Plasma cholesterol esterification and transfer, the menopause, and hormone replacement therapy in women.

With the onset of the menopause, plasma lipids and lipoprotein metabolism changes toward a more atherogenic profile that is improved by HRT. To determine whether cholesterol esterification rate (CER) and transfer of cholesteryl esters from high density lipoproteins to apolipoprotein B-containing lipoproteins are affected by menopause and HRT, plasma newly synthesized cholesteryl ester transfer (NCET) activity, CER and plasma lipids, lipoproteins, and apolipoprotein concentrations were measured in perimenopausal women (age range: 40-55 yr), including 49 premenopausal women and 32 postmenopausal women who were subsequently randomized to receive either placebo or 17-beta estradiol/norethisterone for 6 months. Plasma NCET (P = 0.03) and CER (P = 0.008) were significantly higher in postmenopausal women. Plasma low density lipoprotein cholesterol concentration, high density lipoprotein concentration, and body mass index were independent predictors of plasma NCET in premenopausal women, and plasma triglyceride and apolipoprotein B concentrations were corresponding predictors in postmenopausal women. When data were adjusted for plasma triglyceride, plasma NCET activity was no longer significantly different (P = 0.81) between premenopausal and postmenopausal women. Plasma NCET and CER did not change significantly in postmenopausal women during HRT. These data suggest that the determinants of plasma NCET activity after menopause and increased levels of triglyceride-rich lipoprotein acceptors of cholesteryl esters may lead to increased plasma NCET that is not reduced by HRT in postmenopausal women.

Plasma cholesteryl ester fatty acid composition, insulin sensitivity, the menopause and hormone replacement therapy.

This study was designed to determine the effect of menopause and hormone replacement therapy (HRT) on plasma cholesteryl ester fatty acid (CEFA) composition and insulin sensitivity and the relationships between these variables in perimenopausal women (aged 40-55 years) including 49 who were premenopausal and 32 who were postmenopausal. Plasma cholesteryl ester proportions of dihomo-gamma-linolenic acid (20:3 n-6) were correlated significantly with insulin sensitivity index (r=-0.319, P=0.005), fasting serum insulin levels (r=0.230, P=0.038), body mass index (r=0.242, P=0.03) and per cent body fat (r=0.329, P=0.003) in perimenopausal women (n=81). Similar associations were observed in premenopausal women. Regression analysis suggested the relationships between 20:3 n-6 proportions and indices of insulin action may be partly mediated by levels of adiposity. In postmenopausal women, 6 months of HRT significantly (P=0.008) increased the ratio of arachidonic acid (20:4 n-6) to linoleic acid (18:2 n-6), which is an indicator of activity in the pathway of 20:4 n-6 synthesis, compared with placebo. These findings suggest that the type of fat in the diet indicated by plasma CEFA composition is linked to adiposity and insulin action. They also suggest that in postmenopausal women, HRT may increase the synthesis of 20:4 n-6, which is the precursor for eicosanoids with important cardiovascular functions.

Implementing a system of structured clinical supervision with a group of DipHE(nursing) RMN students.

Clinical supervision is to become an integral part of mental health nursing, and the United Kingdom Central Council for Nursing, Midwifery & Health Visiting has recommended that it be incorporated in pre-registration education. This paper describes teachers' experiences of delivering a programme of clinical supervision education within the mental health branch of a diploma in nursing course. It outlines the implementation and evaluation of the programme, including discussion of the process and difficulties encountered. The programme appears to have provided a positive first experience for the students and to have given them the enthusiasm to adopt clinical supervision as part of their future roles as qualified practitioners.

Clinical characteristics of an anatomical hand index measured in patients with rheumatoid arthritis as a potential outcome measure.

OBJECTIVES: To determine the clinical characteristics of an anatomical hand index previously reported as a potential measure of joint deformity and outcome in patients with rheumatoid arthritis. METHODS: The hand index (open hand span - closed hand span/lateral height of the hand) was measured in a cross-sectional study of 145 out-patients with rheumatoid arthritis with disease durations 0-55 yr. Subsets of patients were restudied at mean follow-ups of approximately 9 months and 4 yr. RESULTS: The hand index fell gradually with disease duration. Correlations were demonstrated with the Sharp index (r = - 0.39, P = 0.000) and to a lesser extent with disease activity score (r = - 0.28, P = 0.001). At 260 +/- 115 days the hand index worsened by 0.09 units (P = 0.09, NS). At 51.6 +/- 5.4 months the index showed a fall from 1.96 +/- 0.73 to 1.61 +/- 0.65 (P = 0.000). During the same interval the Sharp index increased from 60 +/- 68 to 80 +/- 71 (P = 0.000). CONCLUSIONS: Measurement of simple hand dimensions can demonstrate worsening of hand deformity with time in patients with rheumatoid arthritis. We suggest that more sophisticated analysis of digital hand images, as used in our original study, might yield additional information and increase the sensitivity of an anatomical hand index as an outcome measure in rheumatoid arthritis.

Gonorrhoea screening in general practice: perceived barriers and strategies to improve screening rates.

OBJECTIVE: To investigate perceived barriers to gonorrhoea screening in general practice and suggest strategies to overcome them. DESIGN: Questionnaire-based survey. SETTING AND PARTICIPANTS: All 47 general practitioners (GPs) authorised to prescribe subsidised HIV drugs under the Pharmaceutical Benefits Scheme in inner, eastern and northern Sydney. MAIN OUTCOME MEASURES: Agreement on a five-point Likert scale with statements about attitudes and practices in relation to gonorrhoea screening of homosexually active men, and views on how testing rates could be increased. RESULTS: 32 GPs responded (68%). Perceived barriers to gonorrhoea testing included structural measures imposed by the Federal Government to limit pathology testing by GPs (the Medicare "three-test rule") (17 respondents agreed or strongly agreed), pressure from the Health Insurance Commission (HIC) to minimise pathology testing (15), concerns about confidentiality of notification procedures (8), clinical time pressure (8), and concerns about recriminations against HIV patients with gonorrhoea (6). Suggested measures to increase testing were education of gay men to request testing (25), relaxation of the three-test rule (25), easier tests (23), anonymous notification procedures, review of HIC policy on screening, and training about testing (21 each). CONCLUSIONS: Sydney GPs with high HIV caseloads perceived structural barriers to gonorrhoea testing and supported a range of achievable strategies to overcome these. As the sustained epidemic of gonorrhoea in Sydney may be directly promoting HIV transmission, these strategies should be considered urgently.