The insulin response to intravenous fructose in maturity-onset diabetes mellitus and in normal subjects.

Insulin responses to intravenous fructose and glucose were measured in 15 patients with maturity-onset diabetes mellitus. In eight patients given fructose first the insulin responses to fructose and glucose were similar. In seven patients given glucose first the insulin response to subsequently infused fructose was significantly greater than to glucose. Multiple regression analysis showed that the ratio of the fructose to glucose insulin response, assessed by area under the insulin serum concentration-time curve (F/G ratio) in individual patients, correlated most closely with prefructose infusion plasma glucose. Similar analysis, applied to results in 27 normal subjects, showed that the most important determinant of the insulin response to fructose in this group also was the immediate prefructose infusion plasma glucose. Thus in diabetics, as in normal controls, the response of the beta cell to intravenous fructose appears to be sensitively set by the ambient plasma glucose concentration at the onset of fructose infusion.

The insulin response to intravenous fructose in relation to blood glucose levels.

The insulinotropic action of intravenous fructose was examined in 24 subjects without known metabolic disease. When blood glucose values before the fructose infusion were at or below normal fasting levels, fructose elicited only a small plasma insulin response. In contrast, the insulin response was strikingly augmented when preinfusion blood glucose and plasma insulin levels were moderately elevated. The insulinotropic action of fructose appears closely related to the preinfusion blood glucose level. Fructose has little or no insulinotropic action in the absence of glucose but potentiates glucose-mediated insulin release. The insulinotropic potency of other glucose analogues in vivo may show a similar dependence on concomitant blood glucose levels.

Artificial ultraviolet whole-body radiation does not modify serum lipoprotein, plasma fibrinogen, plasminogen or antithrombin III concentrations in post-myocardial infarction patients.

The relationship of ischaemic heart disease (IHD) to seasonal and latitude variation has prompted speculation that exposure to the ultraviolet component of solar radiation may reduce IHD risk. This hypothesis was partially tested by exposing 14 post-myocardial infarction patients to a 6 week course of artificial whole-body ultraviolet radiation (UVR). Serum lipoprotein and plasma coagulation factor concentrations were measured before and after the course of UVR. Results were compared with similar measurements from a placebo-controlled group of 13 post-myocardial patients. Despite a more than two-fold rise in mean serum 25-OHD, serum lipoprotein and plasma fibrinogen, antithrombin III and plasminogen concentrations did not change significantly in the UVR group. Significant but minor change in prothrombin time and thrombin time in the placebo group appear unlikely to be of biological significance. Seasonal and latitude variation in these IHD risk factors appear unrelated to corresponding variation in solar UVR exposure.

Unexplained swelling symptoms in women (idiopathic oedema) comprise one component of a common polysymptomatic syndrome.

BACKGROUND: Non-menstrually-related swelling symptoms (idiopathic oedema) are common in women. The community prevalence of such symptoms, their association with other symptoms, and their underlying aetiology, are uncertain. AIM: To determine the community prevalence of swelling symptoms and the independent contributions of major risk factors. DESIGN: Comparison of major risk factors in women with and without swelling symptoms. METHODS: We assessed 196 women attending a menopause clinic, 201 women attending a fracture clinic and 201 women attending their general practitioner. Each documented family histories of swelling symptoms and diabetes mellitus, age, height and current weight. Women attending the menopause and fracture clinics also completed Visual Analogue Symptom (VAS) scales documenting the perceived severity of swelling symptoms, and of 20 affective, somatic and functional autonomic symptoms. The independent contributions of risk factors to swelling symptom risk were estimated by logistic regression analysis. RESULTS: Of those attending a fracture clinic or their general practitioner, 28% and 33%, respectively, experienced non-menstrually-related swelling symptoms in the month before interview. Severe (RR 43, 95%CI 16-112, p < 0.001) and moderate (RR 7.8, 95%CI 4-15, p < 0.001) affective symptoms, a family history of swelling symptoms (RR 4.5, 95%CI 2.3-8.8, p < 0.001) and a body mass index (BMI) >or=25 kg/m(2) (RR 4.8, 95%CI 2.5-8.9, p < 0.001) were significantly associated with the presence of mild to severe swelling symptoms (VAS 1-9). The prevalence of swelling symptoms increased from 8% in women with no risk factors to 100% in women with three risk factors, which included severe affective symptoms. DISCUSSION: Affective symptom severity provides the principal independent contribution to swelling symptom risk. BMI >or=25 and a family history of swelling symptoms provide smaller independent contributions. The nature of the mechanisms underlying these associations remains uncertain.

The role of diuretics in the aetiology of idiopathic oedema.

The hypothesis that diuretic use and abuse and other purging behaviours cause idiopathic oedema was investigated in 102 patients. Of 91 symptomatic idiopathic oedema patients tested at referral, 16 (17.6%) had diuretic and four (4.4%) laxative in their urine. None had grossly disturbed serum urea and electrolytes. Examination of primary care records from 41 idiopathic oedema patients who denied current diuretic consumption, and denied or were uncertain about past consumption, showed that 20 had not been prescribed diuretics by their general practitioners at any time; a further 18 had not been prescribed diuretics for between seven months and 12 years before referral. The absence of evidence of plasma volume depletion (as judged by similar concentrations of mean serum urea, creatinine, total protein and albumin in patient and age-matched control groups) suggests that neither systematic diuretic and laxative use or abuse, nor episodic overeating and vomiting were responsible for symptoms of idiopathic oedema in our patients. Idiopathic oedema has a strong genetic basis, and correction of major and minor risk factors for this condition leads to substantial amelioration of symptoms in most cases.

Changes in the incidence of acute appendicitis in Glasgow Asian and white children between 1971 and 1985.

Between 1971 and 1985 there was a significant rise in the annual hospital discharge rate for acute appendicitis in Glasgow Asian boys aged 10-19.9 years. A smaller and statistically insignificant rise occurred in Asian girls of 10-19.9 years; discharge rates for younger Asian boys and girls did not change significantly. In keeping with national trends, discharge rates for acute appendicitis in all Glasgow children fell significantly between 1971-85. The divergent trend in older Asian children may reflect dietary adaptation which is most marked in older Asian boys.

Seasonal variation in coronary heart disease in Scotland.

STUDY OBJECTIVE: Seasonality of coronary heart disease (CHD) was examined to determine whether fatal and non-fatal disease have the same annual rhythm. DESIGN: Time series analysis was carried out on retrospective data over a 10 year period and analysed by age groups ( < 45 to > 75 years) and gender. SETTING: Data by month were obtained for the years 1962-71. The Registrar General provided information on deaths and the Research and Intelligence Unit of the Scottish Home and Health Department on hospital admissions. SUBJECTS: In Scotland, between 1962 and 1971, 123 000 patients were admitted to hospital for CHD, of whom 29 000 died. There were a further 97 000 CHD deaths outside hospital. These two groups were also examined as one (coronary incidence) - that is, all coronary deaths and coronary admissions discharged alive. STATISTICAL ANALYSIS AND MAIN RESULTS: Where there was a single annual peak, the sine curve was analysed by cosinor analysis. When there were two peaks the analysis was by normal approximation to Poisson distribution. In younger men (under 45 years) admitted to hospital there was a dominant spring peak and an autumn trough. A bimodal pattern of spring and winter peaks was evident for hospital admissions in older male age groups: with increasing age the spring peak diminished and the winter peak increased. In contrast, female hospital admissions showed a dominant winter/summer pattern of seasonal variation. In male and female CHD deaths seasonal variation showed a dominant pattern of winter peaks and summer troughs, with the winter peak spreading into spring in the two youngest male age groups. CHD incidence in women showed a winter/summer rhythm, but in men the spring peak was dominant up to the age of 55. CONCLUSION: The male, age related spring peak in CHD hospital admissions suggests there is an androgenic risk factor for myocardial infarction operating through an unknown effector mechanism. As age advances and reproduction becomes less important, the well defined winter/summer pattern of seasonal variation of CHD is superimposed, and shows a close relationship with the environment, especially temperature, or the autumn and early winter fall in temperature.

A possible relationship between high-extraction cereal and rickets and osteomalacia.

The evidence of the present study suggests a strong and possibly causal relationship between high-extraction cereal and rickets and osteomalacia. It seems likely that this occurs when vitamin-D status is border-line. The rachitogenic component of high-extraction cereal remains to be identified; dietary phytate now seems unlikely and phytate-derived polyphosphate esters or dietary phosphorus may be incriminated. The present study strongly indicates that Mellanby's original suggestion of an "anti-calcifying substance" in high-extraction cereal remains valid.

Hypernatraemic dehydration in patients in a large hospital for the mentally handicapped.

OBJECTIVE: To determine the prevalence of hypernatraemic dehydration and to assess the hydration and nutritional state of patients in a large hospital for the mentally and physically handicapped; also to assess the efficacy of an intervention programme to reduce the prevalence of hypernatraemic dehydration in the hospital. DESIGN: Prospective study of patients admitted with hypernatraemic dehydration from a large hospital for mentally and physically handicapped patients (hospital A) to a district general hospital between 1986 and 1988. In 1986 the hydration and nutritional state of a random sample of patients from hospital A was compared with a random sample of patients from a small hospital for the physically and mentally handicapped (hospital B) and with control groups from the community. The hydration of the patients from hospital A examined in 1986 was reassessed in 1988. PATIENTS: 12 Patients were admitted from hospital A to the district general hospital during 1986-8 (seven women, five men; age range 29-82). In 1986, 72 patients were randomly selected for the assessment of hydration and nutritional state from hospital A, 33 who required help with feeding and 39 who could feed independently. Fifty patients were similarly selected from hospital B, half of them requiring help with feeding. In 1988 the hydration state of 60 of the 72 patients from hospital was reassessed. Control values were taken from two published studies. INTERVENTIONS: In 1987 nursing staff in hospital A were asked to provide between 2.5 and 3.0 litres of fluid daily for all patients. The use of hypertonic enemas was discontinued, and the ratio of staff to patients was increased. MAIN OUTCOME MEASURES: Serum concentrations of urea and electrolytes (hydration) and body mass index (nutritional state). RESULTS: Of the 10 patients admitted with hypernatraemic dehydration from hospital A to the district general hospital in 1986, four died of intercurrent infection. No patients were admitted from hospital B with hypernatraemic dehydration during the same time. In 1986 the hydration and nutritional state of patients in hospital A were inferior to those in patients from hospital B and control subjects from the community (serum urea concentrations were 6.1 (SD 1.8) mmol/l v 5.5 (1.9) and 5.6 (0.4) mmol/l, respectively) 50% (36/72) of patients in hospital A had a body mass index less than or equal to 20 compared with 34% (17/50) of patients from hospital B and 12% (1141/9434) of control subjects). After the initiation of the preventive programme only one patient was admitted with hypernatraemic dehydration in each of the years 1987 and 1988. The mean serum urea concentration of the 60 patients who were reassessed in 1988 fell significantly between 1986 and 1988 from 6.1 (SD 1.8) mmol/l to 5.7 (2.1) mmol/l, the value in a control group matched for age and sex. CONCLUSIONS: Hypernatraemic dehydration, subclinical underhydration, and undernutrition were common in a large hospital for the mentally and physically handicapped. The problem of hypernatraemic dehydration was successfully dealt with by the hospital management team. Similar problems may be encountered in hospitals for patients who are mentally and physically handicapped and mentally ill, including psychogeriatric units.

Excessive beer consumption and beri-beri.

Alcohol-induced 'wet' or cardiac beri-beri is reported in two middle-aged males who consumed excessive amounts of beer. The high carbohydrate and satiety value of beer together with its low thiamine content places the alcoholic beer drinker at particular risk of thiamine deficiency.

The prevention of vitamin D deficiency in the elderly.

Vitamin D deficiency is common in the house-bound and institutionalised elderly population of Britain. A study of patients over 65 years discharged with a diagnosis of osteomalacia from Greater Glasgow Health Board hospitals between 1970 and 1981 inclusive showed a low incidence in the 65 to 74 years age group but a steeply rising incidence in older age groups. The majority (83%) of patients were female. The fortification of margarine, butter and milk with concentrations of vitamin D acceptable to the general population does not produce significant elevations in serum 25-hydroxyvitamin D (25-OHD) levels in vitamin D-deficient elderly patients. Low intensity background ultraviolet radiation (UVR) and intermittent high intensity UVR produce significant elevations in serum 25-OHD levels in elderly patients but both methods have disadvantages which limit their widespread use. Vitamin D supplements equivalent to 10 micrograms daily produce significant elevations in serum 25-OHD levels in vitamin D-deficient elderly patients. A vitamin D supplement policy for the housebound and institutionalised elderly population of Britain is required.

Acute services. Time to strip the beds?

The health authority and trust proposals for Birmingham's health services, currently the subject of consultation, are radical, untested and uncosted. They assume that once emergency assessment and ambulatory care centres are operational, under half the current caseload will need inpatient stays. University Hospital Birmingham trust's proposal for a new hospital built and operated by the private sector assumes no growth in activity and a 17 per cent reduction in the present bed complement, at a time when emergency admissions in Birmingham are increasing by 5 per cent a year. Analysis of the proposals suggests they will destabilise an already precarious acute service in Birmingham.