Implications of new diagnostic criteria for abnormal glucose homeostasis in women with previous gestational diabetes.

OBJECTIVE: To determine the consequences of applying revised American Diabetes Association (ADA) (1997) and World Health Organization (WHO) (1998) recommendations for the classification of glucose intolerance in women with previous gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: There were 192 women with previous GDM who took an oral glucose tolerance test (OGTT) 1-86 months after delivery and were classified by WHO (1985), ADA (1997, fasting glucose), and revised WHO (1998) guidelines. RESULTS: Among the 165 women without a preexisting diagnosis of diabetes, WHO-1985 and ADA-1997 provided similar estimates of diabetes prevalence (13.3% vs. 11.5%) but widely differing estimates of impaired glucose homeostasis (31.5% impaired glucose tolerance [IGT] by WHO-1985 vs. 10.9% impaired fasting glucose by ADA-1997 criteria). Overall, 56 women (34%) showed a classification discrepancy between WHO-1985 and ADA-1997 criteria, including 44 with normal fasting glucose by ADA-1997 criteria, but abnormal 2-h glucose by WHO-1985 criteria (40 IGT, 4 diabetes). The cardiovascular risk profile of these women was more favorable than that of 18 women with impaired fasting glucose. WHO-1998 recommendations reproduced ADA-1997 findings when used as a fasting screen, but behaved similarly to WHO-1985 criteria when 2-h glucose values were also analyzed. CONCLUSIONS: All criteria produced similar estimates of diabetes prevalence. However, analyses based on a single fasting glucose screen (and a threshold of 6.1 mmol/l) failed to identify 60% of women with abnormal 2-h glucose levels. Screening women with previous GDM (and by analogy, other groups at high risk of diabetes) with a single fasting glucose has low sensitivity for the detection of abnormal glucose tolerance. Recent guidelines recommending this approach require reevaluation.

Vasopressin in human cerebrospinal fluid.

Arginine vasopressin was measured by RIA in samples of plasma and cerebrospinal fluid (CSF) taken synchronously from 62 patients with proven or suspected disorders of the central nervous system in order to determine the relationship between the secretion of vasopressin into the systemic circulation and that into the CSF. In 12 patients without endocrine or brain disease, mean plasma values (+/- SD) were 2.8 +/- 0.7 pg/ml and CSF values were 2.4 +/- 0.7 pg/ml. Thirty-six patients with various intracranial disorders had plasma and CSF values which were both within the range of 1-4 pg/ml. Eight patients had raised plasma concentrations, but their CSF levels were within the normal range. One patient with posttraumatic diabetes insipidus and 2 patients with subarachnoid hemorrhage had concentrations of CSF vasopressin which were greater than plasma levels. These results indicate that a blood CSF barrier to vasopressin exists in man and that under certain pathological conditions excessive amounts of the hormone can be secreted into the CSF independently of that which is released into the blood, a finding which could have clinical significance in disorders of brain function.

Leucocyte and erythrocyte magnesium levels after jejuno-ileal bypass surgery.

Leucocyte magnesium concentration was measured in 25 hypomagnesaemic patients following a jejuno-ilean bypass operation for gross obesity. The mean plasma magnesium concentration in the bypass group was 0.67 mmol/l compared with that of 0.90 mmol/l in a group of 17 healthy volunteers, but the leucocyte magnesium concentration in the two groups was not significantly different. The plasma potassium was found to be significantly lower in the bypass group but there was no significant difference in the leucocyte potassium concentration in the two groups. Simultaneous measurements of erythrocyte magnesium, sodium and potassium were made. There was no evidence of intracellular magnesium depletion on the basis of the tissues studied.

Hypomagnesaemia in diabetes.

The plasma magnesium (Mg) concentrations of 582 unselected diabetic outpatients and 140 control subjects were measured by atomic absorption spectrophotometry. Mean plasma Mg (+/-S.D.) was significantly lower in the diabetic patients (0.737 +/- 0.071 mmol/l) than in the control subjects (0.810 +/- 0.057 mmol/l), and 146 (25%) diabetics had values below those of all control subjects except one. Plasma Mg correlated best with clinic blood glucose concentration (r = -0.32, p less than 0.001) and other significant associations were observed with glycosuria, age, sex, insulin therapy and biguanide therapy. Although its significance is unclear, hypomagnesaemia could conceivably predispose to ischaemic heart disease in diabetes.

The Eluru survey: prevalence of known diabetes in a rural Indian population.

Asian Indian migrants have a strikingly high diabetes prevalence but prevalence in India has been considered to be relatively low. However, there have been few recent studies, especially in rural India. A house-to-house survey was undertaken in a defined area of Eluru, a small town in South India, and in four adjoining villages. A total of 9563 subjects (4729 male, 4834 female) were surveyed, of whom 5699 lived in Eluru and 3864 in the four villages. Enquiry was made for known diabetes in each household. In all, 157 known diabetic subjects (89 male, 68 female) were ascertained. The prevalence of known diabetes was 6.1% in all subjects aged 40 or over and rose to 13.3% in the age group 50-59 years. The overall crude prevalence of known diabetes was 1.6% (1.9% male, 1.4% female). The prevalence in Eluru (1.5%) was similar to that in the four villages (1.9%). The age-adjusted rates for known diabetes in the middle-aged and elderly subjects are unexpectedly high, considering the poor socio-economic circumstances, decreased health awareness and decreased access to medical facilities, and are comparable with those of similar surveys in relatively affluent Delhi, and in Southall, London. The prevalence in rural (as well as urban) India may be much higher than previously realised. Large formal prevalence studies are urgently required.

Evaluation of a non-mydriatic camera in Indian and European diabetic patients.

The value of the Canon CR3-45NM non-mydriatic fundus camera in screening for diabetic retinopathy has been assessed in two ethnic groups, namely, 45 Indian and 40 European diabetic patients. There was 72% agreement between ophthalmoscopy by an ophthalmologist and the photographic assessment, and 100% agreement on clinically important lesions requiring treatment. However, peripheral retinal lesions, seen on ophthalmoscopy but lying outside the photographic field, occurred in 4% of eyes. 6% of photographs were totally unassessable and an additional 12% were only partially assessable. The prevalence and severity of retinopathy was similar in Indian and European patients. The advantages and disadvantages of the non-mydriatic camera in screening for diabetic retinopathy are discussed.

Helicobacter pylori infection and upper gastrointestinal patholgy in a British immigrant Indian community.

OBJECTIVES: To assess the pattern of upper gastrointestinal pathology and the prevalence of Helicobacter pylori infection in the Southall Indian community. DESIGN: A prospective study of endoscopic findings in 124 Indian and 107 whites from the Southall area. In a separate study blood samples were taken from 100 Indian subjects presenting to a single general practitioner in Southall. METHODS: The presence of gastritis and H. pylori infection was assessed histologically in Indian and white patients undergoing endoscopy. Serum samples were analysed using a specific enzyme-linked immunosorbent assay (ELISA) for anti-H. pylori immunoglobulin G. RESULTS: In the endoscopic study, Indian and white patients had the same rate of H. pylori infection (52% vs. 43%, respectively) (P= NS). The pattern of upper gastrointestinal pathology was similar in whites and Indians. In the general practice based study 41 subjects were H. pylori seropositive. Seropositivity increased with age (P<0.05). CONCLUSION: There is no excess of H. pylori-related pathology in Southall immigrant Indians. The similarity of upper gastrointestinal pathology in UK Indian and white patients presenting for endoscopy suggests that the high rates of duodenal ulceration, gastritis and H. pylori infection in India are environmentally rather than racially determined.

Attitudes of consultant physicians to the Calman proposals: a questionnaire survey. North West Thames Diabetes and Endocrinology Specialist Group.

OBJECTIVE: To determine the views of a large and representative group of consultant physicians on the Calman proposals, in which acute general medical services will change from being primarily consultant led to consultant provided. DESIGN: Postal questionnaires. SUBJECTS: All 236 consultant physicians in acute hospitals in North West and South West Thames regions. RESULTS: Replies were received from 179 (76%). One hundred and thirty seven (77%) indicated that they would not resume emergency residential duties, and 126 (71%) indicated that they would probably withdraw from general medical duties under these circumstances. One hundred and twenty six (70%) and 137 (77%) had not inserted a central venous line or temporary pacemaker, respectively, within the previous five years. Of 157 answering a question on the impact of the Calman proposals on the quality of patient services, 125 considered that it would be detrimental, and only 18 (11%) thought that it would be beneficial. CONCLUSION: Most consultant physicians are not prepared to resume emergency duties and could not do so without retraining in practical procedures. There is widespread antagonism to the Calman proposals, and most physicians consider that their impact on the quality of patient services will be detrimental.

Help for house officers: EFCOS--the Ealing Hospital Firm Computer System.

The Ealing Hospital Firm Computer System is a novel database system which has been designed to meet the needs of house physicians in a busy general medical unit. It is maintained exclusively by them and produces instant lists of all patients on their firm, with all relevant information needed to organise their clinical work. It has proved extremely popular, and its value to both junior and senior staff has been documented in an anonymous questionnaire survey. The system is available for distribution on a non-profit basis, and other colleagues are invited to use it.

Coping with pressures in acute medicine. The Royal College of Physicians Consultant Questionnaire Survey.

OBJECTIVES: To assess the impact of reduced junior doctors' hours and increasing emergency admissions on patterns of acute medical care, and to evaluate recent innovations. METHODS: Questionnaire survey of all 2,980 consultant physicians in England, Wales and Northern Ireland potentially involved in acute medicine. The response rate was 63% with 1,3632 respondents undertaking unselected takes. RESULTS: WORKLOAD: The median average number of admissions per 24 h was 20-24, but 25% of consultants admitted > or = 30. The median frequency of take duties was 1 day in 5. COMPOSITION OF RESIDENT MEDICAL TEAMS: The most common permutation was one specialist registrar (SpR), senior house officer (SHO) and house physician (HP), coping with 20 admissions on average. However, the teams of 25% of respondents did not include a SpR, and 9% consisted solely of one SHO and one HP, with an average 17 admissions. PARTIAL SHIFT ROTAS: Forty-two per cent of consultants had introduced these. Most were critical of them because of their adverse impact on continuity of care and junior staff training, and their unpopularity with trainees. PATTERNS OF CARE: Only 10% of consultants indicated that myocardial infarction patients were managed exclusively by a cardiological team. Forty per cent operated an age-limit (varying between 65 and 85) for admission under care of the elderly physicians. Seventy per cent had introduced an admissions ward. NEW INITIATIVES TO COPE WITH ADMISSIONS: These included twice-daily consultant take rounds, use of nurse practitioners and staff-grade doctors, 12-hour takes and ward-based admission schemes. Measures to expedite discharges included 'discharge lounges', nurse facilitators, low-dependency wards and 'hospital at home' schemes.

Consultant post prospects in medical specialties.

Consultant post prospects for Specialist Registrars (SpRs) in all the medical specialties have been analysed using the databases of the Royal College of Physicians and the Joint Committee on Higher Medical Training (JCHMT). A 'bulge' in the numbers of SpRs obtaining Certificates of Completion of Specialist Training (CCSTs) is anticipated over the next 2-3 years, but this effect will be alleviated by the increasing trend to spend extra years in research or flexible training. There are profound differences between the specialties in the ratios of SpRs holding National Training Numbers (NTNs) to consultants, and in the proportions of female SpRs, and these factors will markedly influence consultant post prospects. The outlook within most specialties is favourable, but this is critically dependent on the rate of consultant expansion over the next few years.

The Southall Diabetes Survey: prevalence of known diabetes in Asians and Europeans.

A house to house inquiry for patients with known diabetes was carried out in a defined area of Southall, west London, which contained over 34 000 Asians and 27 000 Europeans in the 1981 Census: 1143 diabetic patients were ascertained, of whom 761 were Asian and 324 European. The prevalence adjusted for age of known diabetes in Asians was at least 3.8 times higher than that in Europeans. For patients aged between 40 and 64 years it was at least five times higher, was over 12% in Asians aged 60-69, and over 8% in those aged 50-59. These data are important in planning for the care of diabetic patients in health districts with large Asian communities. The causes and later consequences of this exceptionally high prevalence require further study.

Coping with pressures in acute medicine--the second RCP consultant questionnaire survey.

The second questionnaire survey of consultant physicians involved in acute unselected takes in 1999 achieved a 76% response rate, and the results have been compared with those from the first survey of 1997. The proportion of consultants whose trainees worked partial shifts had increased from 42% to 61%, although these patterns of duty were adjudged to have detrimental effects on the quality and continuity of care, and on junior staff education and training. The benefits of ward-based systems were counterbalanced by their disadvantages, but introductions of admission wards and assessment units were considered a resounding success. The number of hospitals with 'physician of the week' schemes had increased from 12 to 23, but opinion of their value was sharply divided. The provision and competence of all grades of locums was identified as an increasing problem. Seventy per cent of respondents stated that they would never participate in 'hands-on' emergency care, although 86% thought that future consultants might have to do so. Seventy-nine per cent reported increases in the pressures of their posts and in their working hours, and the tensions between general and specialist duties were highlighted. Most consultants considered that the only long-term solution to the staffing crisis was a marked expansion in the numbers of all grades of medical staff.