The impact of having a carer on adult health and social care utilisation across five settings of care: A matched cohort study.

INTRODUCTION: An estimated 6.8 million people are (informal) carers in the UK. The economic value of annual carer contributions is an estimated .·132bn. Reliance on carers appears to be increasing. There is mixed evidence on whether carers are substitutes for formal care. This study investigated the association between having a carer and service use patterns across five care settings when compared to a matched cohort without a carer. MATERIALS AND METHODS: A matched case-control group analysis using person-level data in Barking and Dagenham (B&D), a London borough in the U.K., to assess the impact of having a carer in terms of the differences in cost-weighted utilisation relative to a matched control group. RESULTS: In 2016/17, for adult residents of B&D, having a carer (n = 1,295) was associated with 27% increased cost-weighted utilisation (mean difference of £2,662, CI £1,595, £3,729, p<0.001) compared to a matched cohort without a carer. 39% of the cost difference was social care. CONCLUSIONS: Findings suggest additional service use induced by carers may dominate any substitution effect. Having a carer may be a key element in enabling access to services. As such, there may be wider inequalities in service access for people without a carer. For an ageing society with projections suggesting there will be more people without carers in the future, these inequalities need to be addressed.

Avascular necrosis in cleft maxillary repositioning: a review of cases and introduction of the 'delayed maxillary flap'.

There is a low incidence of serious complications with the Le Fort I maxillary osteotomy, but avascular necrosis is a serious problem that occurs at a higher frequency in the cleft population compared to non-cleft patients. In this retrospective study, cleft patients who had exhibited any manifestation of avascular necrosis of the maxilla following a Le Fort I advancement were identified. Five patients were found to have had vascular compromise, ranging from loss of gingival tissue to necrosis of bone and loss of teeth. In each case, possible risk factors were assessed, and secondary revision palatal surgery prior to maxillary advancement, particularly closure of oronasal fistulae with transpositional flaps, was noted to be present. Drawing on this finding and a review of the literature, clinical recommendations are made for minimizing the risk of this major complication. The use of the 'delayed maxillary flap' technique is introduced and described as a potentially beneficial procedure for cleft patients with a high risk of vascular compromise.

Common peroneal and posterior tibial ischemic nerve damage, a rare cause.

A 56-year old gentleman presented to our orthopaedic foot and ankle clinic, with unusual symptoms in his left foot. He described a tight sensation over his toes, "like sandpaper under his skin". The pain had started post operatively following a bilateral aorto-femoral bypass. He was subsequently investigated and found to have an ischemic lesion Identified in his common peroneal and posterior tibial nerve with associated muscle atrophy on EMG. This represents a previously unreported complication of aorto-femoral bypass surgery.

Paediatric oral & maxillofacial surgery.

Children have differences in their physiology, anatomy and they are continuing to grow and develop. The management of pathology, trauma, deformity and upper airway obstruction in the young growing patient has to take into account these factors in the treatment planning for these conditions. It is important for Oral & Maxillofacial Surgeons to understand the potential impact of disease or injury on the developing facial skeleton and dentition. This chapter will provide an overview of the some of the major components of paediatric maxillofacial surgery and their management.

Heart-type fatty acid-binding protein (H-FABP) and highly sensitive troponin T (hsTnT) as markers of myocardial injury and cardiovascular events in elective percutaneous coronary intervention (PCI).

BACKGROUND/INTRODUCTION: Type 4a myocardial infarction (MI) occurs when myocardial injury is combined with either symptoms suggestive of myocardial ischaemia, new left bundle branch block, angiographic loss of patency of a major artery or imaging suggestive of new loss of myocardium. Myocardial injury is defined as a rise of >5 x 99th upper reference limit (URL) of 14 ng/l (i.e. >70 ng/l) for highly sensitive troponin T (hsTnT) at 6 h if hsTnT was normal at baseline or >20% rise from 0 to 6 h if hsTnT was >14 ng/l at baseline. AIM: To assess the prognostic value of biomarkers of myocardial injury following elective percutaneous coronary intervention (PCI). DESIGN: A cohort of 209 patients were included of whom 144 (68.9%) were male, mean age was 68.8 years, 28 (13.4%) were smokers, 31 (14.8%) were diabetic, 199 (95.2%) had hypercholesterolaemia and 138 (66.0%) had hypertension. METHODS: We evaluated hsTnT, heart-type fatty acid-binding protein (H-FABP), troponin I (TnI), creatine kinase MB type (CKMB), myoglobin, glycogen phosphorylase BB (GPBB) and carbonic anhydrase III (CA III) at 0, 4, 6 and 24 h following elective PCI. Patients were followed up at 1 year to assess for major adverse clinical events (MACE). RESULTS: Myocardial injury was observed in 37 (17.7%) patients. Median hsTnT/H-FABP at 4 h were most predictive. MACE was noted in 6 (2.9%) patients, 3 had type 4a MI post PCI, P = 0.036. DISCUSSION/CONCLUSIONS: Median 4 h hsTnT/H-FABP were most predictive of myocardial injury following PCI. H-FABP and hsTnT were predictive of MACE.

An unusual cause of locking after total knee replacement.

Locking after total knee replacement is uncommon and is generally caused by the formation of fibrous tissue around the patella. We report an unusual cause of locking resulting from intermittent occlusion of the popliteal artery, which was tethered to cement at the posterior aspect of the tibial component.

Secondary bone grafting of alveolar clefts: a review of outcome at two centres in Australia and the UK.

Secondary alveolar bone grafting is a key procedure in comprehensive cleft services, the main objective of which is to allow the canine to erupt through the bone. We have assessed the outcomes of the procedure at two units, one in Australia and one in the UK. Success was measured using standardised indexes for radiological assessment (Bergland and Kindelan) and clinically by noting eruption of canines through the grafted sites. The two-year review indicated that the two units had comparably high success rates. Canines erupted through cleft sites in 27/28 sites in patients in the UK, and 26/28 in patients in Australia, and the radiological success using the indexes was also high. These rates are in line with international benchmarks.

Skeletal stability of maxillary advancement with and without a mandibular reduction in the cleft lip and palate patient.

The stability of surgical maxillary advancement in a consecutive series of patients with cleft lip and palate who underwent Le Fort I osteotomy with and without simultaneous mandibular setback surgery was evaluated. Preoperative, postoperative, and follow-up lateral cephalograms of 21 patients were assessed to compare differences in surgical movement and postoperative relapse between two groups: those who underwent maxillary surgery alone and those who underwent bimaxillary surgery. Differences in the number of patients who experienced relapse of <2mm, 2-4mm, and >4mm between the groups were also compared. Mean advancement of the cleft maxilla was 5.5mm in the maxilla only group and 3.6mm in the bimaxillary group, with a mean horizontal relapse of 0.8mm and 0.2mm, respectively. Mean surgical movement in the vertical dimension was comparable in the two groups and the magnitude of vertical relapse was less than 0.4mm overall. Approximately 80% of patients in both groups experienced horizontal relapse of less than 2mm. There was no significant difference in the degree of postoperative relapse between those who had single-jaw surgery and those who had two-jaw surgery.

Odontogenic myxoma in the paediatric patient: a review of eight cases.

Paediatric odontogenic myxoma (OM) is a rare pathological condition in the oral and maxillofacial region. There has been much debate in the literature regarding the preferred method of treatment; however due to the rare nature of this disease, definitive algorithms of management are yet to be determined. A case series of eight paediatric patients with OM is presented. Six of the lesions were in the maxilla and two were mandibular lesions. The patients were aged between 2 and 18 years. Treatment ranged from excision and the application of Carnoy's solution to segmental resection and reconstruction. From this case series it can be seen that even in situations where treatment was limited to excision and the application of Carnoy's solution, no recurrences occurred. As such the present authors favour an initially more conservative approach to the management of these lesions where possible and reserving conventional resective treatment for recurrences, lesions causing pathological fracture, and those in regions that are difficult to access.

The effects of probucol and clofibrate alone and in combination on hepatic cholesterol metabolism in the male rat.

Male rats were fed for 10 days on a diet supplemented with either probucol or clofibrate, alone or in combination, and the effects of the drugs on hepatic cholesterol metabolism studied. Plasma triacylglycerols were significantly lowered (15.6%, P < 0.05) by the drugs in combination but not individually whereas plasma cholesterol levels were reduced by probucol alone (22.4%, P < 0.05) and the combined treatment effected a further decrease leading to a total reduction of 50.6% (P < 0.001). Probucol reduced hepatic cellular triacylglycerols (20.0%, P < 0.05) and cholesterol (15.3%, P < 0.05) but cholesteryl esters were unaffected. In combination with clofibrate, probucol accentuated the reductions in both cellular cholesterol and cholesteryl esters produced by clofibrate alone and lowered their levels by 22.8%, P < 0.01 and 38.5%, P < 0.001, respectively. Although probucol, on its own, did not affect the activity of acyl-coenzyme A:cholesterol acyltransferase (ACAT), its combination with clofibrate caused less inhibition (43.5%, P < 0.01) of this enzyme activity than clofibrate alone (65.7%, P < 0.001). Probucol had a similarly moderating effect on the clofibrate-induced reductions in microsomal cholesterol and cholesteryl esters. Neither the microsomal nor the cytosolic neutral cholesteryl ester hydrolase was affected by probucol alone although both enzymes were dramatically increased (between 350% and 550%) by clofibrate and the combined treatment. The activity of the hepatic cytosolic inhibitor of cholesteryl ester hydrolase was unaffected by clofibrate or probucol individually but the two drugs in combination increased the total activity of the inhibitor by 52.1%, P < 0.01. When allowance was made for this increased inhibitor activity, it was clear that probucol accentuated the stimulatory effect of clofibrate on the cytosolic nCEH.

The esterification of cholesterol in the liver of the chick embryo.

The development of the chick embryo was characterised by the accumulation of large droplets of lipid in the cytoplasm of the embryonic liver, as revealed by electron microscopy. Analysis of the lipid composition of the livers indicated that this accumulation resulted from a dramatic increase in the cholesteryl ester content of the tissue during the the latter part of the embryonic period. This lipid is apparently derived from yolk cholesterol and may be taken up by the liver in the form of lipoprotein remnants. Significant levels of acyl-CoA: cholesterol acyltransferase (ACAT) activity were expressed in the liver throughout the second half of the developmental period, and this activity was maximal at the time when lipid transfer from the yolk was most intensive. The activity of microsomal cholesterol ester hydrolase (CEH) was very low throughout development, and no CEH activity was detected in the cytosolic fraction. In addition, substantial amounts of a cytosolic protein which inhibits CEH activity were present. Thus the relative activities of these enzymic systems are consistent with the net accumulation of cholesteryl ester which occurs in the liver during development.

The recurrence of gestational diabetes: could dietary differences in fat intake be an explanation?

OBJECTIVE: To present the results of a comprehensive dietary review of a group of women with a recurrence of gestational diabetes mellitus (GDM), compared with a group of women with no recurrence of GDM during a subsequent pregnancy. RESEARCH DESIGN AND METHODS: The dietary intake of 14 women with a recurrence of GDM was compared with 21 women with no recurrence of GDM. Women with GDM in one pregnancy have a recurrence rate of only 30-50%. While the reasons for this have not been determined, dietary factors have been considered probable. RESULTS: The women with a recurrence of GDM consumed 38.4 (by diet history) and 41.4% (by food record) of their total energy intake as fats, compared with 34.1 (P < 0.01) and 33.1% (P < 0.001), respectively, for women with no recurrence. The percentage intake of polyunsaturated, monounsaturated, and saturated fatty acids was similar in both groups. There was a proportionate reduction in carbohydrate intake as a percentage of total energy and in fiber intake in grams for the women with a recurrence of GDM. CONCLUSIONS: When the relationship between saturated fat intake and insulin resistance is considered, the possibility exists that dietary modification of fat intake before and during pregnancy may reduce the recurrence rate of GDM.

Isolated orbital floor fractures in the paediatric patient: case series and review of management.

Orbital injuries warranting surgical intervention are infrequent in the paediatric population, but 'blowout, trap door' fractures are unique in children and may constitute a relative surgical emergency. A retrospective review of isolated orbital floor fractures at the Royal Children's Hospital of Melbourne over a 10-year period was undertaken to evaluate the outcome of those patients who required surgical exploration. Twenty-two patients with documented isolated orbital floor injuries were studied. Preoperative signs and symptoms including diplopia, ocular motility, paresthesia, enophthalmos, hypoglobus, and the presence of nausea and vomiting were recorded. Thirteen patients underwent non-surgical management and nine patients underwent surgical exploration of the orbital floor via a trans-subconjunctival approach to reduce any entrapped soft tissue. Postoperative follow-up of these patients varied between 1 month and 18 months and none had any visual disturbance or diplopia in central gaze; however, two patients experienced diplopia in upward gaze at follow-up, although this did not impair the quality of life. Due to the risk of permanent soft tissue damage from the entrapment of the periorbita with or without extraocular muscle tissue, it is recommended that exploration be undertaken as soon as possible to minimize the risk of persistent diplopia due to impaired ocular motility.

Inhibition of neutral cholesteryl ester hydrolase by a naturally occurring cytosolic protein in macrophages.

The soluble fraction from a number of macrophage cell lines has been shown to contain a protein(s) that inhibits neutral cholesteryl ester hydrolase. The inhibition is dependent on the concentration of soluble protein used, and the efficiency of the inhibitor can be influenced by the inclusion of oleate and an inhibitor of ACAT. It is suggested that the presence of this material indicates that the macrophage contains a means of negatively controlling the activity of the hydrolytic phase of the cholesterol/cholesteryl ester cycle.

Ontogenetic changes in the retinal photoreceptor mosaic in a fish, the black bream, Acanthopagrus butcheri.

The morphological development of the photoreceptor mosaic was followed by light and electron microscopy in a specific region of dorsal retina of the black bream, Acanthopagrus butcheri (Sparidae, Teleostei), from hatching to eight weeks of age. The retina was differentiated when the larvae reached a total length of 3 mm (3-5 days posthatch). Single cones, arranged in tightly packed rows, were the only morphologically distinct type of photoreceptor present until the larvae were 6 mm (day 15) in standard length (SL). At this time, the rod nuclei had become differentiated and the ellipsoids of selected cones began to form subsurface cisternae along neighbouring cone membranes. In this way, double, triple, quadruple, and occasionally photoreceptor chains of up to 10 cones were formed. At 8 mm SL, there was little apparent order in the photoreceptor mosaic. However, concomitant with subsequent growth, quadruple and other multiple cone receptors disappeared, with the exception of the triple cones, which gradually reduced in both number and retinal coverage to be restricted to central retina by 15 mm SL (days 40-55). Following this stage, the arrangement of double and single cones peripheral to the region of triple cones in dorsal retina was transformed into the adult pattern of a regular mosaic of four double cones surrounding a single cone. These results demonstrate that an established photoreceptor mosaic of rows of single cones can be reorganised to form a regular square mosaic composed of single and double cones.

The carboxy-terminal domain of IGF-binding protein-5 inhibits heparin binding to a site in the central domain.

The IGF-binding protein (IGFBP)-5 protein contains consensus heparin binding motifs in both its carboxy (C)-terminal and central domains, although only the C-terminal site has previously been shown to be functional. We have made two chimeric IGFBP proteins by switching domains between rat IGFBP-5 and -2, named BP552 and BP522 to reflect the domains present, and a truncated rat IGFBP-5 mutant (1-168), named BP550. The ability of these proteins and wild-type (wt) IGFBPs-5 and -2 to bind to either IGFs or heparin was determined using biosensor real-time analysis and heparin ligand blotting respectively. We report that the chimeric molecules have IGF binding affinities comparable to those of the native IGFBPs from which they were derived and, as expected, the binding of BP550 to IGFs was greatly compromised. More surprising was the finding that the ability of BP552 and BP550 to bind to heparin was equivalent to that of wtIGFBP-5, whereas wtIGFBP-2 and BP522 failed to bind. These results demonstrate that the active heparin binding site in BP552 and BP550 is contained within the central domain of IGFBP-5, and that this site is active only in the absence of the C-terminal domain. We subsequently mutated two basic amino acids (R136A:R137A) in the central consensus binding sites between residues 132-140. This resulted in the loss of heparin binding for BP550, confirming the importance of these two basic amino acids in the central domain heparin binding activity. In light of these findings, we suggest that C-terminally truncated fragments of IGFBP-5 generated in vivo by proteolysis could retain heparin/extracellular matrix binding properties.

A quantitative RT-PCR study of the mRNA expression profile of the IGF axis during mammary gland development.

We have used quantitative RT-PCR to analyse the mRNA expression profile of the major components of the IGF axis in different stages of murine mammary gland development, including late pregnancy, lactation and involution. We have shown that all the genes studied, IGF-I, IGF-II, IGF receptor (IGFR) and IGF-binding protein (IGFBP)-1 to -6, were expressed in every stage, albeit at greatly differing levels and displaying unique expression profiles between developmental stages. IGF-I was always expressed at significantly higher levels than either IGF-II or IGFR. This suggests that IGF-I may be the more important IGF during mammary morphogenesis. Overall, IGFBP-3 demonstrated the highest level of expression of any of the IGFBP genes throughout all the developmental stages studied. However, within developmental stages, by far the highest level of expression of any of the IGFBPs was that of IGFBP-5 at day 2 of involution; this was almost an order of magnitude higher than any of the other IGFBP levels recorded. This corroborated our previous findings that the levels of IGFBP-5 protein are highly elevated in the involuting mammary gland, and demonstrated that this up-regulation of IGFBP-5 operates at the level of transcriptional control or message stability. Comparison of the expression profile for these different genes would strongly suggest that they are likely to have differential functions throughout mammary gland development, and also highlights potential interactions and co-regulation between different members of this axis. In addition, our results have identified some similarities and differences in the expression of IGFBPs between the mouse mammary epithelial cell line, HC11, and the normal mammary gland which are worthy of study, most notably the differential regulation of IGFBP-2 and the site of expression of IGFBP-4 and -6. Overall, this study has demonstrated the importance and complexity of the IGF axis during mammary gland development and provides a valuable resource for future research in this area.

Endogenous circadian retinomotor movements in the neon tetra (Paracheirodon innesi).

Retinomotor movements of retinal cones and pigment epithelium melanosomes were studied in the neon tetra, Paracheirodon innesi. The cone myoids clearly contracted during the daytime, but the migration of the total population of pigment granules was less easy to see. However, when rod-shaped melanosomes were measured separately from granular-shaped melanosomes it became evident that the rod-shaped melanosomes, but not the granular melanosomes, did migrate in response to circadian changes in light intensity. Retinomotor movements of both the cones and the rod-shaped melanosomes persisted for at least 2 days in continuous darkness. Microspectrophotometric measurements of spectral transmission of small groups of melanosomes showed that absorption was greatest at shorter wavelengths, but that there was also a distinct absorbance maximum at about 480 nm.

Effects of an antiserum to rat growth hormone and bromocriptine on cholesterol-metabolizing enzymes in the lactating rat mammary gland.

Rats in mid-lactation were treated, for 2 days, with anti-rat GH serum (anti-rGH) and/or bromocriptine before microsomes were prepared from the freeze-clamped mammary glands. The effects of these anti-hormone treatments on the concentrations of microsomal cholesterol and cholesterol esters and on the activities of acyl-CoA:cholesterol acyltransferase (ACAT), neutral cholesterol ester hydrolase and 3-hydroxy-3-methylglutaryl-CoA reductase (HMG-CoA reductase) were measured. HMG-CoA reductase was determined in microsomes prepared in both the presence and absence of phosphatase inhibitors to determine the expressed and total activities respectively. Anti-rGH reduced HMG-CoA reductase and increased microsomal cholesterol and cholesterol esters. Bromocriptine reduced HMG-CoA reductase but increased all of the other parameters. The results indicate that the initial stage in the stimulation of milk secretion involves a decrease in the activity of ACAT and that the phosphorylation level of HMG-CoA reductase is modulated by both prolactin and GH acting in opposition.

Effects of growth hormone on cholesterol metabolism in the lactating rat mammary gland.

Lactating rats were treated for 48 h with bromocriptine (to inhibit prolactin release) or bromocriptine together with an antiserum to rat GH. Animals given the combined treatment were also supplemented concurrently with bovine GH (bGH) or human insulin-like growth factor-I (hIGF-I). The effects of these treatments on the activities of 3-methyl-3-glutaryl-CoA reductase (HMG-CoA reductase), acyl-CoA:cholesterol acyltransferase (ACAT) and neutral cholesteryl ester hydrolase (CEH) and on the microsomal concentrations of non-esterified and esterified cholesterol were measured. Lack of prolactin decreased HMG-CoA reductase but did not affect ACAT, neutral CEH or the concentrations of microsomal cholesterol or cholesteryl esters. In the absence of both hormones, an even greater reduction in HMG-CoA reductase together with increases in ACAT, neutral CEH and both of the microsomal sterols were observed. Concurrent supplementation with either bGH or hIGF-I wholly or partially prevented the effects on HMG-CoA reductase but only bGH was active against the increase in ACAT. Neither bGH nor hIGF-I could prevent the effects of the anti-hormone treatment on neutral CEH, and the changes in ACAT and CEH activities were broadly reflected in the microsomal sterol concentrations. The results indicate that the cessation of lactation brings about rapid changes in the activities of the enzymes involved in cholesterol metabolism within the mammary gland with a definite switch from synthesis to storage. Supplementation with bGH alone was sufficient to maintain cholesterol synthesis at control levels and could also significantly inhibit storage of the sterol as its ester. In the absence of GH, hIGF-I partially supported cholesterol synthesis but had no effect on its conversion to the ester. On a whole-tissue basis, enzyme activities could be correlated with the physiological effects of the anti-hormone treatments.