[Age(ing) and participative neighbourhood development. Obstacles and perspectives for social sustainability]. / Alter(n) und partizipative Quartiersentwicklung. Stolpersteine und Perspektiven für soziale Nachhaltigkeit.

Ageing urban societies face the challenge of enabling a "good" life for older people in their neighbourhood areas. This article focuses on potential obstacles and required preconditions for processes of neighbourhood development, based on results from the research and development project "Quality of life of older people in their neighbourhood" (LiW). Preconditions and obstacles include political and organizational requirements, differing understandings of participation of local experts, as well as the organization of the process and the access to the process. Furthermore, problems and social conflicts, which have to be dealt with on the local level, are examined. An example for such conflicts are statements of group-focused enmity. The paper aims to point out the significials of such processes as well as potential barriers and limits in order to inform academics as well as practitioners and to contribute to the sustainable integration of participative neighbourhood development.

Mortality associated with primary hyperparathyroidism.

561 patients with primary hyperparathyroidism were followed between 1961 and 1994. Relative survival was compared to that of the Australian population studied during the same time interval. Mortality was significantly greater in the hyperparathyroid population (P<0.001). Mortality was not greater in the patients with serum calcium levels >3.00 mmol/L compared to those with a serum calcium levels <3.00 mmol/L. 113 patients did not have parathyroid surgery. Their relative survival was not significantly different from those who had surgery but their mean serum calcium and parathyroid hormone (PTH) levels were significantly lower than those who had surgery. A re-analysis of the 453 patients followed between 1972 and 2011 was carried out and a 20-year survival analysis made of those diagnosed between 1972 and 1981 and those diagnosed between 1982 and 1991. The latter group had significantly worse relative mortality than the former group (P<0.001) but was significantly older at the time of diagnosis (56.94 ± 14.83 vs 52.01 ± 13.58, P<0.001). The serum calcium and serum PTH levels were not significantly different between these two groups.

[Social inequality and participation in aging urban societies]. / Soziale Ungleichheit und Partizipation in alternden Stadtgesellschaften.

The social and political participation of elderly people is characterized by social inequality. Participation processes normally consolidate and intensify the exclusion of senior citizens having low incomes and low educational qualifications. In the research and development project "Quality of Life of Elderly People in Living Quarters" being conducted by Dortmund University of Applied Sciences and Arts, one of the questions being examined is whether and to what extent socially disadvantaged elderly people in a social space typical of the Ruhr region (reference area Gelsenkirchen-Schalke) can be included in the shaping of their quarter. This paper is based on the results of a quantitative, written survey (cross-section) on the subjects of quality of life and participation, and on a trend analysis measuring the effects of participation processes initiated on the elderly persons involved. The results of the study show that it is possible to involve socially disadvantaged elderly people in participation processes geared to the specific social space. They also indicate that elderly people from different income groups increase their social capital in the context of enabling structures.

Intravenous pamidronate in the treatment and prevention of osteoporosis.

BACKGROUND: Potent oral bisphosphonates are the mainstay of therapy for osteoporosis. However, there are patients who cannot have oral bisphosphonates (e.g. because of gastrointestinal side-effects). Therefore, we wanted to examine the effects of intermittent i.v. pamidronate (APD) on bone mineral density (BMD) in patients who needed bisphosphonate therapy but could not have oral bisphosphonates. AIM: To assess BMD before and after intermittent i.v. APD in patients requiring a bisphosphonate either for the prevention of osteoporosis on concurrent steroid therapy or for the treatment of osteoporosis. METHODS: This was a retrospective audit of 84 consecutive patients at risk of fractures commencing APD between October 1997 and May 2000. Patients were treated with intermittent i.v. APD. BMD as measured by dual-energy X-ray absorptiometry before and after APD was the main outcome. RESULTS: The mean length of treatment and mean total APD dose were 16.8 +/- 7.0 months and 186.1 +/- 79.5 mg respectively. The reasons for using APD were failure to qualify for oral bisphosphonates on the pharmaceutical benefits scheme due to lack of documented minimal trauma fractures (58%), symptomatic gastro--oesophageal disease (20%), intolerance of oral bisphosphonates (18%) and lack of efficacy of calcitriol (4%). Mean baseline T-score at lumbar (L) 2-4 spine and femoral neck were -1.54 +/- 1.22 and - 2.87 +/- 1.19, respectively. From baseline to after APD treatment, there was a significant increase in L2-4 BMD (0.883 +/- 0.175 vs 0.912 +/- 0.176 g/cm(2), P < 0.001, mean increase +3.5%), in femoral neck BMD (0.667 +/- 0.137 vs 0.680 +/- 0.134 g/cm(2), P= 0.001, mean increase +2.1%) and in trochanteric BMD (0.549 +/- 0.129 vs 0.566 +/- 0.132 g/cm(2), P < 0.001, mean increase +3.1%). One-third of the patients were on oral glucocorticoids at the time of the present study and they had a similar increase in BMD compared to patients not on gluco-corticoids. Mild side-effects occurred in seven patients, none of whom discontinued treatment. CONCLUSION: Intermittent APD increases BMD and may be a suitable alternative for patients who cannot have oral bisphosphonates.

A case of mistaken identity. A rare presentation of gonadal dysgenesis.

BACKGROUND: The incidence of gonadal dysgenesis (hermaphroditism) is recognised to be low. Rarer still is an initial late presentation in the general practice setting. OBJECTIVE: To present a case study of a 35 year old man diagnosed as a hermaphrodite after routine investigations in general practice for lower abdominal pain. He has normal male external genitalia, a fully formed uterus and vagina, with no identifiable gonads. DISCUSSION: This incidental finding in general practice is supported by a 46,X,i(Yp)/45,X karyotype and mosaicism for an isochromosome of the short arm of the Y. It is not unusual that with normal male genitalia, such patients are likely to survive undiagnosed or incorrectly diagnosed into adulthood.

Outcome of pregnancies complicated by pre-gestational diabetes mellitus.

Pregestational diabetes mellitus (DM) is associated with adverse fetal and maternal outcomes. Studies suggest that optimal control of diabetes before and during pregnancy minimises these risks. There are few recent reviews of outcomes of pregnancies complicated by DM in Australia. Ninety-three pregnancies in women with DM at our hospital since 1989 were identified. We collected data for maternal age, type of diabetes, duration of therapy, complications of diabetes, maternal complications of pregnancy and fetal outcomes including malformations. The rate of pregnancy planning with optimal glycaemic control at conception was low in our population, particularly in patients with Type 1 diabetes. Women who smoked had worse glycaemic control, and a higher rate of miscarriage. There was a high rate of Caesarean section, particularly in those women with Type 1 diabetes (77.4%). The rate of Caesarean section was lower in planned pregnancies. There were no perinatal deaths. The number of neonates with major congenital anomalies was high (13%) in the Type 1 population. It is important to increase the rates of prepregnancy planning and to optimise glycaemic control before pregnancy. In many cases there has been a long interval between diagnosis and pregnancy, so all women with diabetes should receive counselling at frequent intervals about pregnancy and the importance of planning. Women who planned their pregnancies had improved outcomes, with decreased rate of Caesarean section, better glycaemic control and better neonatal Apgar scores. Women with diabetes should not smoke during pregnancy because of the increased risk of miscarriage and poorer glycaemic control.

Prevalence of positive anti-neutrophil cytoplasmic antibody (ANCA) in patients receiving anti-thyroid medication.

OBJECTIVE: Vasculitis is a rare complication of anti-thyroid medications. There are 32 cases of anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis in association with anti-thyroid medication reported in the English literature. The objectives of this study were to assess the frequency of positive ANCA in patients on long-term anti-thyroid medication, and to follow patients prospectively from commencement of medication to determine whether they became ANCA-positive after therapy. DESIGN: Prospectively collected cross-sectional study of two groups of patients: (i) who had received long-term (>18 months) anti-thyroid medication, and (ii) newly diagnosed thyrotoxicosis before commencement of anti-thyroid medication attending clinic between 28 April 1998 and 30 September 1998. Data were collected for age, sex, ethnicity, underlying thyroid disease, medication and duration, and symptomatology. RESULTS: Eight of 30 patients on long-term anti-thyroid medication (26.7%) were ANCA-positive. All ANCA-positive patients were female, seven were taking propylthiouracil (PTU) at the time of testing. ANCA-positive patients had taken PTU for a mean +/- s.d. of 7.9+/-10.2 years, compared with 0.8+/-2.2 years in ANCA-negative patients (Mann-Whitney, P<0.0001). The ten patients with newly diagnosed thyrotoxicosis were ANCA-negative before commencement of carbimazole. One (10%) became ANCA-positive within 8 months of therapy. CONCLUSIONS: In our population, ANCA-positivity in association with long-term anti-thyroid medication is common (26.7%). One patient who was ANCA-negative prior to anti-thyroid therapy has become ANCA-positive. ANCA should be tested in patients receiving long-term anti-thyroid medications, and in patients with adverse reactions. As PTU is more commonly associated with vasculitis and positive ANCA, carbimazole may be the preferred medication for long-term use. Patients with positive ANCA should be followed, and considered for definitive anti-thyroid therapy, to allow cessation of medication. ANCA-positivity may resolve after cessation of anti-thyroid medication.

The relationship of prorenin values to microvascular complications in patients with insulin-dependent diabetes mellitus.

We have performed a cross-sectional analysis of the relationship between prorenin values and the microvascular complications of diabetes in a well controlled population of insulin-dependent diabetes mellitus (IDDM) subjects. One hundred and thirty-nine subjects (75 men, 64 women, age 44 +/- 17 years; duration of diabetes 19 +/- 15 years), formed the study group. Sixty-seven subjects (48.2%) had no complications, 55 (39.6%) had retinopathy alone, and 17 (12.2%) had retinopathy and albuminuria. Patients with no complications had lower prorenin values than those with microvascular complications (p < 0.001), whilst patients with both albuminuria and retinopathy had higher values than those with retinopathy alone (p < 0.05). Retinopathy was associated with duration of diabetes (p < 0.0001), diastolic blood pressure (p < 0.02) and albuminuria (p < 0.0001) while albuminuria was associated with prorenin (p < 0.02), serum triglyceride (p < 0.01) and retinopathy (p < 0.001). Patients with albuminuria were 5.5 times more likely to have raised prorenin values (>80 ng/mL/h) than those with normal albumin excretion [95% confidence interval (CI): 1.48-20.12] and those with retinopathy alone were 2.5 times as likely (95% CI: 1.19-5.15). Eighty patients with IDDM (40 males, 40 females; age: 47 +/- 17 years; duration of diabetes: 20 +/- 15 years), had retinal photography performed to determine the association between the severity of retinopathy and prorenin values. Retinopathy was more severe in patients with retinopathy and albuminuria than in those with retinopathy alone (p < 0.002). When the prorenin values of patients with more marked retinopathy (eye grade greater than 3) were compared, prorenin values of those with retinopathy and albuminuria were greater than those of patients with retinopathy alone [269 (139-1406) versus 91 (41-273) ng/mL/h: geometric mean (range); p < 0.05]. Furthermore, when patients without albuminuria were considered, there was no significant difference between the prorenin levels of patients with more severe retinopathy (eye grade >3) when compared to patients with lesser degrees of retinopathy [91 (41-273) versus 69 (23-375). In patients with microvascular complications, prorenin values were independently predicted by albuminuria (p < 0.0001) and diastolic blood pressure (p < 0.02) but not the severity of retinopathy. In conclusion, prorenin values are significantly associated with the presence of microvascular complications in patients with IDDM. The association with albuminuria may be stronger than the association with retinopathy.

Giant double parathyroid adenoma presenting as a hypercalcaemic crisis.

The largest documented case of a double parathyroid adenoma is reported. The patient presented in hypercalcaemic crisis with a large intrathoracic mass. After removal of a massive cystic parathyroid adenoma from the right superior mediastinum, a second very large parathyroid adenoma was found on the contralateral side adjacent to the left thyroid lobe. This case illustrates the importance of the cervical approach, as well as routine bilateral neck exploration, for all cases of primary hyperparathyroidism.

Articular manifestations of acromegaly.

Forty-five patients with acromegaly or gigantism were reviewed for musculoskeletal abnormalities. Abnormalities of peripheral joints occurred in 74% of the patients and spinal involvement in 47%, leading to significant morbidity. Joint abnormalities most frequently affected the large joints (hips, knees and shoulders) but the wrist and hand were also involved. The radiological features of acromegalic arthropathy are described, including vertical widening of the hip joint, enthesopathy and osteophytosis. A favourable response to treatment is associated with a less severe arthropathy and a good functional outcome.

The effect of o,p'-DDD on adrenal steroid replacement therapy requirements.

Two patients with adrenal carcinoma treated with 2,2-bis (2-chlorophenyl-4-chlorophenyl)-1,1-dichloroethane (o,p'-DDD) as adjuvant therapy were studied. Both patients developed hypoadrenalism while on o,p'-DDD and apparently adequate dexamethasone replacement therapy. The hypoadrenalism was overcome by increasing steroid replacement therapy. Dexamethasone levels were measured in the serum by radioimmunoassay and shown to be lowered by o,p'-DDD therapy. A study of the absorption and disappearance of dexamethasone from the circulation in response to a (1 mg oral dose indicated that the steroid was absorbed normally but was cleared more rapidly from the circulation of these two patients than from normal controls. This may be due to a change in the type of metabolites excreted. It is suggested that many of the reported side-effects of o,p'-DDD may be due to hypoadrenalism and may be controlled by greatly increasing the steroid replacement dose. The adequacy of corticosteroid replacement therapy may best be assessed by monitoring the levels of ACTH.

Thyroglobulin may be undetectable in the serum of patients with metastatic disease secondary to differentiated thyroid carcinoma. Follow-up of differentiated thyroid carcinoma.

To assess the value of serum thyroglobulin (Tg) levels in the follow-up of differentiated thyroid carcinoma after ablative therapy simultaneous Tg estimations and radioiodine (131I) scans were performed on patients during an 18-month follow-up period. In this study, 287 scans were performed on 200 patients who were not receiving Thyroxine (T4) replacement at the time, i.e., off T4. Wherever possible, Tg was also estimated while the patient was receiving T4. All sera were screened for Tg autoantibodies which were detected on 67 occasions in 44 patients (22%). Of the 220 sera without Tg autoantibodies (156 patients), 17 were accompanied by scan evidence of functioning thyroid tissue, although Tg was undetectable (less than 5 micrograms/l) either on or off T4. Serum Tg was only detectable off T4 in a further five patients (six scans) who simultaneously had scan evidence of functioning thyroid tissue. In seven patients the finding of detectable Tg preceded scan evidence of recurrence. Thus, serum Tg is useful in the follow-up of differentiated thyroid cancer after ablative therapy. However, some patients with recurrence or metastasis will be missed if Tg alone is relied on, particularly if thyroxine treatment is continued.

The measurement of antithyroglobulin autoantibodies in the presence of thyroglobulin.

An homogeneous phase radioassay (HRA) for antithyroglobulin autoantibodies (TgAb) in serum was investigated. In this method TgAb is allowed to react with 125I-Tg in solution and the immune complexes formed are separated by precipitation with sheep anti-human gammaglobulin. HRA proved to be suitable for the screening of sera prior to thyroglobulin (Tg) radioimmunoassay; being both sensitive, and unaffected by high endogenous levels of Tg. HRA was more sensitive than either of two commercial TgAb kits; a hemagglutination assay (Wellcome Australia Ltd.) and a solid phase radioassay (CIS France). Positive responses were obtained with 4 out of 42 normal subjects (titers up to 1/10), 24 out of 31 with untreated Graves' disease (titers up to 1/10,000) and all out of 18 with Hashimoto's thyroiditis (titers up to 1/10,000). Binding of 125I-Tg was displaceable with added unlabelled Tg, but in no case could it be abolished with less than 1,000 micrograms/l. Some sera exhibited more than one class of binding site and variation in both affinity and capacity for Tg was observed. It was concluded that the use of an assay standard for the reporting of results in units of concentration is invalid, although units of TgAb activity may be used as long as the analytical method is specified. Serum levels of TgAb may also be reported in semi-quantitative terms, such as in this report where a binding titer is used, or alternatively, antigen binding capacity may be reported.

Venous ACTH sampling in Cushing's syndrome.

A case of Cushing's syndrome in a 36-year-old woman, in whom the corticosteroid levels remained elevated in peripheral blood despite high doses of dexamethasone (8 mg/day), is reported. Although, on her skull X-ray film, the pituitary fossa was seen to be asymmetrically enlarged and had signs of possible erosion and depression of the floor on the left, the question whether this was an anatomical variant was raised. The correct diagnosis was made after measuring ACTH levels in venous blood samples taken from multiple sites, including the left petrosal sinus, in which a significant elevation of ACTH level, compared with the level in peripheral blood, was found.

Acromegaly and the heart--echocardiographic and nuclear imaging studies.

Left ventricular mass (LV mass) and function were assessed in 16 acromegalic patients by echocardiography, and rest and exercise gated blood pool scanning (GBPS) respectively. At the time of study, five patients had active acromegaly, five were hypertensive and three had coexisting coronary artery disease. Increased LV mass was found in six (38%) patients, of whom four were hypertensive and two others had active acromegaly of long duration. One normotensive patient, who did not have coronary disease, had increased LV mass associated with persistently elevated growth hormone (GH) levels for the previous 11 years. Abnormal LV function, as detected by GBPS, occurred only in the three patients with coronary disease. Thus, acromegaly is associated with increased LV mass in hypertensive patients and normotensive patients who have prolonged elevation of GH levels prior to adequate treatment. We found no detectable impairment of LV function, at rest or exercise unless other cardiac disease was present.