CORB is the best pneumonia severity score for elderly hospitalised patients with suspected pneumonia.

Pneumonia severity scoring systems have been developed to identify patients at highest mortality risk, and are used in guidelines to limit use of broad-spectrum antibiotics to patients with severe community-acquired pneumonia. A retrospective audit of hospitalised general internal medicine patients with pneumonia was performed to assess the diagnostic performance of various pneumonia severity scores in an elderly general internal medicine population.

Hyponatraemia in older medical patients: implications for falls and adverse outcomes of hospitalisation.

BACKGROUND: Recent evidence suggests an association between hyponatraemia and falls. AIMS: To determine the association of hyponatraemia with admission-associated falls (i.e. falls as part of the presenting complaint or during admission) and predefined adverse outcomes of hospitalisation. METHODS: A case-control study of patients aged ≥65 years admitted with hyponatraemia during a 6-month period was conducted. The relevant data were collected by review of medical records and analysed in univariate and multivariate models. RESULTS: The prevalence of hyponatraemia was 22% and more likely to be associated with the admission diagnoses of cardiovascular (P = 0.04) and metabolic disorders (P < 0.001), use of diuretics (P = 0.037) and a higher Charlson comorbidity score (P = 0.035). Hyponatraemia was independently associated with admission-associated falls (odds ratio (OR) 3.12, confidence interval (CI) 1.84-4.38, P < 0.001). The increased odds of falling were similar for mild (OR 3.15, CI 1.75-5.66) vs moderate to severe hyponatraemia (OR 3.07, CI 1.57-6.03). Although hyponatraemia had a significant independent association with increased length of stay (LOS) (OR 1.48, CI 1.22-1.79, P < 0.001) and change in residential care status to a more dependent category at discharge (OR 4.28, CI 1.68-10.859, P = 0.002), it was not associated with mortality or time to first unplanned readmission. Hyponatraemia was significantly associated with the need for inpatient rehabilitation; however, this was no longer significant when adjusted for falls. CONCLUSION: Hyponatraemia is independently associated with increased risk of admission-associated falls. The degree of falls risk is similar regardless of the severity of hyponatraemia. Hyponatraemia is also an important determinant of many adverse outcomes of hospitalisation.

Ethnic comparison of the association of undiagnosed diabetes with obesity.

OBJECTIVE: The aim of the study was to investigate the crude prevalence and estimated probability of undiagnosed diabetes in different ethnic groups, given the same level of obesity. DESIGN AND SUBJECTS: Cross-sectional data from 24 515 men and 29 952 women, aged >or=30 years, and free of previously diagnosed diabetes were included. Baseline body mass index (BMI) and waist circumference were measured. Diabetes was defined according to both fasting and 2-h 75-g glucose criteria. RESULTS: Prevalence of undiagnosed diabetes was the highest in Asian Indians, the lowest in Europeans and intermediate in others, given the same BMI or waist circumference category across the BMI or waist circumference ranges (P<0.001 for all BMI or waist categories). beta-Coefficients corresponding to a 1 s.d. increase in BMI were 0.34/0.28, 0.41/0.43, 0.42/0.61, 0.36/0.59 and 0.33/0.49 for the Asian Indians, Chinese, Japanese, Mauritian Indians and European men/women (homogeneity test: P>0.05 in men and P<0.001 in women), and in waist: 0.31/0.31, 0.30/0.46, 0.22/0.57 and 0.38/0.58 for the Asian Indians, Chinese, Mauritian Indians and Europeans, respectively (homogeneity test: P>0.05 in men and P<0.001 in women). CONCLUSION: Prevalence of undiagnosed diabetes increased with an increasing BMI or waist circumference to a similar degree in men in all ethnic groups but to a lesser degree in Asian Indian women than in others, regardless of the higher prevalence in Asian Indians than in others at the same BMI (or) waist circumference levels.

Does abnormal insulin action or insulin secretion explain the increase in prevalence of impaired glucose metabolism with age in populations of different ethnicities?

BACKGROUND: Age is associated with both impaired glucose and insulin metabolism. To what extent the age-related changes in insulin resistance (IR) and beta-cell function contribute to the increase in prevalence of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) is less known, and this is investigated in this study. METHODS: This study included 6610 men and 7664 women of different ethnic groups aged 30-69 years. IR and beta-cell function were examined by the homeostasis model assessment of insulin resistance (HOMA-IR) and homeostasis model assessment of beta-cell function (HOMA-B). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated using logistic regression analysis adjusting for body mass index and study. RESULTS: In Chinese men, the ORs (95% CIs) for IFG were 2.69 (1.70, 4.26), 2.51 (1.49, 4.21) and 2.89 (1.68, 4.97), respectively, in age groups of 40-49, 50-59 and 60-69 years compared with 30-39 years (p < 0.001 for trend); the corresponding figures for IGT were 1.73 (1.25, 2.38), 2.54 (1.78, 3.63) and 3.57 (2.46, 5.19) (p < 0.001 for trend). Similar trends for IGT were observed also in Chinese women and other ethnic groups, but not for IFG in Mauritius Indian and Creole men. Adjustment for HOMA-IR and HOMA-B reduced the ORs in all age groups of all ethnicities for both IFG and IGT, but the risk gradient between age groups remained particularly for the IGT. CONCLUSIONS: The age-related increase in glucose intolerance may not be fully explained by the defect in HOMA-IR and HOMA-B. As HOMA-IR and HOMA-B are only surrogate measures of insulin sensitivity and insulin secretion, the results need to be further investigated.

The effect of the sex, age, and breed of farmed rabbits and the choice of management system on the extensity and intensity of Eimeria infection.

BACKGROUND AND AIM: The most common causes of loss and diarrhea in rabbit farming are nutritional errors and coccidiosis. The infection can spread rapidly throughout a breeding area, reducing the rabbit population, and causing heavy losses. The aim of the study was to determine the influence of the system of animal management on the extensity and intensity of infection by Eimeria of farmed rabbits, together with the effect of the sex, age, and breed of the rabbits themselves. MATERIALS AND METHODS: The study included 91 rabbits (Flemish Giant, New Zealand White, French Lope, Vienna Blue, California White, and mixed breed) from eight domestic (small-scale) farms from Poland. The prevalence and intensity of coccidial infection were determined by the Willis-Schlaf and McMaster coprological methods. The species were determined based on oocyst morphology: Their shape, color, form index, the presence or absence of micropyle and cap, and the presence or absence of residual, polar, and Stiedé bodies. RESULTS: Seven species of Eimeria were isolated from the tested rabbits: Eimeria magna, Eimeria media, Eimeria perforans, Eimeria stiedae, Eimeria coecicola, Eimeria exigua, and Eimeria irresidua. Most infections were found to be of relatively low intensity. No significant differences in the extensity of Eimeria protozoan infection were observed with regard to sex. However, rabbit age had a significant influence on the extensity of infection by E. magna and of Eimerian protozoans combined. The greatest extensity was observed in rabbits aged below 6 months. For all species of Eimeria, greater extensity was observed among rabbits kept in groups than individually. The system of rabbit management also had a significant influence on the intensity of infection. Those kept in groups demonstrated a significantly higher mean intensity of infection of E. magna and all Eimeria species combined than those kept individually. CONCLUSION: Our findings indicate that Eimeria protozoa are a common occurrence on small-scale rabbit farms. As coccidiosis treatment does not always give good results, prevention is very important in the fight against this disease. It is necessary to develop a new preventive paradigm that pays special attention to the factors that promote the spread and development of infection in domestic (small-scale) farms from Poland. For example, it would be recommended to use large, dry, bright rooms with access to the sun, as these are conducive to preventing the occurrence of coccidia infections.

Blood lipid levels in relation to glucose status in seven populations of Asian origin without a prior history of diabetes: the DECODA study.

BACKGROUND: Dyslipidaemia commonly coexists with diabetes. We investigated the association of lipid profiles with glucose levels in populations of Asian origin without a prior history of diabetes. METHODS: Cross-sectional data of 10,374 men and 12,552 women aged 30-74 years from 14 cohorts, representing seven populations of Asian origin were jointly analysed. Multivariable adjusted linear regression analyses with standardized regression coefficients (beta) were performed to estimate relationships between lipids and plasma glucose. RESULTS: Within each glucose category, fasting plasma glucose (FPG) levels were correlated with increasing levels of triglycerides (TGs), total cholesterol (TC), TC to high-density lipoprotein (HDL) ratio and non-HDL cholesterol (non-HDL-C) (p < 0.05 in most of the ethnic groups) and inversely associated with HDL-C (p < 0.05 in some, but not all, of the populations). The association of lipids with 2-h plasma glucose (2hPG) followed a similar pattern as that for the FPG, except that an inverse relationship between HDL-C and glucose was more commonly observed for 2hPG than for FPG among different ethnic groups. CONCLUSIONS: Hyperglycaemia is associated with adverse lipid profiles in Asians without a prior history of diabetes. The 2hPG appears to be more closely associated with lipid profiles than does FPG. When assessing the risk of cardiovascular disease, the association of the dyslipidaemia with intermediate hyperglycaemia needs to be considered.

A socio-historical hypothesis for the diabetes epidemic in Chinese--preliminary observations from Hong Kong as a natural experiment.

It has been hypothesized that the emerging epidemic of diabetes in economically transitioning or recently transitioned populations is due to mismatch between developmental and mature environments. We took advantage of migration within an ethnically homogenous population to investigate this hypothesis, and the potentially modifying role of postnatal growth conditions, proxied by greater height. We used multivariable logistic regression in a population-based cross-sectional study from 1994 to 1996 of 2,341 long-term Hong Kong residents aged 25-74 years, either born in contemporaneously developed Hong Kong or migrants from economically undeveloped Guangdong. Migrant status was not associated with clinically diagnosed diabetes, odds ratio 1.05 (95% confidence interval 0.69-1.58) in adult migrants compared to Hong Kong-born natives and 1.22 (0.83-1.80) in preadult migrants, adjusted for age, sex, socio-economic position, and lifestyle. However, the association of diabetes with migrant status varied with height, suggesting a potentially complex relationship between indicators of prenatal and postnatal nutritional exposures. Compared to tall Hong Kong-born natives, the odds ratio of diabetes was 2.36 (1.20-4.61) in tall migrants, 1.94 (1.07-3.53) in short Hong Kong-born natives, but 1.04 (0.48-2.23) in short adult migrants. Additionally adjusting for body mass index and waist-hip ratio had little effect, apart from attenuating the association between short height and diabetes prevalence in Hong Kong-born natives. Whether the current epidemic of diabetes is a long-standing effect of such mismatch or a "first-generation through effect" generated by rapid economic development causing disproportionate growth remains to be determined.

GooD4Mum: A general practice-based quality improvement collaborative for diabetes prevention in women with previous gestational diabetes.

AIMS: Gestational diabetes (GDM) and Type 2 diabetes pose tremendous health and economic burdens as worldwide incidence increases. Primary care-based systematic diabetes screening and prevention programs could be effective in women with previous GDM. GooD4Mum aimed to determine whether a Quality Improvement Collaborative (QIC) would improve postpartum diabetes screening and prevention planning in women with previous GDM in general practice. METHODS: Fifteen general practices within Victoria (Australia) participated in a 12-month QIC, consisting of baseline and four quarterly audits, guideline-led workshops and Plan-Do-Study-Act feedback cycles after each audit. The primary outcome measures were the proportion of women on local GDM registers completing a diabetes screening test and a diabetes prevention planning consultation within the previous 15 months. RESULTS: Diabetes screening increased with rates more than doubled from 26% to 61% and postpartum screening increased from 43%-60%. Diabetes prevention planning consultations did not show the same level of increase (0%-10%). The recording of body mass index improved overall (51%-69%) but the number of women with normal body mass index did not. CONCLUSIONS: GooD4Mum supported increased diabetes screening and the monitoring of high risk women with previous GDM in general practice.

Prevalence, detection and drug treatment of hypertension in a rural Australian population: the Greater Green Triangle risk factor study 2004-2006.

BACKGROUND: Hypertension is an important risk factor for cardiovascular disease; however, limited findings are available on its detection and management in rural Australia. AIM: To assess the prevalence, awareness and treatment of hypertension in a rural South-East Australian population. METHODS: Three cross-sectional surveys in Limestone Coast, Corangamite Shire and Wimmera regions during 2004-2006 using a random population sample (n = 3320, participation rate 49%) aged 25-74 years. Blood pressure was measured by trained nurses. Information on history of hypertension and medication was obtained by questionnaires. Hypertension was defined as systolic blood pressure >or=140 mmHg and/or diastolic blood pressure >or=90 mmHg and/or on antihypertensive drug treatment. RESULTS: Overall, one-third of participants had hypertension; of these, two-thirds, 54% (95% confidence interval (CI) 47-60) of men and 71% (95% CI 65-77) of women, were aware of their condition. Half of the participants with hypertension were treated and nearly half of these were controlled. Both treatment and control were more common in women (60%, 95% CI 54-67 and 55%, 95% CI 47-64) compared with men (42%, 95% CI 36-49 and 35%, 95% CI 26-44). Monotherapy was used by 55% (95% CI 48-61) of treated hypertensives. Angiotensin-converting enzyme inhibitors were the most frequently used class of antihypertensive drugs in men, whereas angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists and diuretics were all widely used among women. CONCLUSION: This study emphasizes suboptimal detection and treatment of hypertension, especially in men, in rural Australia.

Apolipoprotein E2-Christchurch (136 Arg----Ser). New variant of human apolipoprotein E in a patient with type III hyperlipoproteinemia.

The primary structure of apolipoprotein E (apo E) was investigated in seven type III hyperlipoproteinemic patients with the apo E-2/2 phenotype. Six of the patients had identical two-dimensional tryptic peptide maps. These differed from the normal apo E3 map by the altered mobility of a single peptide. Amino acid analysis and sequencing showed that apo E2 in these patients had a substitution of 158 Arg----Cys. The presence of this mutation in six of the seven type III patients confirms that this is the most common form of apo E2. The seventh type III patient had a unique map with a new peptide resulting from a substitution of 136 Arg----Ser. He was heterozygous for this and for the more common apo E2 (158 Arg----Cys) variant. His very low-density lipoprotein contained approximately five times more apo E2 (136 Arg----Ser) than apo E2 (158 Arg----Cys), as determined by cysteamine treatment and peptide mapping. This new apo E2 mutant thus appears to contribute significantly to the patient's hyperlipidemia.

Is a single definition of the metabolic syndrome appropriate?--A comparative study of the USA and Asia.

The metabolic syndrome has been identified as an increasingly important precursor to cardiovascular diseases in many Asian populations. Our objective was to compare the contribution of component risk factors to the diagnosis of the metabolic syndrome, as defined by the Third report of the National Cholesterol Education Program Expert Panel Adult Treatment Panel (NCEP-ATPIII), in the US and selected Asian populations. Nationally representative survey data from Hong Kong, Taiwan, Thailand and the US were used. Analyses were restricted to men and women aged > or = 35 years. The age-standardized prevalence of the NCEP-ATPIII defined metabolic syndrome was highest in the US (31% in men, 35% in women), and lowest in Taiwan (11% in men, 12% in women). The component risk factors that defined the presence of the metabolic syndrome varied between countries. As expected, abnormal waist circumference was considerably more prevalent among individuals with the metabolic syndrome in the US (72% in men, 94% in women) compared with their Asian counterparts, but substantial variation was also observed between the Asian populations (13-22% in men, 38-63% in women). Furthermore, the relative contribution of other risk factors to the metabolic syndrome was also substantially different between countries. The NCEP-ATPIII definition identifies a heterogeneous group of individuals with the metabolic syndrome in different populations.

Optimal Cut-Offs of Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) to Identify Dysglycemia and Type 2 Diabetes Mellitus: A 15-Year Prospective Study in Chinese.

BACKGROUND: The optimal reference range of homeostasis model assessment of insulin resistance (HOMA-IR) in normal Chinese population has not been clearly defined. Here we address this issue using the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS), a prospective population-based cohort study with long-term follow-up. MATERIAL & METHODS: In this study, normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM) were defined according to the 1998 World Health Organization criteria. Dysglycemia referred to IFG, IGT or T2DM. This study comprised two parts. Part one was a cross-sectional study involving 2,649 Hong Kong Chinese subjects, aged 25-74 years, at baseline CRISPS-1 (1995-1996). The optimal HOMA-IR cut-offs for dysglycemia and T2DM were determined by the receiver-operating characteristic (ROC) curve. Part two was a prospective study involving 872 subjects who had persistent NGT at CRISPS-4 (2010-2012) after 15 years of follow-up. RESULTS: At baseline, the optimal HOMA-IR cut-offs to identify dysglyceia and T2DM were 1.37 (AUC = 0.735; 95% confidence interval [CI] = 0.713-0.758; Sensitivity [Se] = 65.6%, Specificity [Sp] = 71.3%] and 1.97 (AUC = 0.807; 95% CI = 0.777-0.886; Se = 65.5%, Sp = 82.9%) respectively. These cut-offs, derived from the cross-sectional study at baseline, corresponded closely to the 75th (1.44) and 90th (2.03) percentiles, respectively, of the HOMA-IR reference range derived from the prospective study of subjects with persistent NGT. CONCLUSIONS: HOMA-IR cut-offs, of 1.4 and 2.0, which discriminated dysglycemia and T2DM respectively from NGT in Southern Chinese, can be usefully employed as references in clinical research involving the assessment of insulin resistance.

Increased plasma apolipoprotein(a) levels in IDDM patients with microalbuminuria.

Patients with insulin-dependent diabetes mellitus (IDDM) have a significantly increased risk of macrovascular disease, particularly if they have persistent proteinuria. To determine whether altered levels of apolipoprotein(a) [apo(a)], the plasminogenlike glycoprotein of the potentially atherogenic lipoprotein(a); contribute to the increased risk of atherosclerosis, apo(a) levels were measured in 107 patients with IDDM and compared with nondiabetic control subjects and male elective coronary artery graft patients. Apo(a) levels were increased in diabetic patients with microalbuminuria (geometric mean 245 U/L, 95% confidence interval [CI] 142-427, n = 30) and albuminuria (mean 196 U/L, 95% CI 97-397, n = 18) with levels comparable to patients with coronary artery disease (mean 193 U/L, 95% CI 126-298, n = 40), which were higher than in the control group (mean 107 U/L, 95% CI 85-134, n = 140; P = 0.016). Apo(a) levels in diabetic patients without microalbuminuria (mean 86 U/L, 95% CI 63-116, n = 59) were comparable with the control population and less than in those with microalbuminuria (P less than 0.001) and albuminuria (P = 0.014). The elevated apo(a) levels found in patients with IDDM and increased urinary albumin loss may contribute to their heightened risk of macrovascular disease.

Frequency distributions of apolipoprotein(a) kringle IV repeat alleles and their effects on lipoprotein(a) levels in Caucasian, Asian, and African populations: the distribution of null alleles is non-random.

A size polymorphism (K IV VNTR) and largely unknown sequence variation in the apolipoprotein(a) [apo(a)] gene on chromosome 6q26-q27 together determine most of the extreme variation in apo(a) glycoprotein expression and lipoprotein(a) [Lp(a)] plasma concentration in Caucasians. We have determined Lp(a) plasma concentrations, the number of kringle IV (K IV) repeats in the apo(a) gene and the expression of the apo(a) glycoprotein in four ethnic groups (Khoi San, South African Blacks, Hong Kong Chinese and Caucasians from the Tyrol, total n = 788). The distributions of Lp(a) concentrations, the frequencies of expressed and non-expressed apo(a) K IV alleles, and the impact of the size polymorphism on Lp(a) concentrations were all heterogeneous across populations. In contrast, the effect of the K IV repeat alleles appeared homogeneous. Lp(a) concentrations were higher in Africans and Chinese than in Caucasians, but this was not explained by differences in K IV repeat allele frequencies among populations. Lp(a) concentrations were highest in Khoi San, suggesting that high Lp(a) is an old African trait. When expressed as Spearman rank correlations the impact of the size polymorphism was smallest in African Blacks (R = -0.386) and largest in the Chinese (R = -0.692). In all four populations, the distribution of non-expressed apo(a) alleles was non-random. Rather they were significantly associated with distinct size alleles and overall positively with high K IV repeat numbers. The negative correlation of K IV repeat length with Lp(a) concentration was non-linear in Khoi San and the average apo(a)-size-allele-associated Lp(a) concentrations were markedly different between all populations. We conclude that besides the apo(a) size variation, other factors affect Lp(a) concentrations to different degrees in the study populations. Most likely, this is sequence variation in apo(a) which is not the same in the different ethnic groups.

In vitro synthesis of M and Z forms of human alpha 1-antitrypsin.

mRNA was prepared from autopsy liver samples from a homozygote for alpha 1-antitrypsin deficiency (PiZZ) and from a normal (PiMM) subject. Both preparations gave equivalent synthesis of alpha 1-antitrypsin in a wheat germ cell-free system. This suggests that the deficiency of plasma alpha 1-antitrypsin associated with the Z variant is due to a failure of processing and secretion of the protein rather than of its synthesis. It is likely that it is the resultant intracellular accumulation of the Z protein rather than a deficiency of protease inhibitor that is the primary cause of the liver pathology associated with this variant.

Lipids, lipoproteins and apolipoproteins A-I and B and apolipoprotein losses in continuous ambulatory peritoneal dialysis.

Comparison of lipid, lipoprotein and apolipoprotein levels was made between 3 groups: continuous ambulatory peritoneal dialysis patients (n = 5); haemodialysis patients (n = 15) and normals (n = 31). Continuous ambulatory peritoneal dialysis (CAPD) patients showed significantly elevated total cholesterol, low density lipoprotein (LDL)-cholesterol and apolipoprotein B (apo B) levels compared with haemodialysis and normal groups. Both CAPD and haemodialysis (HD) showed reduced levels of high density lipoprotein (HDL)-cholesterol and apolipoprotein A-I (apo A-I). Measurement of apo A-I and apo B in dialysate during a 6 h CAPD session indicated significant losses of apo A-I to dialysate with negligible losses of apo B. Grossly elevated apo B and reduced apo A-I indicates that CAPD patients are at increased risk of coronary heart disease and that their risk is probably greater than for haemodialysis patients.

Apolipoprotein E phenotypes in hyperlipidaemic patients and their implications for treatment.

Apolipoprotein E phenotypes were determined on 417 consecutive lipid clinic patients using an isoelectric focussing technique. Of the 15 patients with phenotype E2/2, 13 (3.1%) had type III hyperlipoproteinaemia and 2 obese identical twins had type V. A further 20 patients (4.8%) had similar plasma and lipoprotein lipid levels but were E2 heterozygotes (14 E3/2 and 6 E4/2). They displayed a widened pre-beta-band almost confluent with the beta-band rather than the broad beta-band shown in classical E2/2 type III patients. In view of the similarities between these heterozygotes and the classical homozygous (E2/2) type III patients and their occurrence in the same families we suggest the nomenclature homozygous and heterozygous type III. In a subsequent comparison between 30 E2/2, 22 E3/2 and 8 E4/2 type III individuals the only significant difference in plasma and lipoprotein lipid parameters was a lower VLDL cholesterol to triglyceride ratio of 0.85 in E3/2 patients than that of 1.24 in E2/2 patients (P less than 0.01). Both homozygous and heterozygous patients showed premature ischaemic heart disease and both responded dramatically and similarly to treatment with clofibrate. These observations indicate that apo E phenotyping is worthwhile in all patients with combined hyperlipidaemia and that homozygous and heterozygous type III hyperlipoproteinaemia is not uncommon.