The high prevalence of unrecognized anaemia in patients with diabetes and chronic kidney disease: a population-based study.

BACKGROUND: Anaemia occurs early in the course of diabetes-related chronic kidney disease (CKD). There is little evidence about the prevalence of anaemia in people with diabetes. The aim of this study was to assess the prevalence of anaemia, by stage of CKD, in the general diabetic population. METHODS: Haemoglobin (Hb) was measured on all glycated haemoglobin (HbA1c) samples and the most recent (< 4 months) estimated glomerular filtration rate (eGFR) was obtained. Anaemia (at treatment level) was defined as Hb < 110 g/l or the use of erythropoetic stimulating agents (ESA). RESULTS: Twelve per cent (10-14%) of people had Hb < 110 g/l. The prevalence of anaemia increased progressively with worsening CKD. People with CKD stage 3 accounted for the largest number of people with anaemia; 18% (95% CI 13-24%) had Hb < 110 g/l. Those with eGFR < 60 ml/min/1.73 m2 and not on ESA or dialysis were four (2-7) times more likely than patients with better renal function to have Hb < 110 g/l. The relation between Hb and eGFR became approximately linear below an eGFR of 83 ml/min/1.73 m2, where, for every 1 ml/min/1.73 m2 fall in eGFR, there was a 0.4 (0.3-0.5) g/l fall in haemoglobin. CONCLUSIONS: This study demonstrates that anaemia, at levels where treatment is indicated, occurs commonly in people with diabetes and CKD stage 3 or worse. The screening for anaemia in current diabetes management should be extended.

Recent developments in biological sequence databases.

Biological sequence databases are currently being re-engineered to make them more efficient and easier to use. This re-engineering is also providing an infrastructure to make it easier to interrogate and integrate data from different sources. The net result of this effort should be a great improvement in the power and availability of bioinformatics resources to the general biology community.

Steroid receptors, pS2 and cathepsin D in early clinically node-negative breast cancer.

Four oestrogen-regulated proteins of reported prognostic value, oestrogen receptor (ER), progesterone receptor (PR), pS2 and cathepsin D (Cat D), have been quantified by immunoassays, and the latter studied by immunohistochemistry (IHC) in primary tumours from clinically node-negative early breast cancer patients, entered into a trial of breast conservation therapy in which all the patients received adjuvant tamoxifen. ER, PR and pS2 significantly co-correlated but none correlated with Cat D. ER, PR and pS2, but not Cat D, were significantly associated with tumour size and grade, although Cat D tended to show an inverse relationship with the latter. Cat D (radioimmunoassay) in pmol/mg significantly correlated with the IHC score for Cat D in carcinoma cells as well as the number of Cat D-expressing macrophages. At a median follow-up of only 16 months, recurrence was significantly more common in patients with tumours having negative status for ER, PR and pS2 but was not associated with Cat D status.

Preservation of ischaemically injured canine kidneys with hypertonic citrate solution: the importance of mannitol.

The ability of hypertonic citrate solution to preserve ischaemically injured canine kidneys was investigated. It was found that if mannitol was given i.v. before ischaemia and again after graft revascularization, kidneys subjected to 30 min of warm ischaemia could be preserved for 24 hr, maintaining immediate life-sustaining function.

Simple hypothermic preservation for transporting human livers long distances for transplantation. Report of 12 cases.

Since 1973, 12 patients in the Cambridge-King's College Hospital liver transplant programme have received livers from donors dying in hospitals considerable distances from the transplant centre in Cambridge. The method of preservation used to transport these livers from 35 to 110 miles was flush perfusion with plasma protein fraction and hypothermic storage in ice. The ischaemia times ranged from 2 hr and 42 min to 4 hr and 22 min. All of the recipients had good or excellent postoperative function of the grafts and 6 of the 12 recipients are alive, the longest survival being 29 months. The preservation technique is simple and easily portable and has given reliable 4-hr preservation of the human liver.

Breast carcinoma cellularity and its relation to oestrogen receptor content.

The cellularity of 104 primary breast carcinomata was determined by semiautomated image analysis to allow the relation between cellularity and oestrogen receptor content values to be assessed. The oestrogen receptor content of tumours detected by a steroid binding assay showed no correlation with cellularity, although a possible weak negative correlation was observed between tumour cellularity and oestrogen receptor content detected by enzyme immunoassay. It is concluded that there is no single direct correlation between tumour cellularity and oestrogen receptor content.

A multicentre study of twice daily acebutolol ('Sectral') in the treatment of hypertension in general practice.

An open multicentre study was carried out under uncontrolled conditions in general practice to investigate the efficacy and acceptability of twice daily acebutolol in patients with mild to severe hypertension. Data from 1007 patients were analyzed. Most (901) had been treated previously with other hypertensive agents before starting on acebutolol. Oral dosages of acebutolol ranged from 200 mg to 1200 mg/day, according to individual requirements, and 331 patients received concomitant therapy, usually with a diuretic, either from the start of therapy or after 4 to 8 weeks. A significant reduction (p less than 0.001) was observed in mean diastolic blood pressure over the 12-week assessment period, and response increased with treatment duration. There were 280 reports of side-effects and 63 patients were withdrawn from the study for this reason.

Ketoprofen ('Orudis') in the treatment of inflammatory arthritic conditions: a multicentre study in general practice.

An open multi-centre study was carried out in general practice to assess the effectiveness and tolerance of ketoprofen in the treatment of 1997 patients with inflammatory arthritic conditions. Patients were treated with 100 mg ketoprofen twice daily for 4 weeks and subjective assessments were made before and after treatment of the clinical symptoms of pain and/or stiffness. The results showed that ketoprofen produced a statistically significant relief of symptoms in painful joints, regardless of whether these were thought to be affected primarily by rheumatoid or osteoarthritic processes. Joint stiffness also improved in the majority of cases. The side-effects reported related mainly to gastro-intestinal symptoms: there were no cases of overt haemorrhage and no serious adverse reactions.

Multi-centre study of acebutolol in hypertensive subjects: results for patients from the 50 to 64-years' old and over 65 years' old age groups.

The results of a multi-centre general practice study on acebutolol in the treatment of hypertension were examined for two age groups of patients, namely those aged from 50 to 64 years and those aged 65 years and over. A total of 1501 patients was studied and followed-up over a period of 3 months. There was a marked reduction in systolic and diastolic blood pressure with treatment and the results, in terms of efficacy and tolerance, were comparable in both age groups. These findings indicate that acebutolol is warranted in the treatment of elderly patients with hypertension.

Final results of the Royal College of Radiologists' trial comparing two different radiotherapy schedules in the treatment of cerebral metastases.

Between February 1990 and February 1993, 25 centres in the UK recruited 544 patients into a prospective randomized trial comparing two whole-brain radiotherapy regimens (30 Gy in ten fractions over 2 weeks versus 12 Gy in two fractions on consecutive days) for the treatment of patients with symptomatic cerebral metastases. Of these patients 533 were eligible for analysis: 270 assigned to the two-fraction arm and 263 to the ten-fraction arm. The two groups were well balanced with respect to patient characteristics. Median survival was 77 days with two fractions (95% CI 68-89) and 84 days for the longer schedule (95% CI 67-102). Analysis of the survival curves showed a marginal advantage for ten fractions (P = 0.04). Performance status (P = 0.0001), site of primary tumour (P = 0.006), dose of dexamethasone (P = 0.004), age (P = 0.04) and randomization treatment (P = 0.03) were independant factors associated with survival. The classification of patients into good or poor risk groups based on these factors, excluding treatment, showed highly significant differences in survival (P < 0.0001). Predictive models suggested that any benefit attributable to the longer radiotherapy schedule was confined to those in a good prognostic group (these patients formed 22% of the study population). Radiation related side effects, other than alopecia, were seen in 12% of patients receiving two fractions and 8% of those given ten fractions. The short survival of many patients hampered the assessment of response, but overall responses were seen in 39% of those given two fractions and 44% of patients receiving ten fractions. These results suggest that any increase in survival due to longer radiotherapy treatment is confined to good prognosis patients, but, for the majority, there is no advantage and the value of radiotherapy for these patients relates purely to the possibility of control or relief of distressing symptoms.

Ketoprofen (Orudis) twice daily dosage in arthritis and tissue injuries: a general practice study.

In a general practice study using ketoprofen (Orudis) in a twice-daily dosage regimen for the treatment of patients with articular and non-articular rheumatic conditions, data were collected on 2,644 patients, over one-third of whom had been previously treated with other anti-rheumatic preparations. More than 80% showed a clinical improvement and the overall incidence of side-effects was relatively low. Three patients suffered a haematemesis--the most serious side-effect encountered. It was concluded that 50 mg or 100 mg twice-daily therapy was equally as effective as the 50 mg thrice daily regimen previously recommended and that the tolerability of ketoprofen was not adversely affected by this concentration of the daily requirement.

A multicentre study of a once daily dosage of acebutolol in the treatment of hypertension in general practice.

A three-month open, multicentre trial was carried out in 2132 hypertensive patients under uncontrolled conditions in general practice, to assess the effectiveness and tolerance of acebutolol when given orally as a single morning dose, in the range of 200 to 1200 mg/day. Concomitant antihypertensive therapy was given to 702 patients. Forty-five patients, out of 1893 who were eligible for analysis, showed inadequate blood pressure control and were withdrawn from the study. There were 602 reports of side-effects of adverse reactions attributed to acebutolol in 584 patients, necessitating 120 withdrawals from the trials. The results showed that acebutolol given once daily produces a substantial and progressive reduction in blood pressure over the three months of the trial. The changes from pre-trial values of all haemodynamic assessments measured were statistically significant (p less than 0.001).

Treatment of essential hypertension with beta-blocker plus diuretic: a study of 1402 patients treated by general practitioners with acebutolol 200 mg combined with hydrochlorothiazide 12.5 mg ('Secadrex') once daily for 3 months.

One thousand four hundred and two patients with essential hypertension were treated by their general practitioners for 3 months with one tablet daily consisting of 200 mg acebutolol plus 12.5 mg hydrochlorothiazide: 813 were newly diagnosed and 589 were known hypertensives already on treatment. There was no 'wash-out' period before the latter changed to the study treatment. Newly diagnosed hypertensives had an average initial mean arterial pressure (MAP) of 129.9 mm Hg which fell on average by 18.2% during the study: 79% of patients had good results with final MAP levels less than 113 mm Hg (equivalent to e.g., 160/90 mm Hg), and a further 7% also had good results in that MAP fell more than 15%, another 12.5% had moderate results (falls of 5% to 15%): and only 1.5% had poor results (fell less than 5%). Known hypertensives had an average MAP of 127 mm Hg on previous treatment, which fell on average by 15.4% during this study: 70% of patients had good results with final MAP levels less than 113 mm Hg and a further 7% also had good results in that MAP fell more than 15%: 18% had moderate results and 3% poor results. Pulse rate fell by 12.5% in newly diagnosed and 10% in known treated hypertensives. If allowance is made for withdrawals due to side-effects and to the need for more than one tablet of Secadrex daily, then over all 75.7% had a good blood pressure response to study medication, 13.7% a moderate response and 10.7% a poor response. Adverse effects caused the withdrawal of 4% of newly diagnosed and 5% of treated hypertensives, predominantly nausea/vomiting, lassitude/fatigue and malaise.(ABSTRACT TRUNCATED AT 250 WORDS)

An open study of acebutolol, given as a single daily dose in the management of hypertension in the Chulalungkorn Hospital, Thailand.

In an open study of fifteen patients with essential hypertension, acebutolol, a cardioselective B 1-adrenoceptor antagonist given orally once daily at dosages of between 400 mg and 1200 mg, produced a substantial and progressive reduction in systolic and diastolic arterial pressure and in the tension time index both in the lying and standing position over the 3 months of the trial. The changes from pre-trial values of blood pressure assessments were statistically significant (p less than 0.001). No side-effects were reported and laboratory monitoring of biological parameters revealed no untoward effects of treatment.

Multicentre study of 'Flagyl' in the prevention of post-operative anaerobic infection.

In a study carried out with 565 patients undergoing gynaecological and general surgical procedures, metronidazole ('Flagyl') was used pre- and post-operatively and the incidence of post-operative infection, particularly that due to anaerobic organisms, was recorded. This was not a controlled study but, by comparison with other series, it would appear that the use of oral metronidazole had substantially reduced the likelihood of supervention of anaerobic sepsis. It is probable that the use of intravenous metronidazole therapy would have reduced the incidence of anaerobic sepsis still further had this preparation been available at the time.

Rural general practitioner preceptors--how can effective undergraduate teaching be supported or improved?

INTRODUCTION: General practitioners (GPs) as rural GP-Preceptors play an important role in medical student teaching within the Discipline of General Practice, University of Tasmania, Australia. As well a significant teaching role, they are responsible for apportioning 20% of the mark medical students receive in the General Practice examination at the end of the rotation. The contribution of the student-rural GP preceptor relationship to recruiting and retaining rural GPs has been acknowledged. Despite these important responsibilities, as honorary teaching staff rural GP preceptors receive no formal training in undergraduate education or assessment, nor did they receive formal peer support. METHOD: To address the lack of educational preparation of GP-preceptors, and in accordance with the stringent teaching and assessment standards of the Australian Medical School Accreditation, a tripartite approach was taken to educational skills development among rural GP-preceptors. The Discipline of General Practice conducted a needs-analysis of 64 rural GP-preceptors, and an evaluation by questionnaire of the teaching efficacy of those 64 rural GP-Preceptors and 76 urban GP-preceptors by 64 final-year medical students after their 3-week rural and urban GP attachments. The second intervention, based on the assessment and evaluation findings, was devised and implemented by the University Department of Rural Health. A series of workshops comprised the interdisciplinary educational and support program for GP preceptors, entitled Preceptor Onsite Preparation Program for Information Education and Support, or POPPIES. RESULTS: The rural GP-preceptor needs analysis indicated that the majority of rural preceptors had no clear understanding of how what they taught fitted into the overall curriculum; they believed that their role as a clinical teacher had not been clearly defined by the program director; and also that undergraduate students had little understanding of what they needed to learn during their attachments. In contrast, preceptors believed they understood what students needed to learn; they were confident in performing the role of preceptor; and were familiar with adult learning principles, goal setting processes, effective student evaluation and the provision of appropriate performance feedback. Evaluation of feedback from students revealed that while rural GP preceptors performed well overall in regard to providing quality teaching and learning experiences, there was a significant spread of scores across all criteria, and approximately 15%-25% of students perceived various aspects of their attachment to be mediocre or poor. CONCLUSION: The combined results of the medical student questionnaire and rural GP-preceptor survey indicated both a need and a desire for educational skills development among rural GP-preceptors. On this basis, the interdisciplinary educational and support program for GP-preceptors (POPPIES) was developed and implemented as a series of workshops throughout rural Tasmania. Although no objective data are yet available about teaching outcomes as a result of POPPIES workshops, preliminary responses from attendee GP preceptors indicated that the workshops were effective in addressing educational needs, and in providing rural clinical teachers with professional teaching development.

Planning research in rural and remote areas.

INTRODUCTION: In order to set a regional research agenda, an interactive research workshop was planned by the joint University of Queensland and University of Southern Quennsland Centre for Rural and Remote Area Health (CRRAH), in which researchers and regional organisations would meet together to discuss and prioritise local research needs, then formulate constructive ideas and activities. METHODS: Selection of Participants: Organisations representing all key consumer, academic and health professionals within the Toowoomba, Queensland, Australia region were sent a letter inviting them to attend and to send at least one representative, resulting in a total of 75 workshop participants from 45 organisations representing 20 separate entities. The Design of the Workshop: The workshop was planned as an interactive research workshop, with a preliminary brainstorming to identify and prioritise topics, followed by facilitated small group discussions, and finally presentations to the reassembled total group. RESULTS: Forty three topics were put forward by participants during the plenary session, in which the following 12 major themes were evident: (1) health professional development and support; (2) mechanisms for identifying regional/local needs; (3) mental health; (4) health and interaction with the environment; (5) management of common conditions of which little is known; (6) post acute/aged care; (7) evidence based practice; (8) health workforce including volunteers; (9) indigenous health; (10) access to health service delivery; (11) economic impact of new programs; and (12) outcomes impact of research partnerships. Five subject areas from four of these themes were chosen for further small group discussion. A summary of the views, ideas and conclusions of each group, which were presented to a plenary session of reassembled participants over a 10-15 minute period by each group facilitators, are discussed below. Following each presentation, a 5-10 minute question session was provided after each topic. CONCLUSION: A workshop, enabling rural and remote organisations and regional researchers to meet and identify local research needs attracted strong local support. Although the final benefits of the workshop remain to be determined, a number of new collaborative research avenues are now being actively explored within the region, by a number of the participants.