarctic island Bouvet, representing a climatologically important but understudied region. We analyze a suite of novel and more familiar organic compounds in the ice core, alongside commonly measured ions. Methanesulfonic acid shows a significant, positive correlation to winter sea ice concentration, as does a fatty acid compound, oleic acid. Both may be sourced from spring phytoplankton blooms, which are larger following greater sea ice extent in the preceding winter. Oxalate, formate, and acetate are positively correlated to sea ice concentration in summer, but sources of these require further investigation. This study demonstrates the potential application of organic compounds from the marine biosphere in generating multiproxy sea ice records, which is critical in improving our understanding of past sea ice changes.

Glucose challenge test screening for prediabetes and early diabetes

AIMS

To test the hypothesis that a 50-g oral glucose challenge test with 1-h glucose measurement would have superior performance compared with other opportunistic screening methods.

METHODS

In this prospective study in a Veterans Health Administration primary care clinic, the following test performances, measured by area under receiver-operating characteristic curves, were compared: 50-g oral glucose challenge test; random glucose; and HbA_1c level, using a 75-g oral glucose tolerance test as the 'gold standard'.

RESULTS

The study population was comprised of 1535 people (mean age 56 years, BMI 30.3 kg/m² , 94% men, 74% black). By oral glucose tolerance test criteria, diabetes was present in 10% and high-risk prediabetes was present in 22% of participants. The plasma glucose challenge test provided area under receiver-operating characteristic curves of 0.85 (95% CI 0.78-0.91) to detect diabetes and 0.76 (95% CI 0.72-0.80) to detect high-risk dysglycaemia (diabetes or high-risk prediabetes), while area under receiver-operating characteristic curves for the capillary glucose challenge test were 0.82 (95% CI 0.75-0.89) and 0.73 (95% CI 0.69-0.77) for diabetes and high-risk dysglycaemia, respectively. Random glucose performed less well [plasma: 0.76 (95% CI 0.69-0.82) and 0.66 (95% CI 0.62-0.71), respectively; capillary: 0.72 (95% CI 0.65-0.80) and 0.64 (95% CI 0.59-0.68), respectively], and HbA_1c performed even less well [0.67 (95% CI 0.57-0.76) and 0.63 (95% CI 0.58-0.68), respectively]. The cost of identifying one case of high-risk dysglycaemia with a plasma glucose challenge test would be $42 from a Veterans Health Administration perspective, and $55 from a US Medicare perspective.

CONCLUSIONS

Glucose challenge test screening, followed, if abnormal, by an oral glucose tolerance test, would be convenient and more accurate than other opportunistic tests. Use of glucose challenge test screening could improve management by permitting earlier therapy.

Intervention fidelity for a complex behaviour change intervention in community pharmacy addressing cardiovascular disease risk

Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements.

Aging is associated with increased HbA1c levels, independently of glucose levels and insulin resistance, and also with decreased HbA1c diagnostic specificity

AIM

To determine whether using HbA1c for screening and management could be confounded by age differences, whether age effects can be explained by unrecognized diabetes and prediabetes, insulin resistance or postprandial hyperglycaemia, and whether the effects of aging have an impact on diagnostic accuracy.

METHODS

We conducted a cross-sectional analysis in adults without known diabetes in the Screening for Impaired Glucose Tolerance (SIGT) study 2005-2008 (n=1573) and the National Health and Nutrition Examination Survey (NHANES) 2005-2006 (n=1184).

RESULTS

Both glucose intolerance and HbA(1c) levels increased with age. In univariate analyses including all subjects, HbA(1c) levels increased by 0.93 mmol/mol (0.085%) per 10 years of age in the SIGT study and by 1.03 mmol/mol (0.094%) per 10 years in the NHANES; in both datasets, the HbA(1c) increase was 0.87 mmol/mol (0.08%) per 10 years in subjects without diabetes, and 0.76 mmol/mol (0.07%) per 10 years in subjects with normal glucose tolerance, all P<0.001. In multivariate analyses of subjects with normal glucose tolerance, the relationship between age and HbA(1c) remained significant (P<0.001) after adjustment for covariates including race, BMI, waist circumference, sagittal abdominal diameter, triglyceride/HDL ratio, and fasting and 2-h plasma glucose and other glucose levels, as assessed by an oral glucose tolerance test. In both datasets, the HbA(1c) of an 80-year-old individual with normal glucose tolerance would be 3.82 mmol/mol (0.35%) greater than that of a 30-year-old with normal glucose tolerance, a difference that is clinically significant. Moreover, the specificity of HbA(1c) -based diagnostic criteria for prediabetes decreased substantially with increasing age (P<0.0001).

CONCLUSIONS

In two large datasets, using different methods to measure HbA(1c), the association of age with higher HbA(1c) levels: was consistent and similar; was both statistically and clinically significant; was unexplained by features of aging; and reduced diagnostic specificity. Age should be taken into consideration when using HbA(1c) for the diagnosis and management of diabetes and prediabetes.

Vitamin B12 deficiency in Australian residential aged care facilities

OBJECTIVE

To determine the prevalence of undiagnosed vitamin B12 deficiency among residential aged care facility residents in southern Tasmania, Australia, and to identify associated risk factors.

DESIGN AND SETTING

Cross-sectional study of residents from five southern Tasmanian residential aged care facilities.

PARTICIPANTS

Two hundred and fifty-nine residents without a prior diagnosis of vitamin B12 deficiency or recorded serum B12 level within the past 6 months were approached to have their serum B12 level tested. One hundred and sixty (61%) residents consented and their doctors were contacted for further consent. A total of 130 (50%) residents completed the study.

MEASUREMENTS

Clinical and demographic characteristics, and serum B12 level.

RESULTS

Of the 130 residents tested, 18 residents (14%) were considered vitamin B12 deficient (serum level <150 pmol/L), 47 (36%) were equivocal (150 pmol/L to 250 pmol/L) and 65 (50%) had normal serum B12 levels (>250 pmol/L). There was a weak negative correlation between age and serum B12 level in those residents not taking a multivitamin (n=120, r=-0.19, p<0.05). The use of a multivitamin or antipsychotic drug were associated with altered mean serum B12 levels (+137 pmol/L, p<0.001 and -70 pmol/L, p<0.001 respectively).

CONCLUSION

As vitamin B12 deficiency can manifest in a range of symptoms that are frequently misdiagnosed, the finding of undetected deficiency in 14% of residents is a cause for concern. Oral multivitamin supplementation may help prevent deficiency, and potentially treat existing deficiencies in older institutionalised people.

Warfarin management after discharge from hospital: a qualitative analysis

WHAT IS KNOWN AND OBJECTIVE

Warfarin is recognized as a high-risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient's discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post-discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post-discharge warfarin management service.

METHODS

Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion-based sampling within two Australian states. Semi-structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach.

RESULTS

Forty-seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home-delivered services are valuable to both patients and healthcare professionals.

DISCUSSION

Although high-quality warfarin education and effective communication at the hospital-community interface were identified as important in post-discharge warfarin management, deficiencies were perceived within current systems. The role of home-delivered services in ensuring timely follow-up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post-discharge management should therefore focus on providing patients with a solid foundation to minimize future problems.

WHAT IS NEW AND CONCLUSION

Addressing the three identified facets of care within a new, collaborative post-discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short- and longer-term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.

Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program

BACKGROUND

Despite the proven effectiveness of antithrombotic therapy for atrial fibrillation (AF), the treatment remains suboptimal. The aim of this study was to implement and evaluate a system to improve the appropriate use of antithrombotics for stroke prevention in AF utilizing a clinical pharmacist as a stroke risk assessor.

METHOD

Hospital in-patients with AF were prospectively identified and they received a formal stroke risk assessment from a pharmacist. The patients' risk of stroke was assessed and documented according to Australian guidelines and a recommendation regarding antithrombotic therapy was made to the medical team on a specially designed stroke risk assessment form.

RESULTS

One hundred and thirty-four stroke risk assessments were performed during the intervention period. For those patients at high risk of stroke and with no contraindication present (warfarin-eligible patients), 98% were receiving warfarin on discharge from hospital compared to 74% on admission (P < 0.001). Of the 50 (37%) assessments that recommended a change of therapy, 44 (88%) resulted in a change in the patient's current antithrombotic therapy compared to their admission therapy. Thirty (68%) of the assessments resulted in an 'upgrade' to more-effective treatment options for example from no therapy to any agent or from aspirin to warfarin.

DISCUSSION AND CONCLUSION

The pharmacist-led stroke risk assessment program resulted in a significant increase in the proportion of patients receiving appropriate thromboprophylaxis for stroke prevention in AF. The methods used in this study should be evaluated in a larger trial, in multiple hospitals, with different pharmacists performing the intervention.

A comparison of planar, laser-induced fluorescence, and high-sensitivity interferometry techniques for gas-puff nozzle density measurements

The distribution of argon gas injected by a 12-cm-diameter triple-shell nozzle was characterized using both planar, laser-induced fluorescence (PLIF) and high-sensitivity interferometry. PLIF is used to measure the density distribution at a given time by detecting fluorescence from an acetone tracer added to the gas. Interferometry involves making time-dependent, line-integrated gas density measurements at a series of chordal locations that are then Abel inverted to obtain the gas density distribution. Measurements were made on nominally identical nozzles later used for gas-puff Z-pinch experiments on the Saturn pulsed-power generator. Significant differences in the mass distributions obtained by the two techniques are presented and discussed, along with the strengths and weaknesses of each method.

Harm minimization strategies: opinions of health professionals in rural and remote Australia

BACKGROUND AND OBJECTIVE

There is some evidence that the problem of illicit drug use (IDU) is increasing in rural areas of Australia. Lack of access to harm minimization (HM) strategies is potentially exacerbated by a shortage of health care facilities and health care professionals in rural areas. This study was conducted to determine barriers to implementation, access to, and success of HM strategies, as seen by health professionals presently working in rural Australia.

METHODS

Four hundred rural pharmacists Australia-wide and 425 doctors in rural Victoria and Tasmania were sent postal surveys to assess their opinions on the level of IDU in their area, the types of drugs commonly used, the adequacy of HM strategies and facilities, and the barriers faced by doctors, pharmacists and clients.

RESULTS

The overall response rate was almost 50%. Slightly less than half of surveyed health professionals felt that IDU was increasing in their area, with heroin perceived to be the most prevalent drug used in all States except Tasmania and the Northern Territory. Both methadone prescribers and dispensers believed the methadone maintenance programmes were highly valuable to the community, but not without problems (e.g. risk of overdose). A lack of time or staff was the greatest influence on doctors not participating in the methadone programmes, whereas safety concerns were prominent with pharmacists. The majority of doctors felt HM facilities were inadequate, with needle-syringe exchange being the most frequently nominated HM strategy lacking.

CONCLUSION

Despite best intentions, there are still problems with HM strategies in these areas. Improving the number and expertise of health professionals in rural areas, and providing adequate support for them, would address some of these problems.

Development of an intelligent decision support system for medication review

BACKGROUND AND OBJECTIVE

The aim was to develop and evaluate a pilot version of a knowledge-based system that can identify existing and potential medication-related problems from patient information. This intelligent system could directly support pharmacists and other health professionals providing medication reviews.

METHODS

Rather than being based on static rules to trigger alerts, this system utilizes a multiple classification ripple-down rules approach, which allows the user to build rules incrementally and improve the accuracy of the knowledge base in identifying medication-related problems while the system is in use, with no outside assistance or training. The system contextualizes the potential drug therapy problems by taking into consideration the patient's demographics, and other medical condition and drugs. The system is capable of both being instructed in the domain of medication review through its routine use by an expert, and acting similarly to the expert when analysing genuine medication review cases. The system was handed over to an experienced clinical pharmacist (expert), with no knowledge or conclusions preloaded into the system. The expert was then able to add the case details and generate the rules required for 126 actual medication review cases.

RESULTS

Over 250 rules were generated from the review cases, incorporating demographics, medical history, symptoms, medications and pathology results from these cases. At the completion of the cases, more than 80% of the potential medication-related problems identified by the expert were also detected by the system. The false positive rate, or number of incorrect medication-related problems identified by the system, was <10% overall and was zero for the last 15 cases analysed. The system found significantly more potential medication-related problems than the expert, with the system consistently remaining at least one finding ahead. There was a high incidence of missed potential medication-related problems by the expert, which were automatically repaired by the system.

CONCLUSIONS

The knowledge-based system has already demonstrated that the technique employed is well suited to a domain of this nature and has furthermore demonstrated that it is capable of improving the quality of service that the medication reviewer can provide. The system will be further enhanced and tested prior to use in the field. It should help pharmacists in the provision of medication reviews, improving their clinical and time management capabilities, and enhancing their ability to contribute to the quality use of medications.

Mucor rouxii ultrastructure: cyclic AMP and actin cytoskeleton

A comparative analysis of the effect of two compounds, dibutyryl-cyclic-AMP (dbcAMP) and latrunculin B, on the morphology and ultrastructure of the dimorphic fungus Mucor rouxii under aerobic growth conditions is presented. dbcAMP acts through the sustained activation of protein kinase A, and latrunculin B through the disruption of the actin cytoskeleton. Upon addition of these compounds to the growth medium at any stage of the germination process, cells lost polarised growth and switched to isodiametric growth. The effect was reversible. The morphologies, visualised by light microscopy or scanning electron microscopy (SEM), were alike. A switch from a rough to a smooth surface was observed by SEM when cells were repolarised by removal of the added compound. Ultrastructural changes under both conditions, as observed by transmission electron microscopy, were similar, the main feature being the enlargement of the cell wall, with irregular depositions, and detachment from the cell membrane. dbcAMP-treated cells showed a decrease in the number of glycogen granules compared with control and latrunculin B-treated cells. F-actin staining with fluorescein isothiocyanate-phalloidin showed that both dbcAMP- and latrunculin B-treated cells displayed a much lower fluorescence than control cells, with only a few pale plaques. The results suggest that the sustained activation of protein kinase A, which impairs polarised growth, might exert its effect through a modification of actin cytoskeleton organisation, very probably also involving an integrinlike pathway, as judged by the cell wall detachment and loss of cell adhesiveness of the dbcAMP-treated isodiametric cells.

Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy

OBJECTIVE

The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs).

METHODS

A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing.

RESULTS

Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2.32+/-0.77 and 2.32+/-0.59 respectively; r=0.88, P<0.0001). A total of 398 additional pharmacy-based tests were conducted in the pharmacy and 8.5% of the additional tests resulted in a subsequent dosage change. The monitoring was well received by pharmacists, GPs and patients.

CONCLUSIONS

The results of the trial were very positive. The CoaguChek S monitor in pharmacy-based testing performed accurately compared with conventional laboratory testing. Further research needs to be conducted on the impact of community pharmacy-conducted INR monitoring on patient care and outcomes.

Improving the outcomes of anticoagulation: an evaluation of home follow-up of warfarin initiation

OBJECTIVES

A number of studies have reported that the risk of bleeding associated with warfarin is highest early in the course of therapy. This study examined the effect of a programme focused on the transition of newly anticoagulated patients from hospital to the community.

DESIGN

Open-label randomized controlled trial.

SETTING

Home-based follow-up of patients discharged from acute care hospital in southern Tasmania, Australia.

SUBJECTS

A total of 128 patients initiated on warfarin in hospital and subsequently discharged to general practitioner (GP) care were enrolled in the study. Sixty were randomized to home monitoring (HM) and 68 received usual care (UC).

INTERVENTIONS

HM patients received a home-visit by the project pharmacist and point-of-care international normalized ratio (INR) testing on alternate days on 4 occasions, with the initial visit two days after discharge. The UC group was solely managed by the GP and only received a visit 8 days after discharge to determine anticoagulant control.

RESULTS

At discharge, 42% of the HM group and 45% of the UC group had a therapeutic INR. At day 8, 67% of the HM patients had a therapeutic INR, compared with 42% of UC patients (P < 0.002). In addition, 26% of UC patients had a high INR, compared with only 4% of HM patients. Bleeding events were assessed 3 months after discharge and occurred in 15% of HM patients, compared with 36% of the UC group (P < 0.01).

CONCLUSIONS

This programme improved the initiation of warfarin therapy and resulted in a significant decrease in haemorrhagic complications in the first 3 months of therapy.

Accuracy, reproducibility and clinical utility of the CoaguChek S portable international normalized ratio monitor in an outpatient anticoagulation clinic

The accuracy and reproducibility of the CoaguChek S, and its clinical agreement with conventional laboratory international normalized ratio (INR) determination, were evaluated in an outpatient anticoagulation clinic setting. Forty-three patients provided 248 paired INR measurements for analysis. The paired results were highly correlated (r = 0.90). The mean coefficient of variation for the CoaguChek S for a random sample of 21 patients with three repeated tests each, was 4%. Clinical applicability was also measured by discrepant INR values, as defined in the literature by expanded and narrow agreement, and by INR values resulting in a different clinical decision by a blinded haematology registrar. Expanded agreement and narrow agreement between the two INR values occurred 90 and 88% of the time, respectively. The stricter criteria set down by the clinician resulted in 73% of paired results producing the same dosage decision. The CoaguChek S displayed good correlation with laboratory determination of INR and compared relatively well with expanded and narrow clinical agreement criteria.

Doctors' beliefs on the use of antithrombotic therapy in atrial fibrillation: identifying barriers to stroke prevention

AIMS

To assess the attitudes of Australian doctors towards the use of antithrombotic drug therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF), and investigate the barriers to prescribing warfarin.

METHODS

A postal survey was undertaken among approximately 10% of all registered general practitioners (GPs), cardiologists and physicians in Australia. The anonymous questionnaire used case scenarios to assess doctors' knowledge of current guidelines for the therapeutic management of AF and sought opinions on potential barriers to the use of anticoagulation.

RESULTS

Completed questionnaires were received from 711 doctors (30% response rate). The GPs performed better than the cardiologists and other specialists in estimating the risk of stroke in case scenarios. However, the cardiologists were more likely to select the recommended treatment, with GPs being more hesitant to use anticoagulation and tending to underestimate its reported benefit for stroke prevention in non-valvular AF. The GPs were also more likely to overestimate the reported risk of major bleeds with warfarin. In contrast, over one-third of the cardiologists went as far as to give warfarin to a low-risk patient and they were more likely to overestimate the reported benefit of aspirin and warfarin in AF. Only half the doctors correctly classified a patient without a previous stroke (but with other risk factors) as being at high risk. Increased experience as a registered medical practitioner was generally related to a poorer performance on classifying patients according to the risk of stroke. The principal barriers to the use of anticoagulation were nominated as: (i) active gastrointestinal bleeding, (ii) previous intracranial haemorrhage, (iii) alcoholism, (iv) a history of daily falls, (v) liver disease, (vi) severe anaemia and (vii) concurrent use of non-steroidal anti-inflammatory drugs.

CONCLUSION

There is scope for improvement in doctors' knowledge about the appropriate use of antithrombotic drug therapy in non-valvular AF and awareness of the results of recent clinical trials. Compilation and dissemination of clear guidelines and focused education on some of the other risk factors (apart from previous stroke or transient ischaemic attacks) in patients with non-valvular

Outcomes in the management of atrial fibrillation: clinical trial results can apply in practice

BACKGROUND

The benefits of antithrombotic therapy in chronic atrial fibrillation (AF) have been established in clinical trials, but there is a paucity of data on outcomes in practice.

AIMS

The objective was to establish a large ongoing database of patients with non-valvular AF, to enable the accurate determination of clinical outcomes.

METHODS

A retrospective review of the medical records for consecutive patients who had AF documented on electrocardiogram at the major teaching hospital in Tasmania between 1 January 1997 and 30 June 1999 was performed. An extensive range of demographic and clinical variables was recorded for all patients with chronic or paroxysmal non-valvular AF.

RESULTS

The 505 patients (60% males) included in the database had a median age of 76 years. According to risk stratification criteria, 79% of the patients with previously diagnosed chronic or paroxysmal AF had a high risk of developing stroke at the time of admission to hospital care. However, only one-third (34%) of these patients were receiving warfarin (or warfarin plus aspirin), with almost one-quarter (24%) receiving no antithrombotic agent. The annual incidence of ischaemic strokes was 3.4% (1.5-6.4%; 95% CI) when taking warfarin, compared to 7.0% (5.2-9.4%) for patients not taking warfarin and 7.8% (5.4-11.1%) for patients taking aspirin. The annual incidence of bleeding complications in patients taking warfarin was 14.2% (10.0-19.5%) overall and 3.4% (1.5-6.4%) for major bleeds. In patients not taking warfarin, the overall annual incidence of bleeds was 8.4% (6.3-10.9%) and 3.9% (2.5-5.7%) for major bleeds.

CONCLUSIONS

Warfarin is underused in patients with AF. In clinical practice, warfarin confers a similar stroke risk reduction to that observed in trials, with an increase in incidence of only minor bleeding complications. Aspirin did not appear to reduce the risk of stroke.

CT appearance of disseminated peritoneal adenomucinosis

Disseminated peritoneal adenomucinosis (DPAM) is a relatively rare cause of pseudomyxoma peritonei, marked by peritoneal lesions with abundant extracellular mucin and little cytologic atypia among exfoliated tumor cells, and usually associated with appendiceal adenomas. Peritoneal mucinous carcinomatosis (PMCA) also causes diffuse peritoneal tumor but is marked by neoplastic mucinous epithelium with cytologic features of carcinoma and associated with appendiceal, colon, gastric, or small bowel carcinoma. Compared with PMCA, DPAM has a different distribution of disease and a significantly better prognosis. DPAM is characterized by the lack of lymph node involvement, with primarily superficial peritoneal involvement, and a relatively benign, relapsing course over many years. Dominant primary masses may not be evident in DPAM. Despite considerable overlap in the two main causes of pseudomyxoma peritonei, there are features of the two that may help differentiate between them. We present the computed tomographic appearance of DPAM in a series of seven cases and emphasize characteristics of the disease.

Gelatinous ascites: a cytohistologic study of pseudomyxoma peritonei in 67 patients

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare condition characterized by gelatinous ascites. Although the histologic attributes of PMP have been well studied, the cytologic features remain ill defined.

METHODS

We reviewed the peritoneal washings (PW) in 67 patients with PMP to identify cytomorphologic features useful in classifying cases as either disseminated peritoneal adenomucinosis (DPAM) or peritoneal mucinous carcinomatosis (PMCA). Histologic specimens were correlated with the cytologic diagnoses. Correlation between cytologic diagnosis and patient outcome was investigated.

RESULTS

Neoplastic epithelial cells were identified in 63 of 67 PW (94%). Concordance with the histologic diagnosis was obtained in 61 of 63 cases. Of these 36.5% were cytologically classified as DPAM with primary appendiceal neoplasms in 19 cases. Thirty-four of 63 cases (53.9%) were cytologically diagnosed as PMCA based on PW cytology. Most were of appendiceal or colonic origin. Four cases displayed cytologic features of both DPAM and PMCA. Two discordant cases each with a cytologic diagnosis of PMCA had an appendiceal adenoma. Acellular mucin alone was identified in the PW in four cases. Analysis of follow-up data revealed that cases diagnosed as DPAM had a better prognosis than those diagnosed as PMCA.

CONCLUSIONS

Cytomorphologic features of epithelial cells in PW material can accurately categorize cases of PMP as either DPAM or PMCA. Furthermore, this categorization appears to have important prognostic implications.

Interfacing computerized biomechanical analysis in monitoring the motor development of children

This research investigated the effectiveness of using kinematic analysis to monitor the motor development of children on three fundamental movement patterns. 12 children with specific motor delays were filmed before and after participation in the 2-hr. per week, 7-wk. program. The film was analyzed (60 frames per second) using a 2-dimensional analysis system. There were no significant differences when a Wilcoxon matched pairs signed-ranks test was applied to the galloping and skipping center of gravity and linear velocities of the ball data. Timing of the peak linear velocities of the upper body showed subjects increasingly exhibited the more advanced, sequential pattern and no longer exhibited the less advanced simultaneous pattern after the program. It was concluded the changes in timing were evidence of improvements in coordination.

Radiation-induced gastrointestinal stromal sarcoma of the esophagus

Esophageal sarcoma is an uncommon tumor, sporadically reported in the literature. Radiation therapy is frequently employed in the treatment of carcinoma of the esophagus, and the increased risk of development of sarcoma arising in irradiated fields is well known. However, to our knowledge, the occurrence of radiation-associated sarcoma of the esophagus after radiation therapy for carcinoma of the esophagus has not been reported. We therefore report the case of a 43-year-old female who developed a gastrointestinal stroma sarcoma 9 years following radiation therapy for esophageal squamous cell carcinoma. The patient underwent resection of her gastrointestinal stromal sarcoma by transhiatal esophagectomy with cervical anastomosis and is doing well 18 months later. The increasing use of radiation therapy for esophageal carcinoma suggests that radiation-associated sarcoma of the esophagus may be seen more frequently in the future.

Traumatic subarachnoid haemorrhage: a 10-year case study and review

Fourteen cases of traumatic subarachnoid haemorrhage (TSAH) from the years 1985-1995 are described. Two of these cases, one paediatric and one involving controlled substances, are considered separately. All 14 cases are then discussed together with the current literature with respect to: typical subject, the circumstances and aetiology of injury, time interval between injury and collapse; time of survival, the role of alcohol, the site of arterial rupture, and the methods recommended by other authors for the location of such an injury. We conclude that TSAH is a poorly understood cause of sudden death; fuller research is needed to clarify aetiology.

Pelvic inflammatory disease in the postmenopausal woman

OBJECTIVE

Review available literature on pelvic inflammatory disease in postmenopausal women.

DESIGN

MEDLINE literature review from 1966 to 1999.

RESULTS

Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses.

CONCLUSION

Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.

Pelvic inflammatory disease in the postmenopausal woman

OBJECTIVE

Review available literature on pelvic inflammatory disease in postmenopausal women.

DESIGN

MEDLINE literature review from 1966 to 1999.

RESULTS

Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses.

CONCLUSION

Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.

Fecal incontinence in women

Pelvic floor disorders are common in women. Most gynecologists are well versed in the management of urinary incontinence and uterovaginal prolapse; however, knowledge of disorders involving the anorectum is often lacking. This review will discuss the issue of anorectal incontinence in women, attempt to provide a logical outline for evaluation and treatment, and offer potential methods of prevention.

Dynamic rearrangement of the filamentous actin network occurs during zoosporogenesis and encystment in the oomycete phytophthora cinnamomi

The organization of filamentous actin (F-actin) in living cells of the oomycete Phytophthora cinnamomi was determined during zoosporogenesis and zoospore encystment by microinjecting sporangia with fluorescently labeled phalloidin and observing resultant fluorescence by confocal microscopy. In multinucleate sporangia prior to the induction of cleavage, phalloidin labeling took the form of plaques which occurred mainly in the periphery of the sporangia. After induction of cleavage, phalloidin labeling showed that the plaques disappeared and that F-actin began to accumulate along the developing cleavage planes and around nuclei and water expulsion vacuoles. F-actin labeling was also observed near the plasma membrane in zoospores and young cysts but reverted to the plaque form in older cysts. Localization of F-actin close to the developing cleavage planes is consistent with the idea that actin microfilaments function in the positioning and expansion of the cleavage membranes. Observations of plaques of actin in living sporangia provide evidence that plaques are not aldehyde-induced fixation artifacts. Copyright 1998 Academic Press.

Sexually transmitted diseases in pregnancy

Sexually transmitted diseases are common complications of pregnancy and may have significant maternal/fetal effects. Knowledge of the symptoms and physical examination features, methods of diagnosis, indications for screening, and appropriate treatment options are essential for obstetric/gynecologic health care providers.

Fecal incontinence in women with urinary incontinence and pelvic organ prolapse

OBJECTIVE

To determine the prevalence of and factors associated with fecal incontinence in women with urinary incontinence or pelvic organ prolapse.

METHODS

Study subjects were recruited prospectively, and all participants received questionnaires regarding bowel function and underwent a standardized history and physical examination. Fecal incontinence was defined as the involuntary loss of feces sufficient to be considered a problem by the patient.

RESULTS

Forty-two subjects had fecal incontinence, an overall prevalence of 17%. One hundred seventy women had urinary incontinence, pelvic organ prolapse, or both, and 36 of these (21%) had fecal incontinence. One hundred (40%) women had urinary incontinence, of whom 31 also had fecal incontinence. Seventy women had isolated pelvic organ prolapse and five (7%) were incontinent of feces. Univariate analysis revealed that any degree of pelvic organ prolapse, increasing degrees of prolapse within each vaginal segment, urinary incontinence, advanced age, postmenopausal status, increased vaginal parity, prior hysterectomy, history of irritable bowel syndrome, and abnormal sphincter tone were associated significantly with fecal incontinence. Multiple logistic regression analysis indicated that only urinary incontinence (odds ratio [OR] 4.6, P < .001, 95% confidence interval [CI] 1.9, 11.2), abnormal anal sphincter tone (OR 2.3, P = .04, 95% CI 1.1, 5.1), and irritable bowel syndrome (OR 8.3, P = .002, 95% CI 2.1, 32.8) were associated with fecal incontinence.

CONCLUSIONS

There is a high rate of fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Clinicians providing health care to a similar group of women should inquire routinely and specifically about fecal incontinence.

A transient rise in cytoplasmic free calcium is required to induce cytokinesis in zoosporangia of Phytophthora cinnamomi

We studied the role of cytoplasmic free Ca2+ concentration ([Ca2+]i) in cytokinesis of zoosporangia of the water mold Phytophthora cinnamomi. In these cells cytokinesis is separated from nuclear division and can be triggered at precisely determined times by cold shock. Changes in [Ca2+]i were monitored by ratiometric fluorescence imaging of pressure microinjected Fura-2 dextran. Two increases in [Ca2+]i always occurred in sporangia that underwent cytokinesis in response to cold shock. Within the first minute of cold shock, [Ca2+]i rose rapidly and transiently to levels 25 to 131% higher than the resting level of 104 +/- 54 nM. By 10 min, [Ca2+]i had decreased and was near the initial resting level. The second increase in [Ca2+]i was gradual and prolonged, accompanying cell division. Near completion of cytokinesis, [Ca2+]i had risen to 231 +/- 165 nM. The initial brief rise in [Ca2+]i was absent in sporangia that did not undergo cleavage. Microinjection of the Ca2+ buffer 5,5'-dibromo-BAPTA before cold shock, blocked cytokinesis suggesting that the transient rise in [Ca2+]i may be necessary for induction. The subsequent gradual increase in [Ca2+]i may not be critical because microinjection of 5,5'-dibromo-BAPTA during cleavage plane development did not always perturb division.

Roles of calcium ions in hyphal tip growth

A role for Ca2+ in the tip growth process of fungal hyphae and other eukaryotic walled cells has been widely explored, following the earlier indications of their importance by Jaffe, Steer, and their colleagues. Analysis of the literature on fungi, with selected comparison with other tip-growing plant cells, shows that the growth rate and morphology of hyphae are sensitive to factors which influence intracellular Ca2+. These factors include variations in extracellular Ca2+ concentrations, Ca2+ ionophores, inhibitors of Ca2+ transport, and calmodulin- and Ca(2+)-binding dyes and buffers introduced into the cytoplasm. The effects of these agents appear to be mediated by a tip-high gradient of cytoplasmic free Ca2+ which is obligatorily present in all critically examined growing tips. Most recent observations agree that the gradient is very steep, declining rapidly within 10 to 20 microns of the tip. This gradient seems to be generated by the combined effects of an influx of Ca2+, via plasma membrane, possibly stretch-activated, channels localized in the hyphal tip, and subapical expulsion or sequestration of these ions. Expulsion probably involves a plasma membrane Ca(2+)-ATPase, but it is not yet possible to differentiate among mitochondria, endoplasmic reticulum, or vacuoles as the dominant sites of sequestration. It is suggested that regulation of the Ca2+ gradient in turn modulates the properties of the actin-based component of the cytoskeleton, which then controls the extensibility, and, possibly, the synthesis of the hyphal apex. Regulatory feedback mechanisms intrinsic to this model of tip growth regulation are briefly discussed, together with suggestions for future experiments which are crucial to its further elucidation and establishment.

Ion channel activity and tip growth: tip-localized stretch-activated channels generate an essential Ca2+ gradient in the oomycete Saprolegnia ferax

The plasma membrane of tip-growing hyphae of the oomycete Saprolegnia ferax contains stretch-activated (SA) Ca(2+)-permeable and Ca(2+)-activated K+ ion channels. Patch clamp measurements on protoplasts derived from specific regions of hyphae demonstrated that SA channels were most abundant in the tip. Gadolinium (Gd3+) inhibited SA channel activity and stopped tip growth. The Ca(2+)-sensitive fluorochrome INDO 1 revealed a tip-high gradient of free cytoplasmic Ca2+ in growing hyphae. This gradient could be dissipated with the addition of Gd3+. The calcium gradient returned and growth resumed when Gd3+ was washed out. This implies a fundamental requirement for growth for Ca2+ influx through the SA channels. Ca(2+)-activated K+ channels were distributed evenly along the hyphae. These channels were inhibited by tetraethylammonium concentrations which caused a rapid but transient decrease in growth. We suggest that the SA channels at the apex act as feedback sensors, responding to membrane stretching at the tip. They are an obligate requirement for tip growth. The Ca(2+)-activated K+ channels may act to maintain turgor pressure, but are not obligatory for growth.

Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study

A sample of 761 subjects 70 years and over was drawn from general-practice records of a rural township. Each subject was assessed and followed for 1 year to determine the incidence of and factors related to falls. The fall rate (number of falls per 100 person-years) increased from 47 for those aged 70-74 years to 121 for those 80 years and over. There was no sex difference in fall rate but men were more likely than women to fall outside and at greater levels of activity. Twenty per cent of falls were associated with trips and slips but we found no evidence that inspection of homes and installation of safety features would have decreased the fall rate. Ten per cent of falls resulted in significant injury. Men who fell had an increased subsequent risk of death compared with those who did not fall (relative risk 3.2, 95% CI 1.7-6.0). Subsequent mortality was increased among women who fell but not to significant levels (relative risk 1.6, 95% CI 0.9-2.7).