Liver fibrosis markers and all cause mortality in people with type 2 diabetes: A population based study (The Ayrshire Diabetes Outcomes Cohort (ADOC) Study).

AIMS: To describe the distribution of the biomarker scores Fibrosis-4 (FIB4), nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), and aspartate aminotransferase to platelet ratio index (APRI), and the associations between risk categories and all-cause mortality. MATERIALS AND METHODS: This was a retrospective cohort study of 12 589 patients, with follow-up from January 2012 until November 2021. The cut-off points used to identify low risk were: FIB4 <1.3 if aged <65 years or <2.0 if aged ≥65 years; NFS < -1.455 if aged <65 years or <0.12 if aged ≥ 65 years; APRI <1 (independent of age). High-risk cut-off points were FIB4 >2.67, NFS >0.676 and APRI ≥1 (all independent of age). Multivariable Cox regression analysis was performed to assess the association between liver fibrosis scores and all-cause mortality. RESULTS: The mean ± standard deviation age was 65.2 ± 12.1 years, 54.5% were men and the median (interquartile range) diabetes duration was 5.8 (2.8-9.3) years. The prevalence of high-risk categories was 6.1% for FIB4, 23.5% for NFS and 1.6% for APRI. During a median follow-up of 9.8 years, 3925 patients (31.1%) died, resulting in a crude mortality rate of 40.4 per 1000 person-years. The overall adjusted all-cause mortality hazard ratios (95% confidence intervals [CIs]) in the high- compared with low-fibrosis-risk groups were 3.69 (1.95-2.75) for FIB4, 2.32 (2.88-4.70) for NFS, and 3.92 (2.88-5.34) for APRI. Stratified adjusted all-cause mortality hazard ratios for individuals under 65 years and people over 65 years of age at cohort entry were 3.89 (95% CI 2.99-5.05) and 1.44 (95% CI 1.28-1.61) for FIB4, 2.50 (95% CI 1.89-3.18) and 1.35 (95% CI 1.24-1.48) for NFS and 3.74 (95% CI 2.73-5.14) and 1.64 (95% CI 1.24-2.17) for APRI. CONCLUSIONS: All three fibrosis risk scores were positively associated with all-cause mortality in people with type 2 diabetes, with higher relative risks in younger than older people. Effective interventions are required to minimize excess mortality in people at high risk of liver fibrosis.

Hypergonadotropic hypogonadism and chromosomal aberrations: clinical heterogeneity and implications on the health of elderly men, case series.

BACKGROUND: Hypogonadism in older men is often considered as late onset hypogonadism. However, this clinical condition results from primary testicular failure which could be of genetic origin with Klinefelter syndrome being the most common chromosomal abnormality associated with it. CASE PRESENTATION: We report a heterogeneous group of cases who were diagnosed with hypergonadotropic hypogonadism in their adulthood and were found to have rare chromosomal aberrations. All were elderly men (in their 70 s and 80 s) for whom the diagnosis was made during the evaluation of incidental symptoms suggestive of endocrinopathy. The first had hyponatremia; the other two had gynaecomastia and features of hypogonadism noted during admission for various acute medical problems. With respect to their genetic results; the first had a male karyotype with balanced reciprocal translocation between the long arm of chromosome 4 and the short arm of chromosome 7. The second case had a male karotype with one normal X chromosome and an isochrome for the short arm of the Y chromosome. The third case was an XX male with unbalanced translocation between the X & Y chromosomes with retention of the SRY locus. CONCLUSION: Hypergonadotrophic hypogonadism in the elderly, may be due to chromosomal aberrations, resulting in heterogeneous and diverse clinical phenotypes. Vigilance must be exercised when seeing cases with subtle clinical findings. This report suggests that in selected cases of adult hypergonadotropic hypogonadism, chromosomal analysis may be indicated.

How effective is public health policy in Scotland on vitamin D deficiency during pregnancy?

OBJECTIVE: To evaluate the uptake of universal vitamin D supplementation during pregnancy, its effectiveness in preventing vitamin D deficiency and the factors associated with these. DESIGN: The regional public health organisation in Ayrshire, Scotland has a policy of universal provision of vitamin D supplements (10 µg/d) to all pregnant women for the duration of their pregnancy. Pregnant women in this area were recruited at their 12-week antenatal appointment. Blood samples were collected at the 12-week and 34-week appointments. To account for the seasonal variation, women were recruited in two cohorts: summer and winter. Telephone interviews were conducted at 34 weeks to assess the uptake of vitamin D supplements during pregnancy. Other variables were obtained from medical records. SETTING: The study was conducted in the NHS Ayrshire and Arran Health Board in Scotland. PARTICIPANTS: 612 pregnant women (aged 15-44 years) living in Ayrshire (latitude 55°), Scotland. RESULTS: Sixty-six percentage took supplementation as recommended. Consumption of supplementation was significantly associated with a higher median serum 25-hydroxyvitamin D concentrations at 34 weeks. Despite this at 34 weeks, 33 % of the summer cohort had insufficient or deficient vitamin D status, while 15 % of the winter cohort had insufficient or deficient status. In multivariable analysis, only adherence and season were independent predictors of vitamin D status. CONCLUSIONS: While supplementation improved and maintained vitamin D status during pregnancy, it was not adequate to ensure all those insufficient at 12 weeks achieved sufficient status at the end of pregnancy.

Quantitative levels of serum N-glycans in type 1 diabetes and their association with kidney disease.

We investigated associations of quantitative levels of N-glycans with hemoglobin A1c (HbA1c), renal function and renal function decline in type 1 diabetes. We measured 46 total N-glycan peaks (GPs) on 1565 serum samples from the Scottish Diabetes Research Network Type 1 Bioresource Study (SDRNT1BIO) and a pool of healthy donors. Quantitation of absolute abundance of each GP used 2AB-labeled mannose-3 as a standard. We studied cross-sectional associations of GPs and derived measures with HbA1c, albumin/creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR), and prospective associations with incident albuminuria and final eGFR. All GPs were 1.4 to 3.2 times more abundant in SDRTN1BIO than in the healthy samples. Absolute levels of all GPs were slightly higher with higher HbA1c, with strongest associations for triantennary trigalactosylated disialylated, triantennary trigalactosylated trisialylated structures with core or outer arm fucose, and tetraantennary tetragalactosylated trisialylated glycans. Most GPs showed increased abundance with worsening ACR. Lower eGFR was associated with higher absolute GP levels, most significantly with biantennary digalactosylated disialylated glycans with and without bisect, triantennary trigalactosylated trisialylated glycans with and without outer arm fucose, and core fucosylated biantennary monogalactosylated monosialylated glycans. Although several GPs were inversely associated prospectively with final eGFR, cross-validated multivariable models did not improve prediction beyond clinical covariates. Elevated HbA1c is associated with an altered N-glycan profile in type 1 diabetes. Although we could not establish GPs to be prognostic of future renal function decline independently of HbA1c, further studies to evaluate their impact in the pathogenesis of diabetic kidney disease are warranted.

Predisposing factors for the development of diabetic ketoacidosis with lower than anticipated glucose levels in type 2 diabetes patients on SGLT2-inhibitors: a review.

PURPOSE: SGLT2-inhibitors (SGLT-2i) have been linked to the risk of potential life-threatening diabetic ketoacidosis (DKA). The U.S. Food and Drug Administration and the European Medicines Agency issued warnings in 2015 and 2016 respectively on the predisposing factors to the development of DKA in individuals on an SGLT2i. New predisposing factors to DKA are still being discovered with the use of SGLT-2i. The list by FDA and EMA is yet to be updated. This article aims to provide a holistic list that includes the newer factors that have been implicated in the development of DKA. The overall aim is to guide physicians in prescribing this class of drugs for type 2 diabetes mellitus (T2D). METHOD: A search was done using PUBMED, Google Scholar, and Directory of Open Access Journals with the following words: SGLT-2 Inhibitors AND Ketoacidosis were entered. We included articles from 2000 to 2020, those in English, those involving any of the approved SGLT2i medications in T2D patients, and studies that focused on DKA linked to SGLT-2i. These articles were reviewed, and relevant data extracted and compiled. RESULTS AND CONCLUSION: The review has revealed that predisposing factors include (excess) alcohol consumption, female gender, starvation due to illness or fasting, withholding the use of SGLT2i for less than 48 h peri-operatively, and the existence of a variations in the expression of SGLT2 receptors. Patients should be advised on "sick day rules," and if a patient becomes unwell while on an SGLT2i, they should be advised to withhold the medication for the duration of the intercurrent illness.

Comparison of serum and urinary biomarker panels with albumin/creatinine ratio in the prediction of renal function decline in type 1 diabetes.

AIMS/HYPOTHESIS: We examined whether candidate biomarkers in serum or urine can improve the prediction of renal disease progression in type 1 diabetes beyond prior eGFR, comparing their performance with urinary albumin/creatinine ratio (ACR). METHODS: From the population-representative Scottish Diabetes Research Network Type 1 Bioresource (SDRNT1BIO) we sampled 50% and 25% of those with starting eGFR below and above 75 ml min-1 [1.73 m]-2, respectively (N = 1629), and with median 5.1 years of follow-up. Multiplexed ELISAs and single molecule array technology were used to measure nine serum biomarkers and 13 urine biomarkers based on our and others' prior work using large discovery and candidate studies. Associations with final eGFR and with progression to <30 ml min-1 [1.73] m-2, both adjusted for baseline eGFR, were tested using linear and logistic regression models. Parsimonious biomarker panels were identified using a penalised Bayesian approach, and their performance was evaluated through tenfold cross-validation and compared with using urinary ACR and other clinical record data. RESULTS: Seven serum and seven urine biomarkers were strongly associated with either final eGFR or progression to <30 ml min-1 [1.73 m]-2, adjusting for baseline eGFR and other covariates (all at p<2.3 × 10-3). Of these, associations of four serum biomarkers were independent of ACR for both outcomes. The strongest associations with both final eGFR and progression to <30 ml min-1 [1.73 m]-2 were for serum TNF receptor 1, kidney injury molecule 1, CD27 antigen, α-1-microglobulin and syndecan-1. These serum associations were also significant in normoalbuminuric participants for both outcomes. On top of baseline covariates, the r2 for prediction of final eGFR increased from 0.702 to 0.743 for serum biomarkers, and from 0.702 to 0.721 for ACR alone. The area under the receiver operating characteristic curve for progression to <30 ml min-1 [1.73 m]-2 increased from 0.876 to 0.953 for serum biomarkers, and to 0.911 for ACR alone. Other urinary biomarkers did not outperform ACR. CONCLUSIONS/INTERPRETATION: A parsimonious panel of serum biomarkers easily measurable along with serum creatinine may outperform ACR for predicting renal disease progression in type 1 diabetes, potentially obviating the need for urine testing.

Impact of free-living pattern of sedentary behaviour on intra-day glucose regulation in type 2 diabetes.

PURPOSE: To investigate how the pattern of sedentary behaviour affects intra-day glucose regulation in type 2 diabetes. METHODS: This intensive longitudinal study was conducted in 37 participants with type 2 diabetes (age, 62.8 ± 10.5 years). Glucose and sedentary behaviour/physical activity were assessed with a continuous glucose monitoring (Abbott FreeStyle Libre) and an activity monitor (activPAL3) for 14 days. Multiple regression models with generalised estimating equations (GEEs) approach were used to assess the associations of sedentary time and breaks in sedentary time with pre-breakfast glucose, pre-lunch glucose, pre-dinner glucose, post-breakfast glucose, post-lunch glucose, post-dinner glucose, bedtime glucose, the dawn phenomenon, time in target glucose range (TIR, glucose 3.9-10 mmol/L) and time above target glucose range (TAR, glucose > 10 mmol/L). RESULTS: Sedentary time was associated with higher pre-breakfast glucose (p = 0.001), pre-dinner glucose (p < 0.001), post-lunch glucose (p = 0.005), post-dinner glucose (p = 0.013) and the dawn phenomenon (p < 0.001). Breaks in sedentary time were associated with lower pre-breakfast glucose (p = 0.023), pre-dinner glucose (p = 0.023), post-breakfast glucose (p < 0.001) and the dawn phenomenon (p = 0.004). The association between sedentary time and less TIR (p = 0.022) and the association between breaks in sedentary time and more TIR (p = 0.001) were also observed. CONCLUSIONS: Reducing sedentary time and promoting breaks in sedentary time could be clinically relevant to improve intra-day glucose regulation in type 2 diabetes.

Persistent C-peptide secretion in Type 1 diabetes and its relationship to the genetic architecture of diabetes.

BACKGROUND: The objective of this cross-sectional study was to explore the relationship of detectable C-peptide secretion in type 1 diabetes to clinical features and to the genetic architecture of diabetes. METHODS: C-peptide was measured in an untimed serum sample in the SDRNT1BIO cohort of 6076 Scottish people with clinically diagnosed type 1 diabetes or latent autoimmune diabetes of adulthood. Risk scores at loci previously associated with type 1 and type 2 diabetes were calculated from publicly available summary statistics. RESULTS: Prevalence of detectable C-peptide varied from 19% in those with onset before age 15 and duration greater than 15 years to 92% in those with onset after age 35 and duration less than 5 years. Twenty-nine percent of variance in C-peptide levels was accounted for by associations with male gender, late age at onset and short duration. The SNP heritability of residual C-peptide secretion adjusted for gender, age at onset and duration was estimated as 26%. Genotypic risk score for type 1 diabetes was inversely associated with detectable C-peptide secretion: the most strongly associated loci were the HLA and INS gene regions. A risk score for type 1 diabetes based on the HLA DR3 and DQ8-DR4 serotypes was strongly associated with early age at onset and inversely associated with C-peptide persistence. For C-peptide but not age at onset, there were strong associations with risk scores for type 1 and type 2 diabetes that were based on SNPs in the HLA region but not accounted for by HLA serotype. CONCLUSIONS: Persistence of C-peptide secretion varies widely in people clinically diagnosed as type 1 diabetes. C-peptide persistence is influenced by variants in the HLA region that are different from those determining risk of early-onset type 1 diabetes. Known risk loci for diabetes account for only a small proportion of the genetic effects on C-peptide persistence.

INCREASED MORTALITY IN PATIENTS WITH PRIMARY HYPERPARATHYROIDISM: DOES SURGERY MAKE A DIFFERENCE?

Objective: Primary hyperparathyroidism (PHPT) is functionally characterized by an inappropriately raised secretion of parathyroid hormone, leading to raised serum calcium levels. Some patients are referred for parathyroidectomy, and some are managed conservatively. The aim of the audit was to compare the mortality outcomes between the two groups. Methods: We retrospectively identified a cohort of inpatients with a main or secondary diagnosis of PHPT between 1986 and 2010 and followed them up to the end of 2011. The risk of mortality in PHPT patients compared to the background general population was estimated by calculating standardized mortality ratios (SMRs), adjusting for age, sex, and person-years at risk. Mortality in surgically treated patients was compared to conservatively treated patients using Cox regression, taking account of the Charlson Comorbidity Index. Results: A total of 2,589 patients (77.9% females) were diagnosed with PHPT in Scotland over this period. Of patients diagnosed with PHPT, 41.6% (1,077/2,589) had died by the end of 2011. The SMR was 1.58 (95% confidence interval [CI], 1.48 to 1.67). A total of 54.8% of the patients underwent surgery (SMR, 1.30; 95% CI, 1.18 to 1.43), while the rest were treated "conservatively" (SMR, 1.88; 95% CI, 1.73 to 2.03) (P<.001). When other significant variables including the Charlson Comorbidity Index were taken into account in the final model, the hazard ratio for the "conservatively" managed group was reduced to 1.49 (95% CI, 1.30 to 1.70; P<.0001). Conclusion: Our study confirmed that inpatients diagnosed with PHPT have increased mortality. The risk of mortality was lower in those treated surgically compared with patients treated conservatively. Abbreviations: CI = confidence interval; HR = hazard ratio; PHPT = primary hyperparathyroidism; PTX = parathyroidectomy; SMR = standard mortality ratio; SMR01 = Scottish Morbidity Records.

Bilateral Femoral Neck Fractures in a Middle-Aged Female After a Low-Energy Fall.

BACKGROUND: Bilateral hip fractures after low-energy mechanism are a rare phenomenon. Most published case reports include presentations of bilateral hip fractures in the elderly with low-energy mechanism. There is no report, to our knowledge, that illustrates this rare occurrence in middle-aged individuals after a low-energy fall from standing height. CASE PRESENTATION: We present a case of a 50-year-old female with history of cerebrovascular accident (CVA) who presented to our institution with bilateral valgus-impacted femoral neck fractures after a mechanical fall from standing height. The patient underwent successful in-situ percutaneous screw placement in bilateral hips. CONCLUSION: Although patient age is an obvious risk factor, middle-aged individuals with a medical history affecting bone mineral content may also be prone to bilateral insufficiency fractures. Individuals complaining of joint pain (with a history of conditions including renal failure, obesity, endocrinopathies, etc.) should have advanced imaging, if screening plain radiographs are negative, in an effort to identify occult fractures.

Mortality risk remains higher in individuals with type 1 diabetes: A population-based cohort study (the Ayrshire diabetes follow-up cohort [ADOC]).

AIMS: Type 1 diabetes is associated with an increased risk of cardiovascular disease and all-cause mortality. Numerous studies have demonstrated that outcomes for diabetes are improved by intensive glycaemic control, blood pressure control, and treatment of dyslipidaemia in addition to cessation of smoking. The aim of this study was to compare mortalities in individuals with type 1 diabetes with that in non-diabetic individuals, and to investigate the effects of age, gender, glycaemic control, socio-economic status, hypertension, ischaemic heart disease (IHD), smoking status, body mass index (BMI) and dyslipidaemia. METHODS: A population-based analysis in Ayrshire and Arran, Scotland included 253 304 non-diabetic individuals and 1324 individuals with type 1 diabetes who were tracked from 2009 to 2014. RESULTS: Patients with type 1 diabetes had higher mortality rates than non-diabetic individuals (HR, 3.20; P < .01), with relative mortality in female individuals with type 1 diabetes being higher than that in males (OR, 2.38 vs 1.52; P < .01). Increasing age (HR, 2.37), smoking (HR, 1.85), IHD (HR, 1.62) and hypertension (HR, 1.21) (all P < .01) increased mortality risk. A hypertensive female with type 1 diabetes and IHD who smoked had an HR of 11.6 compared with a non-smoking, normotensive non-diabetic female without IHD. For a hypertensive male with type 1 diabetes and IHD who smoked, HR was 6.96. BMI > 30 kg/m2 was associated with reduced mortality risk in both non-diabetic (HR, 0.61) and diabetic subjects (HR, 0.40). CONCLUSIONS: This study confirmed that the risk of mortality in individuals with type 1 diabetes remains elevated. Further studies are required to understand how gender affects the disparity in mortality and why obesity appears to be protective.

The effect of continuous high versus low dose oral isotretinoin regimens on dermcidin expression in patients with moderate to severe acne vulgaris.

The continuous low dose (LD) isotretinoin is frequently used in the treatment regimen for acne vulgaris. However, data about its antimicrobial are lacking. The present study aimed to investigate dermcidin expression and the effects of low and conventional dose isotretinoin on its expression in acne vulgaris patients. Skin dermcidin expression was investigated in 30 patients with moderate-severe acne vulgaris and 15 healthy control subjects using ELISA. 15 patients were given continuous low-dose isotretinoin (20 mg/day) and the other 15 given the conventional high dose (0.5 mg/kg/day). Skin biopsies were taken at the start of the study and 6 months later. Dermcidin was significantly lower in acne vulgaris patients (p < .001). Both isotretinoin regimens significantly raised dermcidin levels compared to pre-treatment values (p < .001). Relapse after 12 months was not statistically different among the two isotretinoin regimens (p = .464). Pretreatment global acne grading system score of 28.6 ± 6.4 was reduced to 6 ± 6.1 following isotretinoin treatment (p < .001). Relapse was significantly related to posttreatment dermcidin levels (p = .017). Dermcidin expression is reduced in acne vulgaris. Conventional and LD isotretinoin regimens are associated with increased dermcidin expression.

Primary hyperparathyroidism: Increasing prevalence, social deprivation, and surgery.

OBJECTIVE: To measure the increasing incidence of primary hyperparathyroidism (PHPT) in Scotland, to determine the relationship between PHPT and deprivation, and to investigate the relationship between parathyroidectomy (PTX) and social deprivation. METHODS: We retrospectively identified a cohort of patients diagnosed with PHPT between 1986 and 2013 from the Scottish Morbidity Records (SMR01) database. The diagnosis of PHPT was made in accordance with the International Classification of Diseases code. RESULTS: Between the years 1986 and 2013, 4002 patients were diagnosed with PHPT. There was a significant increase in the incidence of PHPT in this period (p < 0.0001), an association between the incidence of PHPT and deprivation (p < 0.0001) plus an association between a lower rate of PTX and deprivation (p < 0.001). CONCLUSION: The increase in incidence of PHPT may be due to a combination of increased awareness of PHPT, easier diagnosis, and an ageing population. The lower rate of PTX in relation to deprivation may reflect comorbidities, age, and uncertainty about the long-term benefits of PTX in asymptomatic patients.

One step closer to understanding the role of bacteria in diabetic foot ulcers: characterising the microbiome of ulcers.

BACKGROUND: The aim of this study was to characterise the microbiome of new and recurrent diabetic foot ulcers using 16S amplicon sequencing (16S AS), allowing the identification of a wider range of bacterial species that may be important in the development of chronicity in these debilitating wounds. Twenty patients not receiving antibiotics for the past three months were selected, with swabs taken from each individual for culture and 16S AS. DNA was isolated using a combination of bead beating and kit extraction. Samples were sequenced on the Illumina Hiseq 2500 platform. RESULTS: Conventional laboratory culture showed positive growth from only 55 % of the patients, whereas 16S AS was positive for 75 % of the patients (41 unique genera, representing 82 different operational taxonomic units (OTU's). S. aureus was isolated in 72 % of culture-positive samples, whereas the most commonly detected bacteria in all ulcers were Peptoniphilus spp., Anaerococcus spp. and Corynebacterium spp., with the addition of Staphylococcus spp. in new ulcers. The majority of OTU's residing in both new and recurrent ulcers (over 67 %) were identified as facultative or strict anaerobic Gram-positive organisms. Principal component analysis (PCA) showed no difference in clustering between the two groups (new and recurrent ulcers). CONCLUSIONS: The abundance of anaerobic bacteria has important implications for treatment as it suggests that the microbiome of each ulcer "starts afresh" and that, although diverse, are not distinctly different from one another with respect to new or recurrent ulcers. Therefore, when considering antibiotic therapy the duration of current ulceration may be a more important consideration than a history of healed ulcer.

Gout and diabetes: a common combination.

The aims of this cross-sectional study were to compare metabolic parameters in people with gout and diabetes with gout only and type 2 diabetes mellitus (T2DM) only. Fifty General Practices in NHS Ayrshire and Arran (population 340 377) contributed data. The sample was split into three groups, those with both gout and T2DM, those with gout only and those with T2DM only. The prevalence of gout in Ayrshire and Arran was 2.65%. The prevalence of gout in people with type 1 and 2 diabetes was 1.90% (p=0.30) and 10.12% (p<10(-5)), respectively. Patients with both conditions were significantly more likely to be male (p<10(-5)), older (p<10(-5)), have a higher mean body mass index (p<0.001), higher triglycerides (p<10(-4)), lower mean total, high-density lipoprotein- and low-density lipoprotein cholesterol (p<10(-5)), lower estimated glomerular filtration rate (p<0.001), neuropathy (p=0.02), lower haemoglobin (p<0.001), to be prescribed more medications (p<10(-5)) and less likely to smoke (p<0.01). There was an association between lower haemoglobin A1c and increased prevalence of gout (p<0.001). 42.4% of patients with gout alone and 36.2% of those with both gout and diabetes had a urate measure. This study defines much more clearly the association between gout and T2DM. Of interest, in terms of lifestyle, both better glycaemic control and smoking are associated with a higher prevalence of gout.

OUTCOMES FOLLOWING "DOUBLE KNOT" SUSPENSION ARTHROPLASTY FOR BASAL JOINT ARTHRITIS OF THE THUMB.

BACKGROUND: Various surgical options used in the treatment of osteoarthritis of the basal joint of the thumb that are refractory to non-surgical management. This study was conducted to provide short term functional outcomes using the mentioned technique in treating basal joint arthritis of the thumb. METHODS: We treated basal joint arthritis of the thumb by trapeziumectomy and volar oblique ligament reconstruction using flexor carpi radialis tendon and "suspension" interposition arthroplasty using the entire tendon split along its length and tied as a double knot at the base of the thumb metacarpal. Through a questionnaire based survey, we reviewed 24 thumbs in 24 patients with basal joint arthritis of the thumb who were followed up with the hand therapist. Postal questionnaires were sent to these patients to record DASH scores and satisfaction. RESULTS: The mean time from surgery to discharge by the hand therapist following rehabilitation was 10 weeks. The DASH score averaged 25 points at 12 weeks postoperatively: There was statistical significance (p-value=0.0001) between the DASH score compared with time spent with the hand therapist. The postoperative net difference in grip strength and pinch grip compared with non-operated had was 9 kg and 3 kg respectively and the net difference in web span was 2 cm. CONCLUSION: We suggest this technique of "suspension" arthroplasty is a safe and effective method in treating basal joint arthritis of the thumb with good short-term functional outcomes and minimal complications.

The management of risk. Part 1: Why complaints happen and how to prevent them.

UNLABELLED: There is increasing concern amongst dentists, and dental care professionals (DCPs), about the risks associated with complaints from patients and the possibility of escalation to legal action or referral to the General Dental Council (GDC). This is the first of a series of four articles considering the management of risk. It will describe why complaints happen, how to identify problems at an early stage and strategies for preventing complaints occurring. CLINICAL RELEVANCE: The prevention of complaints will reduce stress and anxiety for all members of the dental team.

The management of risk. Part 2: Good consent and communication.

UNLABELLED: Valid consent is an absolute requirement of ethically correct treatment. This second article, in a series covering the management of risk, defines consent but also describes the role that appropriate consent, through good communication, plays in clinical and ethical risk management and the reduction of complaints. CLINICAL RELEVANCE: Valid consent is fundamental to the ethical and legal treatment of patients.

The management of risk. Part 4: Resolving complaints.

Patient complaints invariably cause concern and distress. Whilst prevention should be the primary objective, this is not always possible. This final article in the series describes strategies for the management and resolution of complaints, as well as the advantages of good complaint handling. Clinical Relevance: Early and efficient resolution of complaints will reduce stress to all members of the dental team.