bluuebunny/crossref_metadata_2025 huggingface dataset:
Dietary patterns and changes in inner city adolescents
Authors: Watt R.G. , Sheiham A.
Published: November 2003

The aim of this study was to assess the dietary patterns of a sample of 479 young people aged 13–14 years living in an inner city location in London. The results revealed that although a good level of basic nutritional knowledge was displayed by most of the sample, their attitudes towards food and health were mixed and their involvement in domestic food chores was very limited. Sixty per cent reported consuming three or more snacks on the previous day, and over 33% regularly ate fast foods or take‐aways at school lunch times. Analysis of food frequency data revealed that males were more likely to consume a less healthy diet than females, as were individuals from manual households compared to those living in non‐manual households. A high proportion of the sample reported changing elements of their diets, with 36.4% claiming to have reduced their fat intakes and 33.5% reducing their sugar intakes within the previous 6 months. The main reason for changing their fat or sugar intakes was a desire to improve appearance, with direct health considerations being less important. A range of social and structural factors were identified as having an influence on young people's ability to make future changes. The implications of these findings for health promotion interventions are discussed.
Parental perception of food allergy or intolerance in children under 4 years of age
Authors: Kilgallen I. , Gibney M.J.
Published: November 2003

The perceived prevalence of food allergy among parents of pre‐school children in Ireland is unknown. An interview‐assisted questionnaire was used to interview the parents of 600 children, aged 0–4 years, about food allergy. Twelve and a half per cent of the children were perceived by their parents to be food allergic. However, no instance of food allergy in children aged under 6 months was reported. Hyperactivity was the most common symptom noted, with sweets, sugary drinks and food colours being the most frequently implicated foods. Rash, the second most common symptom cited was largely associated with dairy products and eggs. Neither parental age, education, socio‐economic groups or infant feeding practices affected perception of food allergy. Food allergy was diagnosed primarily by the parents themselves using simple food avoidance.
A study of the use of a photographic food atlas to estimate served and self‐served portion sizes
Authors: Robinson F. , Morritz W. , McGuiness P. , Hackett A. F.
Published: November 2003

Background: Although it is generally accepted that a weighed intake is the most valid way of assessing nutrient intake, this is not always the most appropriate method. Photographs have been suggested as a useful aid in assessing portion size when other methods of recording dietary intake are used.Method: Male and female subjects (n=100) were recruited to assess portion sizes of served amounts of mashed potato or cornflakes using food photographs. A second group of subjects (n=40) were recruited to assess portion sizes of self‐served mashed potato or cornflakes using the same photographs.Results: Estimates varied from −70.6% underestimation to +198.7% overestimation for mashed potato, with less variation for the cornflakes where portions were served.??? Where the food was self‐served, results ranged from −38% and −64% underestimation to +61% and +88% overestimation for cornflakes and mashed potato, respectively.Correlation coefficients between estimated and actual weights of food showed them to be of statistical significance (P<0.05).Conclusion: Food photographs are a useful and convenient aid in the estimation of food portion sizes.
Nutritional considerations in intravenous drug misusers: a review of the literature and current issues for dietitians
Authors: Noble Carole , McCombie Louise
Published: November 2003

Poor nutritional status and inadequate dietary intake in intravenous drug misusers (IVDMs) is a well‐recognized problem among those involved in their care. However, there are very few published studies to substantiate these observations. This paper provides a review of the current literature and outlines the aims of dietary advice for IVDMs.
A study into the practice of trimming fat from meat at the table, and the development of new study methods
Authors: Leeds A. R. , Randle A. , Matthews K. R.
Published: November 2003

Background: Most food surveys do not take account of plate wastage, despite some evidence that fat intakes may be lower than is believed as a consequence of selective trimming of foods. Better study methods and more information about the trimming of food on the plate is needed.Methods: We studied 51 subjects (24 male and 27 female, aged 18–65 years) given a lunch‐time meal composed of a tailed pork steak with boiled potatoes, peas and carrots. The pork steaks were weighed before consumption, as were any residual trimmings remaining after the meal. Each subject then completed a questionnaire which assessed trimming practice by two methods. The ‘photo‐shading’’method required that a full‐sized colour photograph of a pork steak be shaded with a fluorescent marker to denote the area which would be trimmed off. In the ‘photo‐choice’ method subjects viewed four photographs of steaks trimmed to achieve fat reductions of 0, 35, 60 and 90%, and selected the photograph which most closely matched a steak that they would eat without further trimming. Pork steaks used for preparation of photographs and residual trimming following the 51 test meals were analysed for fat by the Soxhlet method. The shaded photographs were cut out and weighed, as was another photograph carefully separated into visible fat and lean tissue.Results: The average fat content of the pork steaks was 29.1 g/100 g. Fifteen of the 51 subjects did not trim the pork steak. Those who did trim the steak removed 4–73 g of tissue, the average fat content of which was 23 g. The effect of trimming was to reduce the average fat content of the steak (as eaten by ‘trimmers’) to 6.1 g/100 g (a 79% reduction). For the group as a whole (including non‐trimmers) the fat content of the steak was reduced to 12.9 g/100 g (a 56% reduction). The average estimate of fat removed by ‘photo‐shading’ was 14.9 g/100 g (8.3% lower than that obtained by direct measurement). The correlation coefficient of actual fat in the trim and fat in the trim predicted by photo‐shading was 0.72. The photo‐choice method proved less useful, only being able to distinguish the maximum trim group (90%) from the zero and 35% trim groups.Conclusions: Those who trim pork steaks remove a very high proportion (79%) of the fat present, and there was a good correlation between actual trimming practice and trimming assessed by the photo‐shading method. We conclude that the photo‐shading method may be useful for more extensive studies concerning meat trimming behaviour.
Maternal employment: does it influence feeding practices during infancy?
Authors: Earland J , Ibrahim S. O , Harpin V. A
Published: November 2003

Background: Although at least 30% of women with young children participate in the labour force, there has been very little research into the effect of maternal employment on the diets of young children. Increasingly it is being recognized that early feeding practices affect future health and may have a part to play in the development of eating disorders. Therefore it was decided to conduct a study in Sheffield to determine whether maternal employment influences infant feeding practices.

Methods: Mothers from social classes I and II (employed n=27; unemployed n=28) with infants aged 10–12 months were interviewed in their homes. Information was collected on past and present food and drink consumption, weaning practices, and progression to independent feeding.

Results: Employed mothers stopped breast‐feeding earlier. This difference became evident after 2 months of age and reached significance at 4 months (P < 0.05). Employed mothers introduced foods earlier and relied more on commercial baby foods, with significantly more spending over ???7–12 per week at the time of the survey (P < 0.05).

Conclusions: Maternal employment does influence infant feeding practices and consequently may have repercussions on future health. Further studies are needed to investigate the long‐term effects of maternal employment on infant feeding practices, particularly amongst lower socio‐economic class families.
Implementing a nutritional assessment tool in the community: a report describing the process, audit and problems encountered
Authors: Hickson M , Hill M
Published: November 2003

This short report outlines the implementation and audit of a nutritional assessment tool designed for use by community nurses working with adults and elderly people. Implementation included providing training and adapting the assessment tool for community use. The audit results, although inconclusive, do suggest that while nurses acknowledged the usefulness of the NAT, there was little change in nursing practice. The difficulties in auditing a change in working practice are demonstrated and the necessity of adapting the assessment tool to ensure it is suitable for local needs is highlighted.
Audit for the Heartbeat Award in staff catering facilities in an NHS Trust
Authors: Oxford L , Stocker S , Howard P
Published: November 2003

Background:The Heartbeat Award Scheme (HBA) is a national initiative whereby caterers receive an award for meeting identified minimum criteria related to healthy menu choices, food hygiene and eating environment. The eligibility of four staff catering facilities in an NHS Trust was assessed by audit.Methods:An audit tool was developed which enabled comparison between food displayed and itemized on the menu board and HBA criteria for each food category. It also contained questions about food preparation and ingredients. The catering facilities were audited on five different weekdays during a 2‐week period (seven for one facility). Observations were recorded about visibility, appearance and plate wastage.Results:Usually it was clear whether food served achieved HBA criteria, but development of quantified criteria were necessary for reliable assessment of main dishes, sandwiches and desserts. A summary of the key findings are presented, including achievement of HBA criteria, together with the resulting recommendations, observations and identification of issues arising from the audit.Conclusion:The benefits of this approach outweigh any drawbacks and include the ability to facilitate assessment for the HBA in the absence of written menus, obtain baseline information, enable repeated audit and provide details to support recommendations made to caterers. The audit tool has now been included as part of the contract specification for the local purchasing commission.
Piagetian principles: simple and effective application
Authors: Williams K. C.
Published: November 2003

A simplified version of Piaget's sensorimotor levels was employed to teach a group of 25 extremely impaired individuals who live in a large residential facility. Throughout the facility, all available formal assessments using the Vineland Adaptive Behaviour Scales (VABS) were compared. Using this tool, an average of 13% of individuals from the common population pool increased their scores over a 6‐year time period. All of the individuals who received training within the experimental group demonstrated increased scores. Scores increased such that an average gain of nearly I month in overall age equivalency per individual per year was realized. A matched group comparison, a prediction test for like sensorimotor skill attainment (the primary distinction of this curriculum methodology), and an historical review of subject skill training, all support the cognltively geared methodology as being primarily responsible for this accelerated progress.
Vision care requirements among intellectually disabled adults: a residence‐based pilot study
Authors: McCulloch D. L. , Sludden P. A. , McKeown K. , Kerr A.
Published: November 2003

Intellectually disabled adults have an high incidence of visual problems and they are often unable to communicate their visual difficulties. At Lennox Castle and Waveriey Park Hospitals, vision care is through referral by medical and nursing staff to designated optometrists and ophthalmologists. This practice has provided a good service when visual difficulties are noticed. The vision care requirements of all residents had not been comprehensively assessed and a new interdisciplinary procedure developed at Waveriey Park Hospital had drawn attention to the fact that only I I % had been offered vision assessment within the previous S years. In this study, 63 residents without specific referral received a comprehensive visual and medical assessment. The residents ranged from age 20 to 85 years and included the full range of disabilities. Objective assessments, ophthalmoscopy and retinoscopy were generally successful for all levels of disability. Visual acuity and visual fields were tested using methods suitable for nonverbal subjects. Success rates for these subjects were generally good, except in the profoundly disabled group where less than 30% were able to respond. A high prevalence of visual impairment, refractive error, squint and other ocular conditions vras found. Visual impairment was most common in the severe and profoundly disabled groups because of optic nerve or cortical dysfunction. New spectacles were recommended for 23 residents (seven others had adequate correction). Nine residents were referred for ophthalmologic consultation, mainly for cataract. Three required monitoring for visual conditions. Thirty‐one residents (49%) required no immediate action beyond documentation of the visual status. This study has shown a high prevalence of visual difficulties which were not previously detected. Routine biennial vision assessment of all residents is recommended to allow timely intervention to correct vision problems, and also to provide the necessary information about vision to plan appropriate programmes of activity.
Life expectancy of mentally retarded hemiplegics
Authors: Jancar J. , Sabogal N. M. , Wiley Y. V.
Published: November 2003

Sixty‐four mentally retarded people with hemiplegia (35 females and 29 males), first recorded in 1963, were re‐examined 30 years later for life expectancy. Detailed physical and mental states, lengths of hospital stays and other information were noted. Recent advances in diagnosis and prognosis of hemiplegics were included. The results of the study indicate that, with special provisions available, people with hemiplegia have the prospect of reaching pensionable age and beyond: the oldest female is 85 and the oldest male 76 years of age.
Cobalamin deficiency with megaloblastic anaemia in one patient under long‐term omeprazole therapy
Authors: BELLOU A. , AIMONE‐GASTIN I. , DE KORWIN J‐D. , BRONOWICKI J‐P. , MONERET‐VAUTRIN A. , NICOLAS J‐P. , BIGARD M‐A. , GUÉANT J‐L.
Published: November 2003

The first case of cobalamin deficiency with megaloblastic anaemia in a patient under long‐term omeprazole therapy is presented. This patient received omeprazole at a daily dose of 40–60 mg for 4 years as treatment for a gastro‐oesophagal reflux complicated by peptic oesophagitis. Seric vitamin B12 was dramatically decreased at 80 pmol L‐1. The Schilling test was normal (13%) with crystalline [57Co] cobalamin and it was at 0% with [57Co] cobalamin‐labelled trout meat. All other assimilation tests were normal except an expiratory hydrogen breath test performed with lactulose. The haematological status was restored after intramuscular treatment with cobalamin. In conclusion, prolonged omeprazole therapy can be responsible for a cobalamin deficiency due to protein‐bound cobalamin malabsorption.
Dietary calcium intake and its relation to bone mineral density in patients with inflammatory bowel disease
Authors: SILVENNOINEN JOUNI , LAMBERG‐ALLARDT CHRISTEL , KÄRKKÄINEN MERJA , NIEMELÄ SEPPO , LEHTOLA JUHANI
Published: November 2003

Objectives. To investigate calcium intake and its association with bone mineral density (BMD) and the type and extent of the disease in patients with inflammatory bowel disease (IBD).

Setting. University hospital clinic.

Subjects. A total of 152 unselected IBD patients and 73 healthy controls.

Measurements. Dietary calcium intake was assessed with a food frequency questionnaire and BMD of the lumbar spina and proximal femur was measured.

Results. The IBD patients had lower dietary calcium intake (1034 [SD 493] mg) than the controls (1334 [514] mg, P<0.001). The difference was significant in the males (1047 [552] mg and 1575 [586] mg, respectively, P<0.001), but not in the females (1020 [422] mg and 1112 [303] mg). The dietary daily calcium intake was below 1000 mg in 53% of the patients and 27% of the controls (P= 0.0004) and below 400 mg in 9.2% of the patients and none of the controls (P=0.007). The calcium intake was not associated with the severity or the type of IBD. Seventy‐one (47%) patients and eight (11%) controls avoided lactose in their diet (P< 0.001). In the IBD patients, no association between the calcium intake and BMD was detected, whereas in the controls a positive correlation between the calcium intake and the BMD of the proximal femur was found.

Conclusions. Calcium intakes below the recommendations are seen more often in the IBD patients than in the healthy controls, but in the IBD patients the calcium intake is not associated with BMD in a cross‐sectional study. A low‐lactose diet is common among IBD patients. To reduce the risk of inadequate calcium intake, unnecessary dietary restrictions concerning, e.g. milk products, should be avoided for these patients.
Hyperparathyroidism and long‐term lithium therapy – a cross‐sectional study and the effect of lithium withdrawal
Authors: BENDZ H. , SJÖDIN I. , TOSS G. , BERGLUND K.
Published: November 2003

Objectives. To assess in patients with long‐term lithium treatment the incidence and prevalence of hypercalcaemia and hyperparathyroidism, and to evaluate the relationship between parathyroid function and renal function: also, to examine the effect of treatment discontinuation.

Design. Part 1. An epidemiological cross‐sectional study covering defined catchment areas.

Part 2. A lithium withdrawal study in a subgroup of the patients who were examined after a mean of 8.5 (4–16) weeks off lithium. Comparisons were made with a group of psychiatric non‐lithium patients matched for sex and age.

Setting. Outpatient treatment at nine psychiatric departments in southern Sweden.

Subjects. Inclusion criterion was 15 years or more on lithium. Excluded from Part 2 were patients with a high risk of relapse. Out of 215 identified patients, 142 (66%) entered and completed Part 1, while 13 of the latter entered and completed Part 2.

Results. The point prevalence of persistent hypercalcaemia was 3.6% and of surgically verified hyperparathyroidism 2.7%. The observed incidence of hyperparathyroidism over 19 years was 6.3%. It was significantly higher than expected in females. In the withdrawal group serum calcium was significantly increased compared to controls, and did not change during 8.5 weeks without lithium. Isostenuria was significantly more common among patients with than without hyperparathyroidism.

Conclusions. The point prevalence, and the 19‐year incidence of hyperparathyroidism, were increased. The point prevalence of hypercalcaemia was also increased, and not reversible during 8.5 weeks off lithium. The findings support the hypothesis of a causal relationship between lithium treatment and hyperparathyroidism. Hypercalcaemia and hyperparathyroidism are sometimes aetiologically related to reduced renal function in long‐term lithium patients.
Twenty‐four hour ambulatory blood pressure in the population
Authors: NYSTRÖM F. , MALMSTRÖM O. , KARLBERG B. E. , ÖHMAN K. P.
Published: November 2003

Objectives. To establish a population‐based 24‐h ambulatory blood pressure (ABP) reference material with day/night mean BP calculated by standardized and true bedtimes.

Design. A cross‐sectional study of 200 randomly selected subjects (20 men and 20 women in each 10‐year age interval 20–70 years) in Linköping, Sweden.

Setting. University Hospital of Linköping, Sweden.

Results. Participation rate was 67%. Mean supine clinic BP (CBP) and 24‐h‐ABP values for the whole material were 123±13/79±8 mmHg and 120± 10/73±7 mmHg, respectively. White coat BP phenomenon increased with age (systolic CBP/ABP ratio versus age, r=0.35, P<0.0001). Seventeen participants had a night/day mean arterial blood pressure ratio >0.9 (non‐dipper) when calculated from their own time‐notations. If standardized day (06.00–23.00) and night (23.00–06.00) limits were used, 24 subjects were non‐dippers. Of these, only eight were ‘true’. ‘True’ non‐dippers had a similar day‐time mean arterial ABP as ‘true’ dippers (92.4±11 mmHg versus 91.9±13 mmHg, P= 0.92) while night‐time BP was higher (89.9± 13 mmHg versus 74.1±7 mmHg, P<0.0001).

Conclusion. Population‐based ABP reference values have been defined. We found 9% non‐dippers and that standardized day/night‐time limits may lead to misclassification. This could be due to gender‐ and age‐differences in sleeping habits, which was also shown in this study. The frequency of white coat BP phenomenon increases with age.
Energy intake in patients on continuous ambulatory peritoneal dialysis and haemodialysis
Authors: FERNSTRÖM A. , HYLANDER B. , RÖSSNER S.
Published: November 2003

Objectives. To compare patients on continuous ambulatory peritoneal dialysis (CAPD) with those on haemodialysis (HD) regarding food composition and energy intake.

Design. Prospective food recording during 5 consecutive days.

Setting. Nephrology section at a University hospital.

Subjects. Fifteen patients on CAPD and 15 patients on HD, matched for age, gender, duration of dialysis and body mass index (BMI).

Main outcome measures. Percentage macronutrient energy composition, with and without inclusion of transperitoneal glucose uptake. Daily energy intake, both total and from the different macronutrients.

Results. The percentage contribution of the dietary macronutrients to the energy intake was about the same in the two dialysis groups, although the actual energy intake in CAPD patients was lower from all three macronutrients (P=0.02–0.04). The mean intraperitoneal glucose load in CAPD patients was 159 g day‐1, which is approximately equivalent to 2700 kJ. Inclusion of this additional energy (estimated uptake: 70% of the intraperitoneal energy load=19% of total energy intake) significantly increased the carbohydrate fraction and decreased the protein and fat fractions (P<0.0001). Furthermore, this inclusion resulted in almost identical values for total energy intake in the two groups (≈ 144 kJ kg‐1 day‐1) and, in CAPD patients, a significantly higher actual energy contribution from carbohydrates (P=0.04).

Conclusions. Transperitoneal energy intake more than compensates for the lower oral dietary energy intake seen in CAPD patients. Nevertheless, the level of total energy intake places both patient groups in the risk zone for developing malnutrition.
Preventive treatment of foot deformities in Type 1 diabetic patients aged 15–50 years – an epidemiological and prospective study
Authors: BORSSÉN BENGT , BERGENHEIM TOMMY , LITHNER FOLKE
Published: November 2003

Objectives. To prevent worsening of foot deformities in diabetic patients.

Design. A population‐based and prospective study.

Subjects. All patients in the county of Umeå with Type 1 diabetes mellitus (DM) (n=308) aged 15–50 years.

Main outcome measures. Examination and individual education was performed. Patients with the most pronounced foot deformities (n=67) were fitted with custom‐made insoles and had repeated foot examinations. An identical examination was used at a 3‐year follow‐up.

Results. Patients who were fitted with insoles had higher sensory thresholds for vibration compared to those with no insoles. They were older and had longer duration of DM. Improvement of foot deformities was significantly more common in patients after treatment with insoles than in patients without. Plantar ulcers did not occur in patients with moulded insoles.

Conclusion. Information, follow‐up examinations and moulded insoles improve neuropathic foot deformities in many patients, even in those with pronounced deformities.
Granulomatous hepatitis induced by aspirin‐kodein analgesics
Authors: ELZOUKI A.‐N. , LINDGREN S.
Published: November 2003

Salicylate‐kodein is a widely used analgesic agent, particularly in outpatient practice. Salicylates have been incriminated in hepatic injury while kodein may induce biliary spasm. We report here a case of granulomatous hepatitis attributed to prolonged intake of this combination, which has never been reported previously to our knowledge.
Screening for diabetic retinopathy in South Africa with 60° retinal colour photography
Authors: JOANNOU J. , KALK W. J. , NTSEPO S. , BERZIN M. , JOFFE B. I. , RAAL F. J. , SACHS E. , VAN DER MERWE M. T. , WING J. R. , MAHOMED I.
Published: November 2003

Objectives. Comparison of 60° mydriatic retinal photography, in screening for diabetic retinopathy, with diabetes clinic doctors, formal ophthalmological assessment, and with one or two 45° fields.

Design. Consecutive subjects screened by clinicians and photography, and selected eyes evaluated by an ophthalmologist. Randomized photographs assessed through one or two 45° fields (by masking the slides), and at 60°.

Setting. The first 663 patients attending for routine clinic visits and screened for retinopathy.

Main outcome measures. The relative diagnostic sensitivity of screening methods, the utility of screening one eye only, and the costs of photographic screening.

Results. Compared to an ophthalmologist’s assessment, retinal photography had a sensitivity of 93% and a specificity of 89% for any retinopathy, and 100 and 75%, respectively, for severe retinopathy. Photography detected 28% more retinopathy (16% severe) than the clinicians. Compared to a 60° field, one 45° field missed 31%, and 2×45° fields 11% of retinopathy. Of 57 patients with retinopathy meeting referral criteria, 31 pairs of eyes had substantially discordant scores. The cost of diagnosis in a patient requiring referral to ophthalmologist was about US$37.00.

Conclusions. 60° retinal photography compares well with an ophthalmologists screening, and is better than clinical and one to two 45° field assessments. Both retinae should be screened. This method is cost‐effective in our hands.
Islet cell and glutamic acid decarboxylase antibodies in hyperthyroid patients: at diagnosis and following treatment
Authors: HALLENGREN B. , PAPADOPOULOS K. I. , LANDIN‐OLSSON M. , SUNDKVIST G. , FALORNI A. , LERNMARK Å.
Published: November 2003

Objectives. To study the frequency of islet cell (ICA) and glutamic acid decarboxylase (GAD‐Ab) antibodies in patients with hyperthyroidism of different types at diagnosis before treatment and in the euthyroid state following treatment.

Setting. Department of Endocrinology, Malmö University Hospital, Malmö, Sweden.

Subjects and design. Blood samples were collected at diagnosis from 129 hyperthyroid patients, and about 6 months later, from 78 of the patients (euthyroid state). Ninety‐two patients had Graves' disease (69 females and 23 males, median age 49 years, range 17–85 years), and 37 patients had toxic nodular goitre/solitary toxic adenoma (34 females and three males, median age 69 years, range 24–86 years).

Interventions. Most patients were treated by radioactive iodine following the first blood sample.

Main outcome measures. ICA and GAD‐Ab in serum.

Results. At diagnosis of Graves' disease, ICA were detected in two out of 92 (2.2%) patients, two out of 85 (2.4%) without diabetes mellitus and in the euthyroid state in one patient. None of the patients with toxic nodular goitre/solitary toxic adenoma had detectable ICA. At diagnosis of Graves' disease, GAD65‐Ab as well as GAD67‐Ab were detected in 11 out of 85 (13%) patients without diabetes. As many as six out of 11 GAD67‐Ab‐positive patients were GAD65‐Ab negative. In the euthyroid state, GAD65‐Ab were found in six out of 51 (12%) and GAD67‐Ab in eight out of 51 (16%) of the non‐diabetic Graves' disease patients. The frequencies of GAD65‐Ab and GAD67‐Ab in toxic nodular goitre/solitary toxic adenoma, diabetes excluded, were 3 and 0%, respectively, in the hyperthyroid state.

Conclusion. The frequency of ICA in patients with hyperthyroidism is not increased as compared to the background population. GAD‐Ab seems to be associated with Graves' disease and not with hyperthyroidism. The presence of GAD67‐Ab in GAD65‐Ab negative sera from patients with Graves' disease indicates autoreactivity against a specific GAD67 epitope.
A new model for classification of disease manifestations in primary Sjögren's syndrome: evaluation in a retrospective long‐term study
Authors: ASMUSSEN KARSTEN , ANDERSEN VAGN , BENDIXEN GUNNAR , SCHIØDT MORTEN , OXHOLM PETER
Published: November 2003

Objectives. The clinical features of 80 patients with primary Sjögren's syndrome (PSS) were revised in order to evaluate the descriptive and analytical facilities of a newly proposed model for classification of the exocrine and nonexocrine disease manifestations in PSS.

Design. Retrospective, long‐term (median 7.5 years follow‐up) observational, clinical study.

Setting. Patients were recruited from our Department, which is a tertiary referral centre for PSS patients.

Subjects. Eighty patients fulfilling the Copenhagen criteria for keratoconjunctivitis sicca and/or xerostomia and followed between 1972 and 1991 were studied.

Results. All patients had ‘surface exocrine disease’ and in 31% this was the only disease manifestation. ‘Internal organ exocrine disease’ was found in 25% of the patients, whilst 2.5% developed ‘monoclonal B lymphocyte disease’ (non‐Hodgkin's lymphoma). 28% displayed ‘inflammatory vascular disease’, 25% ‘noninflammatory vascular disease’, 41% ‘mediator‐induced disease’ and 2.5% ‘autoimmune endocrine disease’ (thyroiditis). In patients with ‘internal organ exocrine disease’ the frequencies of ‘mediator‐induced disease’ (70%; P<0.01) and ‘inflammatory vascular disease’ (50%; P<0.03) were significantly higher than expected by chance. The level of immunoinflammatory activity (assessed by plasma IgG, serum ANA and focus scoring of minor labial salivary gland biopsies) correlated with the extent of clinical disease as assessed by the model.

Conclusions. We conclude that this theoretically based model for classification of disease manifestations in PSS contains descriptive and analytic powers which may assist the clinical handling of these patients.
Autoantibodies against adrenal medulla in type 1 and type 2 diabetes mellitus: no evidence for an association with autonomic neuropathy
Authors: HUSEBYE E. S. , WINQVIST O. , SUNDKVIST G. , KÄMPE O. , KARLSSON F. A.
Published: November 2003

Objective. To examine the role of autoimmunity in the development of autonomic neuropathy in diabetes mellitus.

Design. Retrospective cross‐sectional study.

Setting. The Department of Medicine, University Hospital, Uppsala, and the Department of Endocrinology, University of Lund, Malmö General Hospital, Malmö, Sweden.

Subjects and main outcome measures. We examined 135 patients with type 1 (n=96) or type 2 (n=39) diabetes mellitus. Tests for cardiovascular autonomic functions were performed, and patient sera were analysed for the presence of autoantibodies against the adrenal medulla by indirect immunofluorescence, Western blot and immunoprecipitation techniques.

Results. Sera from 13% (12/96) of the type 1 and 20% (8/39) of the type 2 patients showed a positive cytoplasmic immunofluorescence (IF) staining of the adrenal medullary cells, as did 20% (30/151) of sera from healthy controls. Fifty‐eight and 64% of type 1 and type 2 patients, respectively, had cardiovascular autonomic neuropathy, but no correlation between autonomic neuropathy and positive IF against the adrenal medulla was observed, with the exception of significant drops in diastolic blood pressure 8 min after tilt (P<0.005) in type 1 patients. The various IF‐positive sera reacted with several different proteins when analysed with Western blot technique using a total homogenate of the bovine adrenal medulla. These did not correspond to any of the proteins involved in the synthesis or storage of catecholamines which were considered as putative autoantigens.

Conclusion. The finding of similar frequencies of immunoglobulins binding to adrenal medulla in both type 1 and 2 diabetic patients as well as in normal controls, argues against a role of anti‐adrenomedullary antibodies in the pathogenesis of autonomic diabetic neuropathy.
Strategies for the prevention of senile (type II) osteoporosis: an update
Authors: BOONEN S. , DEQUEKER J.
Published: November 2003

Boonen S, Dequeker J (Department of Internal Medicine, Divisions of Geriatric Medicine and Rheumatology, and the Arthritis and Metabolic Bone Disease Research Unit, Katholieke Universiteit, Leuven, Belgium). Strategies for the prevention of senile (type II) osteoporosis: an update (Review). J Intern Med 1996; 239: 383–91.

Hip fractures in the elderly represent a global issue, associated with significant morbidity and mortality. Considering the magnitude of the problem, any substantial reduction in the hip fracture burden depends on prevention. In view of the complex pathogenesis of senile (type II) osteoporosis, preventive strategies should focus on the frequency of falling in the elderly as well as on the prevalence of compromised femoral integrity as a consequence of bone loss. Although many risk factors for senile osteoporosis are potentially preventible or reversible with targeted interventions, the beneficial effects of most strategies have not yet been adequately documented, indicating the need for additional long‐term controlled studies.
Outcomes associated with diabetes‐related amputations in the Netherlands and in the state of California, USA
Authors: VAN HOUTUM WILLIAM H. , LAVERY LAWRENCE A.
Published: November 2003

Objective. The purpose of this study is to compare the incidence, relative risk, in‐hospital mortality and hospital stay of diabetes‐related lower extremity amputations in the state of California and the Netherlands in the year 1991.

Research design and methods. We used established data obtained from the Office of Statewide Planning and Development for the state of California and from SIG Health Care Information in the Netherlands to identify all hospitalisations for lower extremity amputations. We used age‐ and sex‐specific prevalence rates of diabetes mellitus from the National Health and Nutrition Examination Survey and the Hispanic Health and Nutrition Examination Survey for the state of California and rates from the Central Bureau of Statistics for the Netherlands. A direct standardisation technique with the 1991 Netherlands population as the standard population was used to calculate age‐adjusted incidence rates. Age was categorised into four different groups; 25–44, 45–64, 65–74 and 75 +. Amputations were defined by four levels; toe, foot, leg and thigh.

Results. The age‐adjusted incidence of diabetes‐related lower extremity amputations was significantly higher in the state of California than in the Netherlands (49.9 vs. 36.1 per 10000 diabetics, P< 0.01). The relative risk, comparing the risk in the diabetic with that in the non‐diabetic population, was California 23.7 vs. the Netherlands 19.7. The length of hospital stay was significantly higher in the Netherlands: 40.8 vs. 16.0 (P<0.01).

Conclusions. There are some significant differences in the outcomes associated with diabetes‐related lower extremity amputations. Some of these differences may be explained by differences in access to health care.
Inactivated hepatitis A vaccine in healthy Chinese adults
Authors: LO Y. C. , LEE S. S. , WONG K. H. , LIM W. L.
Published: November 2003

Objectives. To study the safety, tolerability of and immune response to an inactivated hepatitis A vaccine in healthy Chinese adults.

Design. Seronegative subjects were randomized to receive formalin‐inactivated, alum‐adjuvanted hepatitis A vaccine (25 units, MSD) at 0, 24 weeks (group I) or 0, 2, 24 weeks (group II).

Subjects. Healthy Chinese adults aged 18 years or above were recruited. All subjects were staff of a regional hospital and primary care clinic in Hong Kong.

Main outcome measures. Side‐effects, tolerance, seroconversion rate and geometric mean titre (GMT) of the two groups were noted and compared.

Results. Thirty‐two and 28 people were recruited into group I and group II, respectively. Antibody against hepatitis A developed in 100% of the recipients 1 month after the last dose of either regimen, with a GMT of around 450 IU L‐1. High antibody levels were maintained at the end of one year. There was no statistically significant difference in the seroconversion rates and GMTs between the two regimens of vaccination. All subjects in group I seroconverted at 24 weeks after one single dose of the vaccine. No adverse effects were reported except for complaints of some mild local and constitutional symptoms.

Conclusions. The inactivated hepatitis A vaccine is highly immunogenic, safe and well‐tolerated.
Metformin improves blood lipid pattern in nondiabetic patients with coronary heart disease
Authors: CARLSEN S. M. , ROSSVOLL O. , BJERVE K. S. , FØLLING I.
Published: November 2003

Objectives. To study whether the addition of metformin further improves the blood lipid pattern in non‐diabetic patients with coronary heart disease already treated with lovastatin, diet and lifestyle advice.

Design. An open, prospective, randomized study in a university hospital setting.

Subjects. Sixty non‐diabetic male patients previously treated with coronary artery bypass surgery or angioplasty and with serum cholesterol6.0  mmol L‐1 and/or HDL‐cholesterol1.2 mmol L‐1.

Interventions. After a 4‐week run‐in period with lovastatin (40 mg day‐1), and diet and lifestyle advice, patients were randomized into two groups, both continuing the run in treatment. One group received metformin up to 2000 mg day‐1; the control group got no additional treatment.

Main outcome measures. Fasting serum lipids, glucose and weight were registered at entrance (=week‐4), and at weeks 0, 4 and 12. Changes from week 0 to week 4 and from week 0 to week 12 were compared. Side‐effects of the treatment were also registered.

Results. Metformin lowered the LDL/HDL‐cholesterol ratio by 12 and 6% at weeks 4 and 12, respectively, and reduced body weight by 1.8 kg at week 12. There was also a transient lowering effect on LDL‐cholesterol and apolipoprotein B. In the normal weight subgroup of patients (body mass index< 27 kg m‐2), metformin induced a decrease in total cholesterol (‐9%), LDL‐cholesterol (‐12%), LDL/HDL‐cholesterol ratio (‐10%) and apolipoprotein B (‐7%), as compared to the control group. In this subgroup, body weight and fasting glucose were unaffected by metformin. Thus, the lipid lowering effect in normal weight patients was not secondary to changes in body weight or fasting glucose. In overweight patients (body mass index>27 kg m‐2), metformin had no significant effects on blood lipids, but induced a weight loss of ‐3.0 kg and a transient reduction of fasting glucose. No side‐effects were registered apart from those expected from each individual drug.

Conclusions. Metformin given for 12 weeks as a supplement to lovastatin, diet and lifestyle advice to non‐diabetic male patients with coronary heart disease further improves the lipid pattern in normal weight patients, and reduces weight in the overweight patients. Because metformin is cheap and other lipid lowering drugs are expensive, the potential of metformin as a lipid lowering agent should be further investigated.
Prevention of cardiac sudden death by N‐3 fatty acids: a review of the evidence
Authors: LEAF A. , KANG J. X.
Published: November 2003

The essential n‐6 and n‐3 polyunsaturated fatty acids can prevent ischaemia‐induced ventricular fibrillation in rats, dogs and marmosets. In isolated neonatal rat cardiac myocytes, these have been shown to prevent tachyarrhythmias caused by elevated calcium concentrations, toxic levels of ouabain, a β‐adrenergic agent (isoproterenol), lysophosphatidylcholine and acylcarnitine. The antiarrhythmic effect is caused by a reduction in electrical excitability caused by partitioning of the free polyunsaturated fatty acids into the phospholipid cell membranes of the cardiac myocytes, which modulates membrane ion channels. Two clinical trials suggest they could prevent sudden cardiac death in humans.
Tetanus – still a topic of present interest: a report of 27 cases from a Belgian referral hospital
Authors: PEETERMANS W. E. , SCHEPENS D.
Published: November 2003

Objective. To study the clinical presentation, treatment and outcome of tetanus in a European population.

Design. A retrospective study.

Setting. A large university hospital with a regional as well as a referral service.

Subjects. All patients with tetanus from 1983 till 1993.

Results. Twenty‐seven patients (13 men, 14 women; mean age 68.5 years) were studied. Seventeen out of 24 wounds (three patients had no history of a recent wound) were described as tetanus‐prone. Ten patients had medical wound care, but none received tetanus immunoglobulins despite the absence of tetanus immunity. All patients had the generalized type of the disease. The classical symptoms of trismus, dysphagia and muscular rigidity were present in all patients. Treatment consisted of wound management, neutralization of tetanus toxin by immunoglobulins, antibiotics, treatment of muscle spasm and instability of the autonomic nervous system, and supportive care. Twenty‐five patients were admitted to the intensive care unit for a mean duration of 25.7 days. Sixteen patients were artificially ventilated for a mean duration of 27.5 days. Three patients died, 11 patients had a complicated course caused by haemodynamic instability and 15 patients had pulmonary complications.

Conclusions. Tetanus has not vanished. It remains a difficult‐to‐treat disease with a substantial morbidity and mortality rate. Prevention during wound management of tetanus‐prone wounds was inappropriate in many patients. The elderly population may have the highest risk for tetanus since they may not have had tetanus toxoid immunization or regular booster injections.
High‐technology medicine and the old: the dialysis example
Authors: KJELLSTRAND C. M.
Published: November 2003

High‐technology medicine, which is often expensive, and most often very useful for old people, whose numbers are rapidly increasing, is presenting huge moral problems for physicians. There are now pressures to make physicians salaried employees rather than professionals, and this will decrease or obliterate their efficiency as advocates for patients. Advocacy is a previously non‐described duty, which is an important ethical principle for physicians, in addition to the four universally recognized principles: beneficence, non‐maleficence, respect for autonomy, and justice.

Not‐so‐subtle economic pressure by managed care, government, administrators, and politicians, is already in force. If physicians, by advocating expensive treatment for many, irritate those with economic power, they may violently retaliate.

Chronic dialysis illustrates well the dilemma of high‐technology medicine because acceptance numbers are accurate and widely known, most patients are old, the treatment is rationed everywhere by age, and, as patients die if excluded, it can be used to analyse reactions to an ongoing age rationing.

Post‐modern bioethics and moral philosophy appears helpless and, in some regards, irrelevant in elucidating and solving the concrete moral conflict posed by high‐technology medicine and the old. Administrators and politicians wish physicians to be society's economic gatekeepers; however, this is incompatible with classical ethical concepts of the profession of physicians. Physicians and their professional organizations had better realize this in order to map out defensive strategies so that physicians, as a profession, do not disappear.
Daytime sleepiness and napping amongst the elderly in relation to somatic health and medical treatment
Authors: ASPLUND R.
Published: November 2003

Objectives. To investigate daytime sleepiness and napping in relation to age, health and nocturnal sleep.

Design. An epidemiological survey by means of a questionnaire.

Setting. The counties of Västerbotten and Norrbotten in northern Sweden.

Subjects. All 10216 members of the pensioners' association SPF.

Main outcome measures. Daytime sleep, daytime sleepiness, health, night sleep, somatic diseases and medication.

Results. Daytime sleepiness was 4.9 (3.7–6.4) and 5.1 (4.2–6.1) times more common in men and women, respectively, in poor health than in those in good health. It was also more common in subjects suffering from cardiac diseases, diabetes and musculo‐skeletal diseases, urological symptoms, and diseases with sensory and neurological impairments, compared with symptomless subjects. Stepwise regression analysis showed an increase in daytime sleepiness in men in association with impaired general health (r2=0.067), frequent awakenings (r2 =0.098), higher age (r2=0.109) and difficulty in falling asleep again after nocturnal awakening (r2= 0.115), and in the women, in association with impaired health (r2=0.118), difficulty in falling asleep again (r2=0.149), frequent awakenings (r2=0.160) and higher age (r2=0.171). There was no further increase in r2=either for men or women in relation to use of hypnotics.

Conclusion. Age, poor health and different somatic diseases, but not hypnotics, are associated with daytime sleepiness in elderly persons.
Assessment and diagnosis of heart failure
Authors: CLELAND J. G. F. , HABIB F.
Published: November 2003

Cleland J, Habib F (Medical Research Council (UK) Clinical Research Initiative in Heart Failure, West Medical Building, University of Glasgow, Glasgow, and Royal Post‐Graduate Medical School, Hammersmith Hospital, London, UK). Assessment and diagnosis of heart failure (Minisymposium: Heart failure). J Intern Med 1996;239: 317–25.

Diagnosis is the first essential step in the provision of good management of heart failure. Diagnosis of heart failure by clinical means alone may be fairly accurate in advanced heart failure but will only be correct in about 50% of milder cases; little better than guessing. The number of patients with mild heart failure in whom the diagnosis is not even considered is unknown. In at risk groups, such as those who have had a myocardial infarction, symptoms alert the clinician to a possible diagnosis of heart failure which must be confirmed by further investigation. The echocardiogram is the single most useful diagnostic tool for heart failure in widespread use at the present.

Once it is established that the patient has heart failure, its cause must be sought out. As the majority of patients with heart failure are elderly, concomitant diseases may complicate management and should be sought out. European Society Guidelines on the Diagnosis of Heart Failure have been published and provide a minimum data set of investigations that should be carried out in all patients.