Diabetic nephropathy: where are we on the journey from pathophysiology to treatment?

Diabetic nephropathy affects 30-40% of people with diabetes, and is the leading cause of end-stage kidney disease. The current treatment paradigm relies on early detection, glycaemic control and tight blood pressure management with preferential use of renin-angiotensin system blockade. This strategy has transformed outcomes in diabetic kidney disease over the last 20 years. Over the last two decades we have also witnessed significant advances in the understanding of the pathophysiology of diabetic nephropathy; however, despite this new knowledge, we have yet to develop new treatments of proven efficacy. Whilst a continued emphasis on preclinical and clinical research is clearly needed, clinicians treating people with diabetes should not forget that, in the short term, the greatest gains are likely to be realised by more consistent deployment of existing therapies.

Working with risk: occupational safety issues among healthcare workers in Kenya.

The objective of this study was to explore knowledge of, attitudes towards and practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs) in the Thika district, Kenya. We used site and population-based surveys, qualitative interviews and operational research with 650 staff at risk of needlestick injuries (NSIs). Research was conducted over a 5-year period in five phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and acceptability of interventions; in-depth group and individual interviews were conducted; and (5) health system monitoring outside a research setting. The main outcome measures were bio-safety standards in clinical areas, knowledge, attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare workers, uptake of interventions, reasons for poor uptake elucidated and sustainability indicators. Results showed that HCWs had the same HIV sero-prevalence as the general population but were at risk from poor bio-safety. The incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent had had an HIV test in the last year. After one year there was a significant drop in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p<0.001) and a significant increase in the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p=0.003). In comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth interviews revealed this was due to HCWs fear of HIV testing and their perception of NSIs as low risk. We concluded that Bio-safety remains the most significant intervention through reducing the number of NSIs. Post-exposure prophylaxis can be made readily available in a Kenyan district. However, where HIV testing remains stigmatised uptake will be limited - particularly in the initial phases of a programme.

Susceptibility of healthcare workers in Kenya to hepatitis B: new strategies for facilitating vaccination uptake.

Hepatitis B virus (HBV) infection is preventable, yet many healthcare workers (HCWs) in resource-poor countries remain at risk. The aims of this study were to evaluate the susceptibility of HCWs in a Kenyan district to HBV infection, and the feasibility of expanding the Extended Programme of Immunization (EPI) for infants to incorporate hepatitis B vaccination of HCWs. HCWs in Thika district, Kenya were invited to complete an interviewer-administered questionnaire about their immunization status and exposure to blood or body fluids. Participants were asked to provide a blood sample to assess natural or vaccine-induced protection against HBV. All non-immune HCWs were offered hepatitis B vaccination. Thirty percent (168/554) of HCWs reported one or more needlestick injuries (NSIs) in the previous year, with an annual incidence of 0.97 NSIs/HCW/year. Only 12.8% (71/554) of HCWs had received vaccination previously and none had been screened for immunity or for hepatitis B surface antigen. In total, 407 staff provided blood samples; 41% were HBV core antibody, 4% expressed hepatitis B surface antibody from previous vaccination, and 55% were unprotected. Two hundred and twenty-two staff were eligible for vaccine delivered through the EPI infrastructure. Self-motivated uptake of a full course of vaccine was 92% in the smaller health centres and 44% in the district hospital. This study demonstrates the importance of hepatitis B vaccination of HCWs in parts of Africa where high exposure rates are combined with low levels of vaccine coverage. High rates of vaccination can be achieved using childhood immunization systems for the distribution of vaccine to HCWs.

The natural history of congenital epiphora.

By combining three series of congenital epiphora cases it is shown that of projected 180 infants with tear duct obstruction at 7.5 months of age 169 (94 percent) will cure themselves if left untreated till 21 months.

Survey of ophthalmic surgery in North Canterbury and Westland (1970-1975).

The major ophthalmic operations performed in the Christchurch hospitals over five years are listed. This gives the incidence of ophthalmic conditions requiring surgery in a mainly European Community. The results should be useful for planners and epidemiologists in this and others countries.

Transcutaneous bilirubinometry as a screening tool for neonatal jaundice.

Between 25 and 50% of all term newborns develop clinical jaundice, and a serum bilirubin level above 260 microml/l (15 mg/dl) is found in 3% of normal term infants. In the United Kingdom many newborn infants with clinical jaundice have blood samples sent to biochemistry laboratories for assessment of the plasma bilirubin concentration. We planned to assess the cost in terms of finance, medical staff time, numbers of blood samples, and family delay in leaving hospital. We demonstrated that reflectance bilirubinometry is a reliable screening method for identifying which caucasian infants require to have plasma bilirubin concentrations measured in the laboratory. The Minolta Airshields transcutaneous bilirubinometer provided reproducible data, saved time and costs, and often spared infants a capillary or venous blood sample. The transcutaneous bilirubinometer provides a digital assessment of skin pigmentation by xenon reflectance. It has previously been shown to be possible to derive an estimate of plasma bilirubin from the number displayed by the meter and it is suggested as a method for identifying which infants need plasma bilirubin estimations.

An audit of the process of developing the Health Improvement Programme into Strategic and Financial Framework in two health authorities.

Health Improvement Programmes (HImPs) are a means of documenting the health needs of a population and are intended to be translated into commissioning decisions by the Strategic and Financial Framework (SaFF). This paper examines some major influences on the process of translating the HImP into the SaFF. The Directors of Public Health in two Health Authorities were concerned that the development of the SaFF did not always represent a clear progression from the HImP. An audit to pinpoint where commissioning decisions did not match the identified health improvement needs in two Health Authorities was carried out between November 2000 and February 2001. The overall findings confirmed that needs identified in the HImPs were not fully reflected in the service provision described in the final SaFFs. The audit provided evidence that was useful in identifying major issues and influences that facilitated or hindered the development of the SaFF from the HImP. Some of the ways in which HImP priorities disappeared from the SaFF and non-HImP priorities appeared in it were also distinguished. The conclusion is that a clear, criterion-based process should enable health and social care communities and Primary Care Trusts to develop a more responsible commissioning process in future, and specific recommendations to that effect are made.

Pseudophakic cystoid macular oedema and its treatment with local steroids.

The treatment of 26 cases of cystoid macular oedema following cataract extraction is reviewed. Cases treated early and more aggressively with betamethazone drops and subtenons injection of methylprednisolone, responded well to treatment. Those given later and less aggressive treatment had a less satisfactory outcome. Our results would suggest that local steroids are effective in the treatment of pseudophakic cystoid macular oedema.

Risk identification, assessment and management in public health practice: a practical approach in one public health department.

BACKGROUND: The continuing identification, assessment and management of risks are key themes for clinical governance. These themes are being integrated into both primary and secondary care practice; however, integration into public health practice appears much slower. This paper describes the recent approach that we have taken in Sheffield, and proposes a model for public health departments to identify, assess and manage risks, which complements other risk management processes and is transferable to other settings. It assumes that public health practice is not a risk-free activity and holds that the process of identifying, assessing and managing risks is a key component to raising standards. METHODS: A number of risk 'management' models were reviewed and a primary care approach was applied to public health practice. A list of potential risks was identified using a number of methods including reflective practice, information from complaints and/or critical incidents. Risks were assessed by likelihood and impact, and were captured in a risk framework. RESULTS: By March 2002, 21 risks had been identified and characterized, and progress had been made to manage 11 of these risks. CONCLUSION: This process, and the development of a risk framework, was useful in identifying a prioritized work programme to improve standards of public health practice in this department. This model can also be used not only for planning risk management activities, continual identification and assessment of risks but also to provide inspiration for other clinical governance activities including public health audit.

Retinoblastoma mutation rate in New Zealand and support for the two-hit model.

Age-specific incidence rates for 96 New Zealand patients with sporadic retinoblastoma peaked earlier for bilateral patients than for unilateral patients. The cumulative log survival until diagnosis for bilateral and unilateral patients followed linear and quadratic curves respectively, and supported the two-hit hypothesis for retinoblastoma. The germ cell mutation rate for retinoblastoma, assuming a single major gene, was calculated to be in the order of 9.3 X 10(-6) to 10.9 X 10(-6) for the New Zealand population.

The incidence and epidemiology of retinoblastoma in New Zealand: A 30-year survey.

One hundred cases of retinoblastoma were diagnosed in New Zealand-born children between 1948 and 1977 inclusive. Five patients had an affected parent, and of the remaining sporadic cases 25 had bilateral and 70 unilateral tumours. The frequency of retinoblastoma, 1 in 17,500 births, was similar to that reported for most other countries. There was no evidence of an increase in the incidence of all cases of sporadic retinoblastoma during the 30-year period studied, nor was there any significant fluctuation in their incidence with space and time. There was an excess of bilateral sporadic cases in the southern-most districts of New Zealand, but this was of marginal significance. There was no significance evidence for any environmental influence on the occurrence of retinoblastoma.