bluuebunny/crossref_metadata_2025 huggingface dataset:
The clinical relevance of sex hormone levels and sexual activity in the ageing male
Authors: Ahn H.S. , Park C.M. , Lee S.W.
Published: March 2003

Objectives To assess the changes in sex hormone levels with age and the relationship of sexual functioning to testosterone levels, evaluating serum testosterone levels and erectile function in men with lower urinary tract symptoms (LUTS).

Patients and methods The study included 213 men with LUTS (age range 31–78 years) who had no confirmed erectile dysfunction. Their serum total and free testosterone, and sex‐hormone binding globulin (SHBG) levels were measured, and they completed the International Index of Erectile Function (IIEF) questionnaire.

Results The total and free testosterone levels decreased and SHBG increased with age, but only the change in free testosterone and SHBG were statistically significant. The correlation with age was closer for free testosterone (r = − 0.356, P < 0.001) than for SHBG (r = 0.177, P = 0.010). Regression analysis of the five domain scores of the IIEF and three hormonal levels, after correcting for age, showed that free testosterone level was significantly correlated with erectile function (r = 0.2136, P = 0.005) and orgasmic function (r = 0.179, P = 0.020), but SHBG levels were significantly correlated only with orgasmic function (r = − 0.154, P = 0.046). Total testosterone levels showed no significant correlation with any of the five domains of the IIEF.

Conclusions Of the sex hormone levels, the change in free testosterone correlated most closely with ageing and had the closest correlation with sexual activity. Contrary to previous reports, free testosterone and SHBG levels were significantly correlated with orgasmic function and/or erectile function rather than sexual desire. A complete study of sex hormone levels is needed to evaluate patients with erectile dysfunction.
Association of dietary fatty acids with urinary oxalate excretion in calcium oxalate stone‐formers in their fourth decade
Authors: Naya Y. , Ito H. , Masai M. , Yamaguchi K.
Published: March 2003

Objective To examine the influence of the dietary intake of fatty acid on urinary oxalate excretion in calcium oxalate stone‐formers in their fourth decade, as previous reports show that animal fat intake is associated with urinary oxalate excretion.

Patients and methods The dietary intake of 58 idiopathic stone‐formers in their fourth decade was recorded using the dietary‐record method. The patients collected 24‐h urine samples at home and their urinary oxalate excretion was measured in a clinical biochemistry laboratory. The results were used to determine the relationship between the dietary intake of fatty acids and urinary oxalate excretion. Associations between urinary oxalate excretion and dietary contents of animal fat, animal protein and various fatty acids were assessed using Spearman's correlation coefficient and multiple regression.

Results The dietary content of arachidonic acid was positively correlated with urinary oxalate excretion, as assessed by univariate and multivariate analysis.

Conclusion The association between arachidonic acid and oxalate excretion suggests that arachidonic acid increases the intestinal absorption of oxalate and increases the clearance of oxalate in the kidneys.
A comparative review of extracorporeal shock wave generation
Authors: Wilbert D.M.
Published: March 2003

Shock waves are specific sound waves produced by shock‐wave generators; the generators currently available have different physical properties and represent different technical solutions. The measurement of shock‐wave pressure is necessary in laboratory settings to define the physical characteristics of a given shock‐wave source. Under clinical conditions other variables, e.g. the stone‐free rate or the percentage of complications, are used to describe the efficacy and safety of a lithotripter.
Gleason score on biopsy: is it reliable for predicting the final grade on pathology?
Authors: Lattouf J.‐B. , Saad F.
Published: March 2003

Objective  To assess the correlation of the Gleason score on biopsy and the final pathology after radical prostatectomy (RP) for prostate adenocarcinoma.

Patients and methods  In a retrospective analysis within a tertiary‐care centre, the charts of 537 patients who had undergone radical prostatectomy from April 1989 to November 2000 were reviewed. The RPs were undertaken in one institution; 167 biopsies were taken and interpreted in the referring centres, and 355 were taken and interpreted in the authors’ institution by up to 15 pathologists. All the final pathology specimens were interpreted by the same group of pathologists. The main outcome measures were: the pathological report of the biopsy including the primary and secondary Gleason grade; the final pathological grade (primary and secondary); the margin status; and the identification of the pathologist for the biopsy and final pathology.

Results  In all, 390 patients had inclusion criteria (the Gleason grade before and after RP) available. For the individual scores 38.2% of tumours were undergraded, 32.6% overgraded and only 29.2% had identical grading in preoperative biopsies and final specimens. When grouped into more meaningful categories (Gleason 2–4, 5–6, 7 and 8–10) the correlation improved, with 48.5% of patients remaining in the same group after RP. For 39 patients the same pathologist assessed the biopsy and final specimen; in these cases individual scores were identical in 49% and group scores were identical in 64%.

Conclusion  Gleason grading of the prostate biopsy remains a poor predictor of pathological outcome. Assessment by the same pathologist reduces the discrepancy but over half the patients are under‐ or overgraded on final pathology. Clinicians should be aware of these limitations when using the biopsy Gleason grade in decision making.
Healing of unstented tubularized incised plate urethroplasty: an experimental study in a rabbit model
Authors: Hafez A.T. , Herz D. , Bägli D. , Smith C.R. , McLorie G. , Khoury A.E.
Published: March 2003

OBJECTIVE

To develop a rabbit model to study the temporal healing taking place after an unstented tubularized incised plate urethroplasty (TIPU).

MATERIALS AND METHODS

The study comprised 13 New Zealand white rabbits (3–4 kg); the ventral wall of the penile urethra was excised to create a hypospadias‐like defect. A vertical incision was made in the dorsal urethral plate and the incised urethra tubularized. Two animals were killed at 2 days and two at 5 days after surgery, and the remainder killed at 2, 6 and 12 weeks (three each). A retrograde urethrogram was taken at autopsy. Serial sections of the penis were stained with haematoxylin and eosin, and Masson trichrome for microscopy.

RESULTS

There were no deaths related to the procedure and all animals voided spontaneously. Retrograde urethrograms showed no fistulae or stricture. Microscopic examination at 2 and 5 days showed partial coverage of the incision with regenerating urothelium. At 2 weeks there was full‐thickness urothelium with a mild inflammatory reaction. At 6 and 12 weeks, remodelling of the peri‐urethral connective tissue with minimal fibrosis completed the healing.

CONCLUSION

The mechanism of healing of the incised urethral plate involves normal urothelial regeneration into the depth of the incised defect, which explains the gain in urethral diameter after TIPU. Urine flow, during normal voiding, might be responsible for keeping the incised plate open during urothelial regeneration. A urethral stent was not necessary for normal healing in this model.
Glanular reconstruction and preputioplasty repair for distal hypospadias: a unique day‐case method to avoid urethral stenting and preserve the prepuce
Authors: Gray J. , Boston V.E.
Published: March 2003

OBJECTIVE

To report the early outcome of> 200 boys who underwent a glanular reconstruction and preputioplasty (GRAP) repair for distal hypospadias, to assess the functional and anatomical outcome of the penis at least 10 years after surgery, and to compare these data with otherwise ‘normal’ aged‐matched controls.

PATIENTS AND METHODS

The GRAP repair is a novel method for the day‐case reconstruction of distal hypospadias, and uniquely allows the anatomical reconstruction of the prepuce as part of penile reconstruction for hypospadias. We retrospectively reviewed the notes of 205 consecutive cases of distal hypospadias who had a GRAP repair carried out by one surgeon. Of these, there were 63 consecutive patients who had been repaired using the GRAP ≥ 10 years earlier. In these patients a questionnaire was used to assess their perception of the appearance of their penis, the urinary stream, any problems with the foreskin and their recollection of surgery. Similar questionnaire data, except for the latter, were obtained from aged‐matched controls for comparison.

RESULTS

Of the 205 patients, 183 (89%) were day cases; the remaining 22 remained in hospital overnight for medical or social reasons. Sixteen (7%) developed a urethral fistula, the incidence of which correlated positively with the length of the repair. Four children (2%) were circumcised, in two for phimosis resulting in a spraying stream, in a third for dribbling after voiding, and the fourth for a cosmetically unsatisfactory foreskin. Questionnaire responses were received from 45 boys (71%), while 18 were untraceable. The mean (sd) age at surgery and at survey was 3.25 (2.6) and 14.26 (2.8) years, respectively. Forty‐two (95%) children felt their penis was normal or only slightly different in appearance, two (5%) felt it looked fairly different and only one mostly avoided communal situations because of this. On voiding three boys (7%) sprayed most of the time while the remainder either never or sometimes sprayed. One youth sometimes had to sit to void because of difficulties in directing the stream; the rest (98%) always stood to void. There were no further circumcisions. These results were not significantly different from those of the age‐matched controls. Most children had no (68%) or only slight (30%) recollection of hypospadias surgery.

CONCLUSION

The complication rate and patient satisfaction with GRAP is comparable with those of other techniques. GRAP is a simple day‐case procedure with few complications, thus avoiding an overnight hospital admission for most patients. Importantly, the prepuce can be preserved and refashioned to give a good cosmetic result, with no phimosis, which is increasingly important as circumcision becomes less acceptable to both the general public and the medical profession.
Enterocystoplasty in childhood: a second look at the effect on growth
Authors: Gerharz E.W. , Preece M. , Duffy P.G. , Ransley P.G. , Leaver R. , Woodhouse C.R.J.
Published: March 2003

OBJECTIVE

To re‐evaluate the assumption that enterocystoplasty in children has a detrimental effect on linear growth (which is almost exclusively based upon a chance finding in a retrospective study 10 years ago) in a larger cohort and with a longer follow‐up.

PATIENTS AND METHODS

The original 12 children who had impaired linear growth in a previous study 10 years earlier were re‐measured. A larger cohort was identified from the 242 children and adolescents who had undergone enterocystoplasty between 1982 and 1997. Patients with conditions involving organ systems apart from the urinary tract, and those with myelomeningocele, malignant diseases, reduced glomerular filtration rate and incomplete notes were excluded. In the definitive study cohort (123; mean age at operation 8.6 years; mean age at investigation 16.8 years) enterocystoplasty had been undertaken using colon in 70, ileum in 37, a combination of both in 11, ileocaecal segments in three and stomach in two patients.

RESULTS

Of the original 12 patients, six had regained or surpassed their preoperative position on their growth charts. In all patients with a known target centile range the final height was within their genetic growth potential. In the cohort of 123 patients, 1215 height and weight measurements had been recorded. The distribution of percentile positions before and after enterocystoplasty showed a normal configuration, with 83% and 80% of patients growing within two standard deviations of the 50th percentile. After surgery, 85% either remained on the same or reached a higher centile. Nineteen (15.5%) were in a lower position, with a similar tendency in the weight centile. A clinically relevant growth disorder was recognized in four patients with a complete endocrinological evaluation; in none of these was enterocystoplasty thought to be a causal factor.

CONCLUSIONS

It is very unlikely that the loss of the preoperative percentile position on the growth curve in 15% of children after enterocystoplasty is a consequence of the surgery. Rather it is a non‐specific phenomenon that has to be considered in any clinical population of the same size and age distribution after the same length of time.
Correlation of intravesical prostatic protrusion with bladder outlet obstruction
Authors: Chia S.J. , Heng C.T. , Chan S.P. , Foo K.T.
Published: March 2003

OBJECTIVES

To determine the effect of intravesical protrusion of the prostate (IPP, graded I to III) on lower urinary tract function, by correlating it with the results of a pressure‐flow study.

PATIENTS AND METHODS

In a prospective study men (aged> 50 years) with lower urinary tract symptoms were initially evaluated as recommended by the International Consultation on Benign Prostatic Hyperplasia, together with the IPP and prostate volume, as measured by transabdominal ultrasonography. These variables were then correlated with the results from a pressure‐flow study.

RESULTS

The IPP was a statistically significant predictor (P < 0.001) of bladder outlet obstruction (BOO) compared with other variables in the initial evaluation. In all, 125 patients had significant BOO, defined as a BOO index of> 40. Of these men, 94 had grade III and 30 had grade I–II IPP. Seventy‐five patients had a BOO index of < 40; 69 had grade I–II and six grade III IPP. In patients with BOO confirmed on the pressure‐flow study, grade III IPP was associated with a higher BOO index than was grade I–II (P < 0.001).

CONCLUSION

The IPP assessed by transabdominal ultrasonography is a better and more reliable predictor of BOO than the other variables assessed.
NF‐κB nuclear localization and its prognostic significance in prostate cancer
Authors: Lessard L. , Mes‐Masson A.‐M. , Lamarre L. , Wall L. , Lattouf J.‐B. , Saad F.
Published: March 2003

OBJECTIVE

To detect the subcellular localization of NF‐κB (p65) in human prostate cancer tissues of different histological grades, and to test whether NF‐κB localization alone, or combined with the histological grade, can be used to predict patient outcome.

PATIENTS AND METHODS

Prostate cancer tissues were obtained from radical prostatectomy specimens; the histological grade was determined using the Gleason grading system. Clinical outcomes were defined as good (5‐year disease‐free survival with undetectable levels of prostate specific antigen) or poor (progression to bone metastases). The subcellular localization of NF‐κB was visualized by immunohistochemistry using an anti‐p65 antibody.

RESULTS

The NF‐κB subcellular localization was initially assessed in 45 specimens; in these samples a nuclear localization of NF‐κB was specific to cancer tissues, but did not correlate with the Gleason score (P = 0.089). NF‐κB was then assessed as a prognostic marker to complement Gleason score in predicting cancer progression. Tumour tissues from 30 men with a known clinical outcome were included; 10 of 17 patients who had a poor outcome were positive for NF‐κB nuclear staining, whereas only two of 13 with a good outcome were positive (P = 0.026). When NF‐κB subcellular localization and Gleason score were combined, two risk categories of progression were defined. Eleven of 13 specimens from those with a good outcome were in the low‐risk category (Gleason 2–4 or Gleason 5–7 with negative nuclear NF‐κB) and 12 of 17 in the poor outcome group were in the high‐risk category (Gleason 8–10 or Gleason 5–7 with positive nuclear NF‐κB; P = 0.004).

CONCLUSION

NF‐κB is detectable in the nucleus in prostate cancer tissues and positivity can be used to help predict patient outcome. Multivariate analyses using other clinical and molecular variables are underway, and will validate the usefulness of NF‐κB as a prognostic factor.
Diabetes in the elderly: problems of care and service provision
Authors: Croxson S.
Published: March 2003

Diabetes is common in the elderly and old UK citizens, affecting between 10% and 25%. There is considerable associated morbidity and mortality, with dementia being a common problem. The diabetic elder is also at risk of drug side‐effects. Most of the evidence base for treatment is based on trials performed in younger diabetic subjects or older nondiabetic subjects; however, we can practice evidence‐biased medicine whilst awaiting the results of ongoing trials. The older persons national service framework (NSF) may share some similarities with the diabetes NSF; it was 1 year late, and had no clear funding, amongst several other worries. Residential care, which is more likely to be required by diabetic elders, is also under‐funded with major concerns about the quality of care for the diabetic resident. The little evidence that we have regarding care of the older diabetic person also suggests inadequacies. Given the likelihood that we will have to manage with present resources, managed clinical networks may be one way to cope.
Association of British Clinical Diabetologists (ABCD): survey of specialist diabetes care services in the UK, 2000. 4. Dietetic services and nutritional issues
Authors: Winocour P. H. , Mearing C. , Ainsworth A. , Williams D. R. R. ,   the Association of British Clinical Diabetologists
Published: March 2003

Aims To examine the provision of, and variations in, dietetic services for diabetes in secondary care in the UK.

Method A postal survey of all secondary care providers of diabetes services.

Results There was a 77% response rate. A dedicated dietician supported diabetes services in 73% of responses, but only 45% were able to see newly diagnosed patients within 1 month. Only 3% of responses documented that dietetic services provided the recommended minimum 22 h weekly input to diabetes care, and an annual dietetic review was said to be available in 15%. An opportunity for more frequent visits was most likely if there was poor glycaemic control (78% of responses), particularly when services were provided by a dedicated diabetes dietician. Although dieticians frequently provided input to patient education (88%), specific training for this purpose and provision for continuing education of these individuals was less common (14% and 63%, respectively). Nutritional guidelines were available in 74%, but only 31% of responses documented current guidelines on obesity management. Of bids for additional dietetic resources, only 21% had been successful. There was evidence of regional variation in service provision, and no greater provision of dietetic services in areas with a large South Asian population and an expected high prevalence of diabetes. In broad terms, dietetic services for diabetes care had not altered in comparison with a similar survey in 1997.

Conclusions The level of dietetic support of secondary care diabetes services remains dramatically lower than recommended in advisory documents, and appears to have changed little over the last 3 years. This is compounded by marked regional differences, and was no better in areas with a higher than average prevalence of diabetes. The survey also highlights the need for more co‐ordinated and structured education and training of dieticians as well as more consistency in nutritional guidelines.
Patterns of contraception in UK women with Type 1 diabetes mellitus: a GP database study
Authors: Lawrenson R. A. , Leydon G. M. , Williams T. J. , Newson R. B. , Feher M. D.
Published: March 2003

Aim To establish the patterns of contraceptive prescribing for women aged 15–49 with Type 1 diabetes mellitus (DM) and compare them with the patterns in women without diabetes.

Methods This was a cross‐sectional study using a UK primary care database.

Results Nine hundred and thirty‐eight women with a diagnosis of Type 1 DM were identified. A comparison group of women aged 15–49 without diabetes (n = 10 000) were randomly selected from the database. Twenty‐five per cent of the women with diabetes and 32% without diabetes were prescribed a hormonal contraceptive in 1994. Women with Type 1 DM were more likely to be prescribed a combined oral contraceptive than a progestogen only pill (POP) but were 2.12 (95% CI 1.65–2.72) times more likely to be prescribed a POP than women without diabetes and were less likely to be prescribed a combined pill – odds ratio 0.53 (95% CI 0.44–0.64). The pregnancy rate in women with Type 1 DM over the age of 25 years was lower than for women without diabetes. Women under 25 years with Type 1 DM seemed more likely to record a pregnancy.

Conclusions Differences between women with Type 1 DM and those without diabetes highlight the variation in the way that GPs and patients evaluate the risks and benefits when deciding on contraception.

Diabet. Med. 16, 395–399 (1999)
A high uptake eye and foot screening service for an urban population
Authors: Bryant V. M. , Wilson A. , Jones T. H. , Hague R. V.
Published: March 2003

Aims A community diabetes eye screening service using slit‐lamp biomicroscopy and colour fundus photography was set up in 1993 at the Barnsley District General Hospital Diabetes Centre with a foot screening service being added in 1994. The service is available for all diabetic patients in the Barnsley health district (encompassing 220 000 people). After 4½ years, a survey was carried out to establish the uptake of this service.

Methods All diabetic patients on the local diabetes register were checked for attendance at the eye screening service or the Barnsley District General Hospital Eye Department. Questionnaires were sent to general practitioners to establish what screening was received by those attending neither of these services.

Results More than 10% of patients were found to be incorrectly registered. Of the 4000 correctly registered diabetic patients, 62% were screened annually by this service and 25% were under the care of the Department of Ophthalmology. Half of the remaining 13% were screened at other hospitals or by opticians or general practitioners and the other half were either too old or ill to be screened or were non‐compliant.

Conclusions This service has a high uptake, and is recommended for a circumscribed urban population.
Is undetected autonomic dysfunction responsible for sudden death in Type 1 diabetes mellitus? The ‘dead in bed’ syndrome revisited
Authors: Weston P. J. , Gill G. V.
Published: March 2003

Aims Sudden nocturnal death in young persons with Type 1 diabetes mellitus has been recently described, and is known as the ‘dead in bed’ syndrome. Its aetiology is unknown, and we have therefore explored the details of all papers recording the syndrome, to formulate a hypothesis of causation.

Methods Literature review of ‘dead in bed’ reports as well as of nocturnal hypoglycaemia, and autonomic dysfunction in relation to baroreceptor–cardiac reflex sensitivity.

Results Clinical reports of ‘dead in bed’ cases strongly suggest that nocturnal hypoglycaemia is a likely precipitant, but that the death is sudden and probably arrhythmic. Ventricular dysrhythmias may occur in the context of early autonomic neuropathy, with relative sympathetic overactivity, in young Type 1 diabetic persons.

Conclusion We conclude that the ‘dead in bed’ syndrome probably occurs in Type 1 diabetic persons with early autonomic neuropathy, resulting in relative sympathetic overactivity. In such persons, risks of ventricular dysrhythmias will be compounded by nocturnal hypoglycaemia, which may be associated with an increase in the electrocardiographic Q–T interval, and Q–T dispersion. This could lead to the observed sudden death in undisturbed beds. Further research in this area is urgently needed, in particular into the possible protective use of drugs that modulate the autonomic nervous system.
Gastrointestinal symptoms in Chinese patients with Type 2 diabetes mellitus
Authors: Ko G. T. C. , Chan W. ‐B. , Chan J. C. N. , Tsang L. W. W. , Cockram C. S.
Published: March 2003

Aims To examine and compare gastrointestinal (GI) symptoms in Hong Kong Chinese Type 2 diabetic outpatients and non‐diabetic control subjects.

Methods A total of 149 Chinese Type 2 diabetic patients (66 men and 83 women, age (mean ± sd) 46.8  ± 11.1 years) newly referred to the diabetes clinic of the Prince of Wales Hospital, Hong Kong were examined. Sixty‐five age and sex‐matched non‐diabetic subjects were recruited from the community as controls (22 men and 43 women, age (mean ± sd) 46.5 ± 6.6 years, P = 0.820). All patients were interviewed regarding GI symptoms over the past year, using a questionnaire that covered 14 items. A scoring system from 0 to 4 was used to grade severity.

Results Diabetic patients had higher blood pressure, fasting plasma glucose and glycated haemoglobin and were more often smokers than control subjects. Of the 149 diabetic subjects, 105 (70.5 ± 45.8%) had GI symptoms while only 20 (30.8%) of the 65 control subjects had GI symptoms (P < 0.001). The respective percentages of upper and lower GI symptoms in diabetic and normal subjects were 44.3% vs. 24.6% (P = 0.006) and 54.4% vs. 13.9% (P < 0.001). The three commonest GI symptoms in diabetic patients were diarrhoea (34.9%), constipation (27.5%) and epigastric fullness (16.8%). After adjustment for age, sex, duration of diagnosed diabetes and smoking, patients with or without metformin had similar percentages or scores for GI symptoms. On multivariate analysis using age, body mass index, fasting plasma glucose, glycated haemoglobin, duration of diagnosed diabetes and presence of peripheral neuropathy as independent variables, duration of diabetes was the only independent parameter associated with total score for GI symptoms (β = 0.116, P = 0.003), for upper GI symptoms (β = 0.073, P = 0.005) and for lower GI symptom (β = 0.043, P = 0.020).

Conclusions Up to 70% of the Chinese Type 2 diabetic outpatients have GI symptoms, which is a much higher rate than in non‐diabetic control subjects. Duration of diabetes is the most important factor associated with the presence of such GI symptoms.
The prevalence of multiple diabetes‐related complications
Authors: Morgan C. LL. , Currie C. J. , Stott N. C. H. , Smithers M. , Butler C. C. , Peters J. R.
Published: March 2003

Aims To determine the prevalence of the complications of diabetes and the interrelationship between them within a United Kingdom district health authority population.

Methods Data extracted from a general practice diabetes audit were combined with data for patients with diabetes derived from a patient index constructed using record linkage techniques.

Results A total of 10 709 patients were identified as having diabetes (prevalence 2.47%). Coronary heart disease was present in 25.2%, cerebrovascular disease in 9.6%, complications of the ‘diabetic foot’ in 18.1%, retinopathy in 16.5% and nephropathy in 2.0%. Over a half of the patients (52.1%) had none of the studied complications, 30.2% had one, 12.7% had two, 4.1% had three, 0.8% had four and 0.1% had all five. All complications were related to both age and duration of diabetes but duration was particularly apparent for the microvascular complications (retinopathy and nephropathy). Macrovascular complications in the Type 2 diabetic population appear advanced in onset compared with Type 1.

Conclusions Multiple complications are apparent in almost one fifth of patients with diabetes. Macrovascular morbidity in Type 2 diabetes of early onset indicates that a targeted approach to treatment may prove most beneficial in both patient and health service terms.
Aldose reductase gene polymorphisms and susceptibility to diabetic nephropathy in Type 1 diabetes mellitus
Authors: Moczulski D. K. , Scott L. , Antonellis A. , Rogus J. J. , Rich S. S. , Warram J. H. , Krolewski A. S.
Published: March 2003

Aims To investigate association and linkage between DNA sequence variants in the aldose reductase (AR) gene on chromosome 7q35 and diabetic nephropathy (DN) in Type 1 diabetes mellitus.

Methods By sequencing the promoter region and 10 exons in eight DN cases and eight controls, a frequent bi‐allelic polymorphism (C‐106T) was discovered. This polymorphism and the known 5′ALR2 dinucleotide repeat polymorphism were genotyped in unrelated cases with advanced nephropathy (n = 221) and unrelated controls with normoalbuminuria (n = 193). For a family based study, 166 case‐trios (case and both parents) and 83 control‐trios (control and both parents) were also genotyped.

Results In the case–control study, carriers of the Z‐2 allele of the 5′ALR2 polymorphism had a significantly higher risk of DN than non‐carriers (odds ratios: 1.6 for heterozygotes and 2.1 for homozygotes, P < 0.05 for each). The same was true for carriers of the T allele of the C‐106T polymorphism (odds ratios: 1.6 for heterozygotes and 1.9 for homozygotes, P < 0.05 for each). Moreover, the haplotype carrying both risk alleles was in excess in DN cases. In the family study, transmission of risk alleles from heterozygous parents was consistent with the case–control study, excess transmission in case‐trios and deficient in control‐trios.

Conclusions Association between DN and two DNA sequence variants in the promoter region of the AR gene implicates the polyol pathway in the development of kidney complications in Type 1 diabetes mellitus. Further examination of the molecular mechanisms underlying these findings may provide insight into the pathogenesis of DN.
Is mild gestational hyperglycaemia associated with maternal and neonatal complications? The Diagest Study
Authors: Vambergue A. , Nuttens M. C. , Verier‐Mine O. , Dognin C. , Cappoen J. P. , Fontaine P.
Published: March 2003

Aims To evaluate the maternal and neonatal complications rates of mild gestational hyperglycaemia (MGH) compared to a control group in France.

Methods A systematic screening by a 50‐g glucose challenge test was offered to all women between 24 and 28 weeks of gestation in 15 maternity units. If the 50‐g glucose challenge test was ≥ 7.2 mmol/l, a 100‐g 3‐h oral glucose tolerance test (OGTT) was performed. MGH (n = 131) was defined by one abnormal value on the 3‐h OGTT (Carpenter and Coustan criteria). The control group (n = 108) was defined by a 50‐g glucose challenge test below 7.2 mmol/l. Women with MGH received no treatment or specific advice during the pregnancy. Large for gestational age (LGA) was defined by a birth weight of at least the 90th percentile on French standard growth curves.

Results Women with MGH were older than the controls (28.8 (5.8) vs. 27.0 (5.2); P < 0.05) and had a higher body mass index (24.8 (4.8) vs. 23.0 (3.9); P < 0.01). The rate of pregnancy‐induced hypertension and Caesarean section were not different between the MGH and control group. The rate of LGA was significantly higher in the MGH group than the control group (22.1% vs. 11.4%; P < 0.05). After adjustment for confounding factors of macrosomia (pre‐pregnancy body mass index > 27, maternal age > 35, multiparity and educational level), there was a persistent relationship between LGA and MGH (odds ratio 2.50; 95% confidence interval (1.16–5.40); P < 0.05). MGH was more frequently associated with adverse maternal and fetal outcome than in the controls (53.4% vs. 28.7%; P < 0.01).

Conclusions This study suggested that the increased rate of adverse maternal and fetal outcome, especially LGA, was associated with untreated mild gestational hyperglycaemia women compared to a control group. This link to lower degrees of hyperglycaemia during pregnancy is independent of confounding factors.
Impaired glucose tolerance and fasting hyperglycaemia have different characteristics
Authors: Davies M. J. , Raymond N. T. , Day J. L. , Hales C. N. , Burden A. C.
Published: March 2003

Aims Use of the oral glucose tolerance test (OGTT) to define glucose intolerance in the general population may bias towards selection of those with insulin resistance. Beta cell function and insulin resistance markers were analysed in four groups: controls (n = 101); fasting hyperglycaemia (FH, n 45); impaired glucose tolerance; (IGT, n = 16) and those with features of both FH and IGT (‘Both’, n = 30).

Methods Subjects underwent an OGTT. Plasma glucose, fasting lipid profiles, fasting, 30 and 120 min insulin were measured and beta cell function (% B) and insulin sensitivity (% S) assessed by homeostatic model assessment (HOMA)

Results The FH group compared to controls had a significantly lower % B. The IGT group compared to controls had features of insulin resistance (higher body mass index (BMI), systolic blood pressure and 2 h insulin concentration). Subjects with ‘both’ IGT and FH had features of insulin resistance (higher BMI, systolic and diastolic blood pressure and triglyceride concentration) as well as beta cell dysfunction with a lower % B and 30 min insulin–glucose ratio compared to controls. There was a preponderance of males in this group. In all, 192 subjects' 30‐min insulin concentration and incremental insulin response showed only a significantly negative correlation with fasting glucose concentration. In a linear regression analysis, a low 30‐min insulin–glucose ratio was only a significant factor in the fasting glucose model. Thus, higher fasting glucose concentrations appear to be associated with beta cell dysfunction. However, HbA1 only showed a significant correlation with 120‐min glucose, not fasting glucose concentration.

Conclusions In those with milder degrees of glucose intolerance, FH is associated with beta cell dysfunction and those with IGT and a relatively ‘normal’ fasting glucose have features of the insulin resistance syndrome.
Blindness following a diabetic foot infection: a variant to the ‘eye–foot syndrome’?
Authors: Yuen K. C. J. , Baker N. R. , Reddy A. , Edelsten C. , Rayman G.
Published: March 2003

SUMMARY

Aims  The ‘eye–foot syndrome’ was initially described by Walsh et al. to highlight the important association of foot lesions in patients with diabetic retinopathy. We present a case of a 58‐year‐old patient with Type 2 diabetes mellitus who developed blindness following endogenous staphylococcal endophthalmitis from an infected foot ulcer.

Results  Our case describes the link between the eye and the foot but is somewhat different to the association as described by Walsh et al. Endogenous endophthalmitis is rare with diabetic patients being especially at risk, and we report the first case of endogenous staphylococcal endophthalmitis related to a diabetic foot lesion.

Conclusions  Our case illustrates several important issues in the management of diabetic patients admitted to hospital with infection; the need to thoroughly examine the feet to ascertain any foot lesions and any underlying peripheral vascular disease or peripheral neuropathy, to treat aggressively any infected foot lesions to prevent serious complications of septicaemia and to consider rare conditions like endogenous endophthalmitis in any diabetic patient presenting with acute visual impairment and septicaemia.
Improving foot care for people with diabetes mellitus – a randomized controlled trial of an integrated care approach
Authors: Donohoe M. E. , Fletton J. A. , Hook A. , Powell R. , Robinson I. , Stead J. W. , Sweeney K. , Taylor R. , Tooke J. E.
Published: March 2003

SUMMARY

Aims  To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care‐based diabetic annual review.

Methods  A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1939 people with diabetes (age ≥ 18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization.

Results  Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29–5.07) between the groups.

Patients  knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: −0.09 (95% CI −1.81–1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change −0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30–18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14).

Conclusions  Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services.
Predictive genetic testing in maturity‐onset diabetes of the young (MODY)
Authors: Shepherd M. , Ellis I. , Ahmad A. M. , Todd P. J. , Bowen‐Jones D. , Mannion G. , Ellard S. , Sparkes A. C. , Hattersley A. T.
Published: March 2003

SUMMARY

Introduction  Maturity‐onset diabetes of the young (MODY) is characterized by autosomal dominant inheritance of young‐onset non‐insulin‐dependent diabetes. It accounts for approximately 1% of Type 2 diabetes (approximately 20 000 people in the UK). Diagnostic and predictive genetic tests are now possible for 80% of MODY families. Diagnostic tests can be helpful as the diagnosis can be confirmed and the subtype defined which has implications for treatment and prognosis. However predictive genetic testing, particularly in children, raises many scientific, ethical and practical questions.

Methods  This is a case report of a family with diabetes resulting from an hepatic nuclear factor (HNF)1α mutation, who request a predictive test in their 5‐year‐old daughter. The scientific issues arising from molecular genetic testing in MODY are discussed, along with the process of genetic counselling. The views of the family and the clinical genetics team involved are presented.

Results  The implications of positive and negative predictive test results and the possibility of postponing the test were among many issues discussed during genetic counselling. The family remained convinced the test was appropriate for their daughter and the clinical genetics team fully supported this decision. The family, motivated by their family history of diabetes and personal experiences of the disease, wished to reduce uncertainty about their daughter's future irrespective of the result.

Conclusions  This case emphasizes that decisions on predictive testing are very personal and require appropriate counselling.
Peritoneal dialysis: new developments and new problems
Authors: Gradden C. W. , Ahmad R. , Bell G. M.
Published: March 2003

SUMMARY

Aims  To ascertain the incidence of hyponatraemia, and the impact of an icodextrin‐based dialysis solution regime on hyponatraemia, in diabetic and non‐diabetic patients using peritoneal dialysis (PD).

Methods  Following severe hyponatraemia, resulting in neurological sequelae, in two diabetic patients who were on icodextrin‐based PD for established renal failure, we reviewed the results of all our PD patients. Data was gathered retrospectively, from our database and case notes, on plasma sodium, haematocrit, dry weight estimation, plasma albumin and residual renal function. Patients using icodextrin‐based solutions were compared with a random selection of patients using dextrose‐based peritoneal solutions. We also compared diabetic patients on and off icodextrin with their non‐diabetic counterparts using the same dialysis regime. The data were analysed using the paired Student's t‐test.

Results  Plasma sodium was significantly lower in all patients using icodextrin‐based solutions compared with those patients on dextrose‐based PD. Plasma sodium was also found to fall in all patients following the initiation of an icodextrin‐based PD regime. The fall in plasma sodium was statistically significant in diabetic and non‐diabetic patients, but only fell below the laboratory reference range in the diabetic patients.

Conclusions  Icodextrin‐based PD is a risk factor for hyponatraemia and may produce clinically relevant symptoms if, as in our two cases, the hyponatraemia is compounded by other factors.
What is hypertension in diabetes? Ambulatory blood pressure in 137 normotensive and normoalbuminuric Type 1 diabetic patients
Authors: Hansen K. W. , Poulsen P. L. , Ebbehøj E. , Mogensen C. E.
Published: March 2003

SUMMARY

Aims  To establish reference data for ambulatory blood pressure (AMBP) in normotensive, normoalbuminuric Type 1 diabetic patients and characterize the relation to clinic blood pressure (BP). To evaluate the statement of the third working party of the British Hypertension Society (BHS) that a target clinic BP in diabetes < 140/80 corresponds to a target day‐time AMBP < 130/75 mmHg.

Patients and Methods  AMBP were performed in 172 normoalbuminuric, adult Type 1 diabetic patients, who had never received anti‐hypertensive drugs. Clinic BP was determined as the mean of at least three auscultatory (Hawskley random zero manometer) and as the mean of at least three oscillometric (Spacelabs) BP values obtained just prior to ambulatory monitoring. Five patients with more than three missing hours/24 h were excluded.

Results  For 30 patients auscultatory clinic BP exceeded 140 mmHg systolic and/or 90 mmHg diastolic. For the remaining 137 normotensive patients day‐time AMBP was 125.7/77.2 mmHg and oscillometric clinic BP was 125.3/76.5 mmHg (mean difference 0.3/0.7 mmHg; 95% confidence interval (CI) −0.9 to 1.5/−0.3 to 1.7 mmHg, P = 0.6/P = 0.2). Sixty‐five percent of the patients had a diastolic day‐time AMBP > 75 mmHg.

Conclusions  Clinic BP and day‐time AMBP measured by the same method were indistinguishable. The target for day‐time diastolic AMBP (< 75 mmHg) proposed by the BHS is too low and is based on the misconception that in normotensive subjects day‐time AMBP is lower than clinic BP. If the BHS guidelines are strictly adhered to, the consequence may be overtreatment in patients with normoalbuminuria and no end organ damage.
Low prevalence of cardiac autonomic neuropathy in Type 1 diabetic patients without nephropathy
Authors: Meinhold J. A. , Maslowska‐Wessel E. , Bender R. , Sawicki P. T.
Published: March 2003

Aim To assess the prevalence of cardiac autonomic neuropathy (CAN) in Type 1 diabetic patients with and without nephropathy.

Methods  Sixty‐six consecutive patients without nephropathy (n = 24), with incipient (n = 26) or overt nephropathy (n = 16) and a diabetes duration between 21 and 31 years were examined. Heart rate variability (HRV) as measure for CAN was investigated with short‐term spectral analysis in the low‐frequency (LF) band (0.06–0.15 Hz), reflecting sympathetic and vagal activity, and high‐frequency (HF) band (0.15–0.50 Hz), reflecting vagal activity. HRV was expressed as spectral power (ms2, log‐transformed). Normal, age‐corresponding reference values were established in 184 controls. QTc intervals and dispersion were measured.

Results  After adjustment for age, there was no significant difference between healthy controls and patients without nephropathy. After further adjustment for diabetes duration, HbA1c, hypertension and treatment with β‐blockers, HRV in both frequency bands decreased with evidence of nephropathy. LF band (supine): patients without nephropathy 5.56 (4.89–6.21) (least squares means and 95% confidence interval (CI)), incipient nephropathy 5.72 (5.15–6.29) and overt nephropathy 4.11 (3.27–4.96). HF band (supine): without nephropathy 5.93 (5.26–6.60), incipient nephropathy 5.99 (5.41–6.57) and overt nephropathy 4.84 (4.00–5.68). Significant differences were found for patients without and with incipient nephropathy compared with those with overt nephropathy in the LF band and between patients with incipient nephropathy compared with those with overt nephropathy in the HF band. QTc intervals and QTc dispersion increased significantly with increasing nephropathy.

Conclusions Long‐term Type 1 diabetes without nephropathy was not associated with impaired cardiac autonomic function in our study. However, in those with nephropathy, a loss of both vagal and sympathetic activity was present, and the severity of CAN correlated positively with more advanced nephropathy.

Diabet. Med. 18, 607–613 (2001)
Association of macular involvement with proliferative retinopathy in Type 2 diabetes
Authors: Tong L. , Vernon S. A. , Kiel W. , Sung V. , Orr G. M.
Published: March 2003

SUMMARY

Aims  To determine whether documented evidence of pre‐existing maculopathy is present in Type 2 diabetic patients who require photocoagulation or vitrectomy for proliferative disease. This is a retrospective case notes review.

Methods  The study was performed at Queen's Medical Centre, UK. All patients listed in the laser register and operating theatre register over 5 years (March 1994 to March 1999) who had undergone pan retinal photocoagulation (PRP) for diabetic retinopathy, in one consultant firm, were studied. The medical records of patients who had undergone vitrectomy as their first treatment for proliferative diabetic retinopathy in a vitreo‐retinal firm over the 5 years were examined. The proportion of patients with documented maculopathy before development of proliferative retinopathy was determined.

Results  All except 1/134 or 0.7% (95% confidence interval 0.1–4.5%) patients had documentation of macular signs in at least one eye prior to the patient's first session of PRP. Of the remaining 133, 104 (78%) had had focal or grid photocoagulation of the macula. The median time between the documentation of maculopathy before the first PRP treatment session was 16 months (interquartile range 7–36). Fourteen patients had vitrectomy and endolaser performed as the initial treatment for proliferative disease. All patients had documented maculopathy before the onset of proliferative disease.

Conclusions  The results of this study suggest that in Type 2 diabetes, proliferative disease occurs relatively late compared with maculopathy. In such patients, maculopathy is almost invariably present when proliferative disease is detected.