Calcium requests in a primary care; An observational audit of biochemical requests and frequency of abnormal results.

BACKGROUND/AIMS: This aim of this audit was to assess the extent of serum calcium testing and the frequency of hypercalcaemia in the primary care setting. We also assessed the appropriateness of subsequent investigations with repeat serum calcium and PTH testing if hypercalcaemia was identified. METHODS: All laboratory requests for adjusted calcium and PTH samples sent from primary care in Glasgow were analysed over a 12 month period. This covered approximately 125 GP practices and a patient population of over 590,000. RESULTS: There were 78,845 requests for adjusted calcium and 2053 PTH requests from 62,745 patients aged 16-105 years (median age 57, IQ range 30 years). Of these requests 1423 (2.3%) of patients had biochemical evidence of hypercalcaemia (adjusted calcium ≥ 2.61 mmol/L). Of the 1423 patients with hypercalcaemia, 368 patients (45.8%) had a single raised calcium level that was within the normal range on repeat testing. Of the 400 patients with persistent hypercalcaemia on 2 or more samples, 210 (52.5%) had a PTH measured. Eight patients had a PTH < 2.0 pmol/L, whilst 202 (96.1%) had a PTH ≥ 2.0 pmol/L (range 2.1-106.1 pmol/L). CONCLUSIONS: Serum calcium was checked in 10.6% of the population per year within primary care. In the 2.4% with a raised calcium on initial testing, approximately half (45.8%) will normalise on repeat testing. Of those who remained persistently hypercalcaemic, only half (52.5%) had a PTH measured and the majority (96.1%) were in keeping with primary hyperparathyroidism being the most common cause of hypercalcaemia.

How tightly controlled do fluctuations in blood glucose levels need to be to reduce the risk of developing complications in people with Type 1 diabetes?

In 2011, the James Lind Alliance published a 'top 10' list of priorities for Type 1 diabetes research based on a structured consultation process. Whether reducing fluctuations in blood glucose can prevent long-term microvascular and macrovascular complications was one of these. In this narrative review, 8 years on, we have assessed the updated evidence for the assertion that increased glucose variability plays an independent and clinically important role in the complications of Type 1 diabetes, over and above mean blood glucose and the effects of hypoglycaemia: the 'glucose variability hypothesis'. Although studies in cultured cells and ex vivo vessels have been suggestive, most studies in Type 1 diabetes have been small and/or cross-sectional, and based on 'finger-prick' glucose measurements that capture glucose variability only in waking hours and are affected by missing data. A recent analysis of the Diabetes Control and Complications Trial that formally imputed missing data found no independent effect of short-term glucose variability on long-term complications. Few other high-quality longitudinal studies have directly addressed the glucose variability hypothesis in Type 1 diabetes. We conclude that there is little substantial evidence to date to support this hypothesis in Type 1 diabetes, although increasing use of continuous glucose monitoring provides an opportunity to test it more definitively. In the meantime, we recommend that control of glycaemia in Type 1 diabetes should continue to focus on the sustained achievement of target HbA1c and avoidance of hypoglycaemia.

Are hepatic and soleus lipid content, assessed by magnetic resonance spectroscopy, associated with low birth weight or insulin resistance in a rural Indian population of healthy young men?

AIMS: To assess young healthy men from rural India, who had normal or low birth weights, using magnetic resonance spectroscopy to determine the potential differences in ectopic fat storage between birth weight groups, and to determine if ectopic fat storage was associated with insulin resistance in this population. METHODS: A total of 54 lean men with normal birth weight and 49 lean men with low birth weight (age range 18-22 years) from rural India were recruited. All the men underwent anthropometry, magnetic resonance spectroscopy, a hyperinsulinaemic-euglycaemic clamp and a dual-energy X-ray absorptiometry. RESULTS: The median (interquartile range) values for hepatic cellular lipids, intramyocellular lipids and extramyocellular lipids, measured using magnetic resonance spectroscopy were 0.76 (0.1-1.8)%, 1.27 (1.0-2.3)% and 1.89 (1.3-3.2)%, respectively, for the normal birth weight group and 0.4 (0.1-1.3)%, 1.38 (0.9-2.2)% and 2.07 (1.2-2.8)%, respectively, for the low birth weight group (P > 0.05). No difference in ectopic fat storage was observed between the low and normal birth weight groups, with or without adjustment for age and total fat percentage. Homeostatic model assessment of insulin resistance values were not associated with hepatic cellular, intramyocellular or extramyocellular lipid content in any of the groups. Total fat percentage was the only independent predictor of intramyocellular and extramyocellular lipid content. CONCLUSION: Young and lean men from rural India with low birth weight were not observed to have ectopic fat storage in the liver or muscle, and the amount of liver and muscle fat was unrelated to insulin resistance. Older age and/or an urban affluent lifestyle may be required to show a potential role of ectopic fat storage on insulin resistance in Indian people with low or normal birth weight.

A critical review of powered mobility assessment and training for children.

PURPOSE: Assessment and training of young children using powered mobility tends to be based on expert opinion although research in this area has recently been completed. This review critiques available research and discusses the studies in relation to theory and expert opinion. METHOD: A literature review was completed to identify research regarding powered mobility training for children with developmental disabilities. Two recent qualitative studies were identified and their models and assessment tools were compared and discussed with recommendations for clinical practice and research. RESULTS: The focus of the two studies is on a continuum of learning, the reciprocal relationship of trainer and trainee, and impact of the social and attitudinal environment on powered mobility skill development. The assessment tools and training protocols are backed up by motor learning principles and expert opinion. Further research is required to incorporate the tools into clinical practice and to examine additional psychometric properties. CONCLUSIONS: Rather than focusing on readiness skills or pass/fail tests, clinicians should explore early mobility options for clients at the beginning of the continuum of learning, reflect on how they relate to and impact on their clients' learning, and set up the environment to facilitate independent learning and exploration.

Elastic depolarization of OH(A) by He and Ar: a comparative study.

Two color polarization spectroscopy has been employed to measure the collisional depolarization of OH(A(2)Sigma(+), v = 1) by He and Ar. Complementary experiments using Zeeman quantum beat spectroscopy have also been performed to determine separately the cross sections for rotational energy transfer (RET) out of selected rotational levels of OH(A, v = 0) + Ar, as well as those for elastic depolarization. This has been achieved by dispersing the emission, so as to observe a single fluorescence transition. Elastic depolarization of OH(A) by Ar is found to be significant with that for loss of rotational alignment exceeding that for loss of orientation. In the case of OH(A) + He, the polarization spectroscopy measurements suggest that elastic depolarization plays a relatively minor role in the loss of the polarization signal compared with RET. The experimental data for OH(A) + Ar are compared in detail with the results of quasi-classical trajectory calculations that accommodate the effects of electron spin. These classical calculations are assessed against the results obtained using full close-coupled open shell quantum mechanical scattering methods. Overall the level of agreement between the two experiments, and between experiment and theory, is very reasonable. Surprisingly, at low N the elastic depolarization cross sections for OH(A) + Ar are found to be quite similar in magnitude to those observed for OH(X) + Ar despite the fact that the well depth in the latter system is considerably smaller than that for OH(A)-Ar. However, for OH(A) + Ar the depolarization cross sections are insensitive to N in the range 1-14. It is proposed that this behavior partly reflects the relatively anisotropic nature of the potential energy surface, which exhibits deep wells of different depths at the two linear configurations OH(A)-Ar and Ar-OH(A), and partly the nature of elastic depolarizing collisions, which must occur with a velocity component perpendicular to the plane of rotation of the diatomic molecule.

Variations in the cerebral venous anatomy and pitfalls in the diagnosis of cerebral venous sinus thrombosis: low field MR experience.

BACKGROUND: Knowledge of variations in the cerebral venous anatomy and apparent signal abnormalities seen on Magnetic resonance (MR) angiography are essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST), while interpreting the MR angiograms. AIMS: To evaluate the variations of cerebral venous anatomy and signal abnormalities by using 3D phase contrast MR angiography performed in a 0.5 Tesla MRI scanner. MATERIALS AND METHODS: One hundred patients who underwent MR imaging and MR angiography examinations at our institution from March 2004 to February 2005, with normal MR imaging of brain were studied retrospectively. Patients with clinical suspicion of CVST and patients who underwent color doppler evaluation for suspected deep vein thrombosis were excluded. RESULTS: The superior sagittal, straight sinus and the internal cerebral veins were visualized in all patients. There was hypoplasia of the right transverse sinus in 13 patients, left transverse sinus in 35 patients, right sigmoid sinus in 6 patients and left sigmoid sinus in 19 patients. Absence of transverse sinus on left side was observed in one patient and absence of sigmoid sinus in 2 patients on left side. Flow gaps were observed in non-dominant transverse sinus, sigmoid sinus as well as transverse sigmoid sinus junctions. The occipital sinus was visualized in 17 patients. CONCLUSIONS: MR angiography done at low field strengths is also a reliable method, for assessing cerebral venous sinuses. Awareness of the normal anatomical variations of venous sinuses and apparent MR angiographic flow gaps prevent misdiagnosis of cerebral venous sinus thrombosis.

Evaluation of work practices and radiation dose during adult micturating cystourethrography examinations performed using a digital imaging system.

A micturating cystourethrography (MCU) examination is a specific radiological procedure that is performed under fluoroscopic screening to visualize the bladder by filling it with contrast material and to evaluate the urethral morphology during voiding. It is necessary to evaluate radiation dose during MCU examination since it involves radiosensitive organs such as the gonads. Radiation dose imparted to 109 patients undergoing MCU examination were measured using a dose-area product (DAP) meter. Patients were categorized into two groups based on whether filling of the bladder with contrast medium was done retrogradely (MCU) or by the suprapubic percutaneous route (SP-MCU). The DAP values to Group A (MCU) and Group B (SP-MCU) patients varied from 0.43 Gycm(2) to 9.26 Gycm(2) and 0.54 Gycm(2) to 9.87 Gycm(2), respectively. Reduction of radiation dose to patients was possible by the use of optimized exposure factors, precise collimation of X-ray beam, use of 0.2 mm copper filters and by acquiring images digitally.

Survival of Apligraf in acute human wounds.

Apligraf consists of bovine collagen dermis seeded with allogeneic male fibroblasts and keratinocytes. It is been shown to promote healing, but the length of persistence and pathological features have not been characterized previously in acute wounds. Forty-eight deep dermal wounds were created and Apligraf, a split-skin graft (SSG), or a dressing was applied. Biopsies of wounds were taken for immunohistochemical analysis and polymerase chain reaction was performed to detect the Y chromosome from Apligraf cells in 14 female wounds. Male allogeneic DNA was detected in wounds for the first 4 weeks. All subsequent time points were negative apart from one biopsy at 6 weeks. The wounds took 4-9 weeks to heal, with the Apligraf exhibiting no features of engraftment. This was in contrast to the rapid healing seen in the SSG control group. Histology revealed a more intense cellular infiltrate, but less vascularization below Apligraf compared with controls. Evidence of an epidermal-mesenchymal interaction was observed. This is the first article to elucidate the survival of Apligraf allogeneic cells in acute wounds in immunocompetent human subjects for up to 6 weeks and demonstrates that in the management of acute surgical wounds, Apligraf has a role only as a temporary biological dressing.

Radiation dose to voluntary kidney donors during renal angiography procedures.

The radiation dose to voluntary kidney donors undergoing renal angiography performed using digital subtraction angiography (DSA) was estimated. The effective dose was calculated from values of dose-area product measured using a Diamentor dose-area product meter. The duration of the fluoroscopic screening and the number of image acquisitions during each examination varied depending upon the number of arteries supplying the kidneys and other parameters. The effective dose varied from 2.3 mSv to 30.5 mSv. The clinical aspects involved during the study were also taken into consideration in the analysis of the data.

Pregnancy and cystic fibrosis.

Despite reduced fertility, pregnancy is likely to occur with increasing frequency in cystic fibrosis in proportion to the number of patients reaching childbearing age. Thirty-eight pregnancies in 25 patients with cystic fibrosis are presented. Twelve of the 25 mothers were pancreatic-sufficient. Despite previous reports of the hazards of pregnancy in cystic fibrosis, we found that pregnancy was well tolerated by the vast majority of our patients and had little effect on their pulmonary and nutritional status. Therapeutic abortion for medical indications was required in two pregnancies. The incidence of prematurity and the neonatal mortality rate were low, and no congenital abnormalities occurred. We conclude that pregnancy can be tolerated by the majority of cystic fibrosis patients, particularly those who are pancreatic-sufficient.

Colchicine therapy in primary amyloidosis of the bladder: a case report.

A patient with diffuse localized amyloidosis of the bladder was considered for cystectomy because of intractable gross hematuria. Oral colchicine (2 mg. daily) was commenced and 4 years later the patient was asymptomatic with minimal evidence of amyloidosis cystoscopically.

Elevated renal nerve activity after spinal transection: effects on renal function.

Spinal transection approximately doubles renal sympathetic activity (RSA) in rats. These experiments localized spinal pathways inhibiting RSA and determined the effects of transection-elicited renal sympathetic hyperactivity on renal circulation and renal function. Experiments were conducted in chloralose-anesthetized, paralyzed, artificially respired, male Sprague-Dawley rats. RSA was measured from an electrode on the left renal nerve. Renal arterial blood flow (RABF), glomerular filtration rate, urine flow rate, and renal sodium and potassium excretions were also measured. Localized lesions of the cervical spinal cord indicated that spinal generators of RSA were inhibited by pathways descending in the dorsal cervical cord. Autoregulation of RABF prevented transection-elicited increases in RSA from affecting renal vascular resistance. Renal sodium and potassium excretions were dramatically reduced after spinal transection, although these reductions were ameliorated somewhat by fixing posttransection renal arterial pressure at pretransection levels. We conclude that the vascular effects of transection-elicited elevations in RSA are minimized by autoregulation of RABF and that posttransection changes in renal function result from changes in both arterial pressure and RSA.

Cis-platin combination chemotherapy for non-seminomatous germ-cell tumours of the testis.

Eighteen patients with metastatic non-seminomatous germ-cell tumours (NSGCTs) of the testis were treated with cis-platin combination chemotherapy between 1979 and 1985. Three of the patients received chemotherapy after a staging lymphadenectomy (stage 2 disease) and were free of disease at follow-up. Fifteen patients with stage II disease and adverse prognostic factors or stage III disease received initial chemotherapy followed in 11 cases by surgical exploration. Eleven of these patients were free of disease at a median follow-up of 52 months, 1 was alive at 35 months with a mature teratoma, which is non-progressive, 2 died of their cancer, and 1 died of acute respiratory distress syndrome after surgery. The patients who failed to respond to therapy had associated bulky disease. The overall 5-year survival rate is 81%. Before the introduction of cis-platin there were no survivors among 9 patients with metastatic NSGCTs treated initially with chemotherapy. These findings indicate that the good results reported with cis-platin combination chemotherapy for NSGCTs are reproducible in other populations and centres.

Inhibition of renal nerve sympathetic activity by spinal stimulation in rat.

We determined the physiological and anatomical properties of systems mediating renal nerve inhibition elicited by electrical and chemical stimulation of the cervical dorsolateral funiculus of the anesthetized spinally transected rat. Stimulus-response characteristics suggested that this system was well suited for a role in tonic inhibition of sympathetic activity. Inhibition was elicited from a region of the cervical spinal cord extending from a lateral position near the accessory nerve to the dorsal columns. Inhibition could not be elicited by spinal stimulation before lesions had been placed rostral to stimulation sites in the lateral funiculi. Inhibition was blocked by similarly placed lesions caudal to stimulation sites. Therefore, this system may course in the lateral funiculus, and it may be tonically active in intact rats. Renal sympathetic activity could be inhibited by electrical stimulation caudal to large, chronic, spinal lesions. Therefore, some component of the inhibitory system was either antidromically activated or propriospinal. Glutamate applied to the dorsolateral surface of the cervical spinal cord elicited inhibition indistinguishable from that elicited by electrical stimulation, which suggested that neurons with somas located superficially at cervical levels may be responsible for some component of the spinally elicited inhibition.

Testicular tumours in children.

The rarity of testicular and paratesticular cancer makes the evaluation of treatment and results difficult. One childhood tumour which differs from adult testicular cancer is the yolk-sac tumour. Because of its less aggressive nature and the young age at which these children present, radical orchidectomy is adequate surgery. There is little evidence to support the view that retroperitoneal node dissection, radiotherapy or prophylactic chemotherapy improves the survival rate. By careful follow-up, metastatic disease or recurrence can be detected and early chemotherapy instituted. The overall prognosis for children with these tumours is good. In a series of 9 patients with yolk-sac tumours 8 have survived free of disease for 9 months-14 years since diagnosis.

Comparative cervical microflora shifts after cefoxitin or cefazolin prophylaxis against infection following cesarean section.

The aerobic and anaerobic cervical microflora was determined before operation and on day 4 after operation in groups of women undergoing a clinical trial of prophylaxis with three doses of cefoxitin, cefazolin, or placebo for infectious complications of nonelective cesarean section. Floral shifts occurred post partum, with return of Escherichia coli and Bacteroides fragilis and a decrease in Candida colonization. No significant differences in flora existed preoperatively among patients receiving cefoxitin, cefazolin, or placebo, but by day 4, both antibiotic groups had greater enterococcal colonization. This difference was more marked with cefoxitin than with cefazolin. No difference in E. coli or B. fragilis colonization was noted by day 4 in placebo and antibiotic groups. Resistance developing in isolates in the antibiotic groups was mainly a result of enterococcal colonization. Results of this study indicate that a three-dose cephalosporin prophylactic regimen resulted in a significant selection of resistant enterococcal colonization but there was no increase in nosocomial infection in the antibiotic groups compared to the placebo group. There did not appear to be significant differences in either species selection or antibiotic resistance of aerobic or anerobic microflora between the cefoxitin and cefazolin groups.

Multicenter comparison of cefoxitin versus cefazolin for prevention of infectious morbidity after nonelective cesarean section.

A randomized double-blind placebo-controlled comparison of prophylactic cefoxitin, an antibiotic with good activity against anaerobic bacteria, with cefazolin, an agent effective predominantly against aerobes, was undertaken in 354 women who underwent nonelective cesarean section (124 receiving cefoxitin, 119 cefazolin, and 111 placebo). Among the placebo group, 24.3% developed genital tract-related infection, in comparison to 5.6% of the cefoxitin patients and 6.7% of the cefazolin patients (P less than 0.001). Standard febrile morbidity, fever index, and duration of postoperative hospital stay were also significantly less in the antibiotic prophylactic groups. For patients with febrile morbidity, the mean fever index was less in the cefoxitin group (24.8 degree-hours) than that in the cefazolin group (42.7 degree-hours), and this difference approached statistical significance (P less than 0.1, greater than 0.05). Postoperative hospital stay longer than 1 week for infectious morbidity occurred in 26% of cefoxitin patients, a significantly lower incidence compared to the 66% rate for patients who received cefazolin, and the 57% incidence for patients in the placebo group (P less than 0.05).