Effect of high-fat diet on glucose homeostasis and gene expression in glucokinase knockout mice.

AIM: We have generated a heterozygous glucokinase knockout mouse (gk(del/wt)), upon which we investigated the effect of high-fat diet (HFD) with respect to metabolic control and both hepatic and beta-cell gene expression. We also investigated the in vitro efficacy of a glucokinase activator (GKA) on glucose-stimulated insulin secretion (GSIS) in gk(del/wt)mouse islets. METHODS: Male gk(del/wt)and gk(wt/wt)mice were grouped (n = 8-10) at 10 weeks of age and fed HFD or chow diet (CD) for 10 weeks. Multiple parameters including blood glucose, plasma insulin and glucose tolerance were assessed. Further animal groups were used for in vitro GSIS and islet and liver gene expression analysis. RESULTS AND CONCLUSIONS: gk(del/wt)mice showed early-onset persistent hyperglycaemia, raised glycated haemoglobin levels, impaired GSIS and glucose tolerance but no change in plasma cholesterol, non-esterified fatty acids or triglyceride levels. After HFD feeding, insulin levels of gk(del/wt)mice were less than half that of gk(wt/wt)mice, although they were equivalent to gk(wt/wt)mice on CD. While gk(wt/wt)mice maintained moderate hyperglycaemia, gk(del/wt)mice became overtly diabetic, with worsened glucose tolerance. A GKA (GKA50) increased GSIS, at 10 mM glucose, in gk(del/wt)mice to an extent at least as great as that seen in gk(wt/wt)mice on both CD and HFD. gk(del/wt)mice showed only a small number of changes in gene expression compared with gk(wt/wt)mice. We propose the high fat-fed gk(del/wt)mouse as a model of type 2 diabetes and report retained efficacy of a GKA on in vitro GSIS.

BILAG 2004. Development and initial validation of an updated version of the British Isles Lupus Assessment Group's disease activity index for patients with systemic lupus erythematosus.

OBJECTIVE: To devise a more discriminating version of the British Isles Lupus Assessment Group (BILAG) disease activity index and to show that it is reliable. METHODS: A nominal consensus approach was undertaken by members of BILAG to update and improve the BILAG lupus disease activity index. The index has been revised following intense consultations over a 1-yr period. It has been assessed in two real-patient exercises. These involved patients with diverse clinical features of SLE, including gastrointestinal, hepatic and ophthalmic problems, which the earlier versions of the index did not fully take into account. Reliability in terms of the ability to differentiate patients was assessed by calculating intraclass correlation coefficients. The level of agreement between physicians was determined by calculating the ratio of estimates of the standard error (SE) attributable to the physicians to the SE attributable to the patients. RESULTS: Good reliability and high levels of physician agreement were observed in one or both exercises in the constitutional, mucocutaneous, neurological, cardiorespiratory, renal, ophthalmic and haematological systems. In contrast, the musculoskeletal system did not score as well, although providing more clear-cut glossary definitions should greatly improve the situation. CONCLUSIONS: Some significant changes in the BILAG disease activity index to assess patients with SLE are proposed. The process of demonstrating validity and reliability has started with these two exercises assessing real patients. Further validation studies are under way. BILAG 2004 is likely to be valuable in clinical trials assessing new therapies for the treatment of SLE, as it provides a more comprehensive system-based disease activity measure than has been available previously.

Comparing and contrasting undergraduate competence in musculoskeletal medicine with cardiovascular medicine and neurology.

OBJECTIVES: With an increasing prevalence of musculoskeletal conditions within the UK, specialty bodies are concerned that graduating medical students may lack appropriate knowledge in this system. We investigated the knowledge base of final year Sheffield medical students in the musculoskeletal system, compared with other major body systems. METHODS: A computer-based assessment was designed covering core topics that a pre-registration house officer should know about in musculoskeletal medicine, cardiology and neurology, using a predesigned testing format. The test was blueprinted against internal and external guidelines. It comprised 24 extended matching questions, each with three stems. A sample of 74 volunteer students from the final year (year 5) of the medical course at the University of Sheffield took part in the assessment. RESULTS: Overall scores of students on the test ranged from a baseline of 45% to a maximum of 85%. Test reliability was 0.75 (Cronbach's alpha). On stratifying the overall percentages into marks for individual systems, it was found that there were no significant differences between scores in musculoskeletal medicine, cardiovascular medicine or neurology. CONCLUSIONS: Despite the disparity of teaching between musculoskeletal medicine and other major organ systems within Sheffield's integrated medical curriculum, the knowledge base of medical students in the basic and clinical musculoskeletal sciences appears to be similar to that for cardiovascular medicine and neurology by the time of graduation. Nevertheless, several important issues must be addressed before these findings can be generalized.

Rheumatology training in the United Kingdom: the trainees' perspective.

BACKGROUND: Rheumatology training has undergone significant changes in the last decade with Calmanization, implementation of the New Deal for junior doctors and newer educational strategies for improving musculoskeletal training, like a core curriculum. However, concerns have been expressed about the quality of postgraduate training programmes in the UK. OBJECTIVES: First, to assess current trainees' perceptions of the quality of core and subspecialty training, the impact of workload on training, and to explore demographic variations in training experience. Secondly, to identify educational strategies that trainees felt would enhance their training. METHODS: The questionnaire was initially distributed to all specialist registrars attending the BSR Annual Meeting in Brighton in April 2002. Subsequently, the questionnaire was posted to all registrars on the Joint Committee for Higher Medical Training list with a reminder after 4 weeks. RESULTS: Trainees rated positively training in routine patient care, musculoskeletal examination and injection skills while training in primary care rheumatology, epidemiology, paediatric rheumatology and sports medicine was rated negatively. There is agreement that the reduction in junior doctors' hours has adversely affected training, and issues relating to workload have overtaken training issues. Trainees undertaking dual accreditation are more likely to feel this. Educational strategies deemed to enhance training included training workshops focused on specific topics, such as musculoskeletal radiology (89.2%), and an adequate debriefing session after an out-patient clinic (81.6%). An independently administered, reliable and valid scale for quality of training could be used to assess regional variations in training and monitoring quality. CONCLUSIONS: The changes to junior doctors' hours, the working patterns of doctors and service commitments have all affected the quality and time available for certain aspects of rheumatological training. A major effort to enhance quality is necessary to ensure that the objectives of training are met within the intended training budget.

The value of masters educational programmes for specialist registrars in rheumatology.

The training of junior doctors has undergone major changes in recent years. There is now more structure, with defined assessment time points leading to a Certificate of Specialist Training. This certificate provides documentation indicating that the trainee has undergone a satisfactory period of training and that they are sufficiently competent to practise as a specialist, unsupervised. The changes have led to re-examination of the role of, and educational provision for, research training as well as clinical training. In this article we review these issues and argue that the development of masters educational programmes may help to address several concerns.

The role of somatic mutation in determining the affinity of anti-DNA antibodies.

Combinatorial antibody libraries were constructed from the spleen of a patient with concomitant systemic lupus erythematosus and idiopathic thrombocytopenia. Following selection of the libraries with DNA, a panel of 15 anti-DNA Fabs was isolated. Sequence analysis of these antibodies coupled with measurements of their affinities for ss- and dsDNA were used to investigate the role of somatic mutation in affinity maturation of the anti-DNA response. Examination of the germline genes used by these Fabs supports previous studies that suggest there is no restriction of the gene usage in the anti-DNA response. However, data are presented indicating that VH3 genes and the A27 V(kappa) paired with the J(kappa)1 may be over-expressed in the anti-DNA repertoire. Analysis of the role of somatic mutation in increasing affinity for DNA indicates that affinity maturation has occurred and suggests that the CDR1 and CDR2 of the heavy chain are of importance in this process.

A selective peroxisome proliferator-activated receptor delta agonist promotes reverse cholesterol transport.

The peroxisome proliferator-activated receptors (PPARs) are dietary lipid sensors that regulate fatty acid and carbohydrate metabolism. The hypolipidemic effects of the fibrate drugs and the antidiabetic effects of the glitazone drugs in humans are due to activation of the alpha (NR1C1) and gamma (NR1C3) subtypes, respectively. By contrast, the therapeutic potential of the delta (NR1C2) subtype is unknown, due in part to the lack of selective ligands. We have used combinatorial chemistry and structure-based drug design to develop a potent and subtype-selective PPARdelta agonist, GW501516. In macrophages, fibroblasts, and intestinal cells, GW501516 increases expression of the reverse cholesterol transporter ATP-binding cassette A1 and induces apolipoprotein A1-specific cholesterol efflux. When dosed to insulin-resistant middle-aged obese rhesus monkeys, GW501516 causes a dramatic dose-dependent rise in serum high density lipoprotein cholesterol while lowering the levels of small-dense low density lipoprotein, fasting triglycerides, and fasting insulin. Our results suggest that PPARdelta agonists may be effective drugs to increase reverse cholesterol transport and decrease cardiovascular disease associated with the metabolic syndrome X.

The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index for Systemic Lupus Erythematosus International Comparison.

OBJECTIVE: To compare patients with systemic lupus erythematosus (SLE) from different centers with respect to demographics and Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI) scores, and to assess whether the SLICC/ACR DI changed over time, and whether initial DI scores were related to outcome. METHODS: Members of SLICC completed DI scores and patient demographics on patients followed in their centers. Information was provided at 2, 5-10, and > 10 years of followup. Data were entered on computer and analyzed on SPSS/PC+ and SAS using descriptive statistics and analysis of variance. RESULTS: Information for 1297 patients within 2 years of first clinic visit was submitted from 8 centers. There were 1187 women and 110 men with a mean age at diagnosis of SLE of 32 years. Seven hundred sixty-two were Caucasian, 423 were black, and the remainder were of other races. There were more blacks in the American centers than in Canadian or European centers. Five centers provided information for the 3 time periods. The DI increased over time. Ninety-nine patients had died. Higher SLICC/ACR DI scores were documented in patients who went on to die. CONCLUSION: The SLICC/ACR DI is a valid measure for damage in SLE.

Assessment, investigation, and management of acute monoarthritis.

Trauma is the commonest cause of acute monoarticular joint pain and swelling in patients attending an accident and emergency (A&E) department. However, in a significant minority of patients there will be no history of trauma and consequently a different approach to assessment and investigation is required. Our aim is to offer an outline of how to assess, investigate, and manage a patient with monoarthritis. Despite advances in antibiotic treatment diagnostic delay partly explains why septic arthritis is still associated with considerable morbidity and mortality. It is therefore imperative that joint infection is considered above all other diagnoses. Arthrocentesis is a relatively safe procedure and doctors in A&E medicine are encouraged to develop the skills required to aspirate large joints. In the same way that the A&E department is often portrayed as the shop window of a hospital, the joint can reflect a wide variety of internal diseases. Connective tissue disease, inflammatory bowel disease, sarcoidosis, and vasculitis can all present with a monoarthritis. A non-specific reactive monoarthritis may be a feature of a wide variety of common and uncommon infections including, brucellosis, Lyme disease, and leptospirosis. Drugs are also associated with acute arthritis either through their metabolic consequences or as idiosyncratic drug reactions. The ability for the joint to reflect multisystem disease necessitates close liaison with specialists from other fields. A multidisciplinary approach to the management of these patients is strongly encouraged as some will have unusual diseases that require specialist advice. It is not difficult to appreciate how the patient with monoarthritis can present the clinician with a fascinating diagnostic and therapeutic challenge, which we hope this article will help to unravel.

Generic and condition-specific outcome measures for people with osteoarthritis of the knee.

OBJECTIVES: The aims of this study were to evaluate two condition-specific and two generic health status questionnaires for measuring health-related quality of life in patients with osteoarthritis (OA) of the knee, and to offer guidance to clinicians and researchers in choosing between them. METHODS: Patients were recruited from two settings: 118 from knee surgery waiting lists and 112 from rheumatology clinics. Four self-completion questionnaires [Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Health Assessment Questionnaire (HAQ), Short Form-36 (SF-36) and Euroqol] were sent to subjects on two occasions 6 months apart. Construct validity, convergent validity, internal consistency and responsiveness were examined using primarily non-parametric methods. RESULTS: All instruments proved satisfactory in terms of ease of use, acceptability to patients, internal consistency and reliability. In the surgical group, the OA-specific WOMAC performed better than the HAQ and the generic measures in terms of validity and responsiveness to change, whereas in the rheumatology group the SF-36 was more responsive. CONCLUSION: WOMAC is the instrument of choice for evaluating the outcome of knee replacement surgery in OA. The SF-36 provides a more general insight into patients' health and may be more responsive to change than the WOMAC in a heterogeneous rheumatology clinic population. Researchers wishing to undertake an economic evaluation might consider the EQ-5D for a surgical, but not a rheumatology clinic group.

The reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index in patients with systemic lupus erythematosus.

OBJECTIVE: To test the reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) in the assessment of patients with SLE. METHODS: Ten patients with SLE, representing a spectrum of damage and activity, were included. Each patient was examined by 6 of 10 physicians from 5 countries, representing 10 lupus clinics. The SLICC/ACR Damage Index was used to assess accumulated damage, and the SLEDAI was used to assess disease activity. The order of the patients and physicians was randomized according to a Youden square design. RESULTS: The SLICC/ACR Damage Index detected differences among patients (P < 0.001). There was no detectable observer difference (P = 0.933), and there was no order effect (P = 0.261). Similar results were obtained with the SLEDAI. There was concordance in the SLICC/ACR Damage Index among observers, despite a wide spectrum of disease activity detected by the SLEDAI. CONCLUSION: Physicians from different centers are able to assess patients with SLE in a reproducible way, using the SLEDAI to assess disease activity and the SLICC/ACR Damage Index to assess accumulated damage.

Genomic structure and chromosomal mapping of the mouse nov gene.

The nov gene encodes a cysteine-rich protein that is overexpressed in avian nephroblastomas. It is a member of the CCN family of proteins, all of which are involved in cell growth. Genomic and cDNA clones encompassing the mouse nov gene have been isolated and characterized. The mouse nov gene is highly conserved with the human and chick nov genes at the level of nucleotide sequence and genomic organization. The exon structure reflects the modular organization of the NOV protein in a number of structural domains. These are highly conserved with other members of the CCN family, as is the distribution of 38 of its 40 cysteine residues. The nov gene maps to chromosome 15, between D15 Mit 153 and D15 Mit 183, in a region of conserved synteny with human chromosome 8.

An Escherichia coli system for assay of F1p site-specific recombination on substrate plasmids.

We have developed an Escherichia coli system for testing the behaviour of plasmids carrying target sites for the F1p site-specific recombinase. The E. coli strain BL-FLP is described, which carries a chromosomally integrated bacteriophage T7 RNA polymerase gene expressed from a lac promoter, and harbours the plasmid pMS40.pMS40 has the features: (i) it carries the FLP recombinase gene under the control of a bacteriophage T7 promoter, (ii) it confers kanamycin resistance, and (iii) it uses an R6K origin of replication; these two latter features make it compatible with most conventional cloning vectors. Substrate plasmids carrying F1p-recognition targets (FRT) are transformed into BL-FLP, and the consequences of F1p-mediated recombination can be analysed after subsequent extraction of plasmid DNA. We show that this system is capable of base-perfect F1p-mediated recombination on plasmid substrates. We also present a corrected sequence of the commonly used F1p substrate plasmid, pNEO beta GAL (O'Gorman et al. (1991) Science 251, 1351-1355).

How effective is therapeutic ultrasound in the treatment of heel pain?

OBJECTIVES: To evaluate the therapeutic effect from ultrasound in the treatment of plantar heel pain by physiotherapists and podiatrists, and to quantify the placebo effect of this electrophysical agent. METHODS: Patients experiencing episodes of plantar heel pain were allocated randomly, at each episode, to receive either true ultrasound (machine calibrated to deliver a dose of ultrasound at 0.5 w/cm2, 3 MHz, pulsed 1:4), for eight minutes, or sham ultrasound (only the timer on the machine activated). Each episode was treated, according to randomisation, eight times. An independent observer set the equipment before obscuring the control panel with a drape. All treatments were undertaken by the same operator. Patients' pain scores were measured on a 10 cm linear analogue scale before the course of eight treatments commenced and at the end of the course, and analysed using a Wilcoxon Signed-Ranks test. RESULTS: Nineteen patients experienced episodes of heel pain (seven bilateral). Both groups showed a reduction in pain; the improvement was 30% in the treated group and 25% in the placebo group (p = 0.5). CONCLUSIONS: Therapeutic ultrasound at a dosage of 0.5 w/cm2, 3 MHz, pulsed 1:4, for eight minutes is no more effective than placebo in the treatment of plantar heel pain.