The predictors of foot ulceration in patients with rheumatoid arthritis: a preliminary investigation

We explored the predictors of foot ulceration in patients with rheumatoid arthritis (RA). The cases were 15 patients with RA reporting foot ulceration in response to a postal survey of patients sampled from a diagnostic register in secondary care (n = 1,130). The controls were 66 patients with RA randomly sampled from the survey respondents (n = 883) after matching for age, sex and disease duration. Patients with co-existent diabetes were excluded. Clinical examination included the assessment of known risk factors for foot ulceration in diabetes including: neuropathy (insensitivity to 10 g monofilament), peripheral vascular disease (ankle brachial pressure index [ABPI]), foot deformity (Platto indices) and raised plantar pressure (PressureStat™ readings). A 44 swollen-joint count, the presence of pre-ulcerative lesions and current steroid therapy were identified through univariate analysis as additional potential predictors in patients with RA. Forward step-wise logistic regression analysis showed that the following variables were significant predictors of ulceration: steroid therapy (OR = 9.70, 95%CI = 2.09–45.11, p = 0.004), abnormal ABPI (OR = 13.45, 95%CI = 1.19–151.43, p = 0.035), the presence of pre-ulcerative lesions (OR = 7.40, 95%CI = 1.51–36.30, p = 0.014) and swollen-joint count (OR = 1.25, 95%CI = 1.02–1.53, p = 0.034). Abnormal sensation, foot deformity and raised plantar pressures were not significant predictors of ulceration. The wide confidence intervals for ABPI were due to sparse data with very few abnormal values, and the results of exact logistic regression (more accurate where data is sparse and case matching employed) found that ABPI was no longer a significant predictor (p = 0.054). The significance of the other predictors did not differ substantially. In this preliminary study, abnormal sensation, foot deformity and raised plantar pressures were not significantly associated with foot ulceration but active disease and current steroid therapy were. The contribution of peripheral vascular disease to risk is unclear and further investigation is needed in a larger cohort.     

Lipoprotein receptor associated protein (LRPAP1) insertion/deletion polymorphism: association with gallbladder cancer susceptibility

Background Low-density lipoprotein receptor-related protein associated protein (LRPAP1) insertion/deletion polymorphism influences cholesterol homeostasis and may confer risk for gallstone disease and gallbladder carcinoma (GBC) incidence usually parallels with the prevalence of cholelithiosis. Aim We aimed to examine the role of LRPAP1 polymorphism in susceptibility to GBC. Methods Present case control study included 129 proven GBC patients, 183 gallstone patients, and 208 healthy controls. Genotyping was done by polymerase chain reaction–restriction fragment length polymorphism method. Results The D allele of LRPAP1 was significantly higher in GBC patients as compared to gallstone patients (p = 0.013; OR = 1.6, 95% CI = 1.1–2.4). However, II genotype and I allele was associated with reduced risk of GBC as compared to gallstone patients (p = 0.002; OR = 0.1, 95% CI = 0.1–0.6; p = 0.013; OR = 0.6, 95% CI = 0.4–0.8) The increased risk due to D allele was limited to female GBC patients (p = 0.021; OR = 1.8, 95% CI = 1.1–3.0). However, reduced risk due to II genotype and I allele was observed which was also confined to female GBC patients (p = 0.005; OR = 0.1, 95% CI = 0.1–0.6; p = 0.021; OR = 0.5, 95% CI = 0.3–0.8). On comparing GBC patients having gallstone with gallstone patients, high risk was observed in the GBC patients having gallstone due to the presence of D allele (p = 0.032; OR = 1.7, 95% CI = 1.0–2.8). However, low risk was observed because of I allele in GBC patients with gallstone in comparison to gallstone patients (p = 0.032, OR = 0.6, 95% CI = 0.4–0.9). Conclusion It appears that ‘D’ allele may modulate the susceptibility of GBC, and the risk is independent to genetic risk of gallstone.     

Incidence,consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study

Background Anastomotic dehiscence is the most severe surgical complication after large bowel resection. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with anastomotic leakage after colorectal surgery. Materials and methods All procedures involving anastomoses of the colon or the rectum, which were performed between November 2002 and February 2006 in a single institution, were prospectively entered into a computerized database. Results One thousand eighteen colorectal resections and 811 anastomoses were performed over this 40-month period. The most frequent procedures were sigmoid (276) and right colectomies (217). The overall anastomotic leak rate was 3.8%. The mortality rate associated with anastomotic leak was 12.9%. In univariate analysis, the following parameters were associated with an increased risk for anastomotic dehiscence: (1) ASA score ≥ 3 (p = 0.004), (2) prolonged (>3 h) operative time (p = 0.02), (3) rectal location of the disease (p < 0.001), (4) and a body mass index > 25 (p = 0.04). In multivariate analysis, ASA score ≥ 3 (OR = 2.5; 95% CI 1.5–4.3, p < 0.001), operative time > 3 h [OR = 3.0; 95% CI 1.1–8.0, p = 0.02), and rectal location of the disease (OR = 3.75; 95% CI 1.5–9.0 (vs left colon), p = 0.003; OR = 7.69; 95% CI 2.2–27.3 (vs right colon), p = 0.001] were factors significantly associated with a higher risk of anastomotic dehiscence. Conclusions Three risk factors for anastomotic leak have been identified, one is patient-related (ASA score), one is disease-related (rectal location), the third being surgery-related (prolonged operative time). These factors should be considered in perioperative decision-making regarding defunctioning stoma formation.     

HLA class 1 associations in Henoch Schonlein purpura: increased and decreased frequencies

Henoch Schonlein purpura (HSP) is the most common vasculitis of childhood. Susceptibility to HSP and associated clinical heterogeneity in HSP may be conferred by a number of genetic loci, including the major histocompatibility complex. We aimed to investigate the implications of the human leukocyte antigen (HLA) class 1 alleles in susceptibility to HSP and determine the possible associations with renal, gastrointestinal (GI), and joint manifestations of the disease. 110 children with HSP (66 boys, 44 girls) and 250 unrelated healthy controls were enrolled in the study. The mean age was 8.65 ± 3.59 years. HSP was diagnosed on the basis of clinical and laboratory data according to the American College of Rheumatology classification. The diagnosis was supported with skin and/or kidney in most of the patients. Clinical and laboratory findings revealed: skin involvement in 110 (100%), joint manifestations in 82 (74.5%), GI symptoms in 58 (52.7%), and hematuria and/or proteinuria in 36 (32.7%) patients. HLA class 1 alleles were identified by DNA amplification, hybridized with specific primer sequences. Comparison of frequencies between patients and controls were made by using the Fisher’s exact test. Odds ratio (OR) was used as the measure of association. HLA A2, A11, and B35 antigens showed an increased risk for predisposition to HSP (OR = 1.714, 95%CI = 1.088–2.700, p = 0.020; OR = 2.185, 95%CI = 1.289–3.703, p = 0.003; and OR = 2.292, 95%CI = 1.451–3.619, p = 0.000, respectively), while HLA A1, B49, and B50 antigens revealed decreased risk for predisposition to HSP (OR = 4.739, 95%CI = 1.828–12.345, p = 0.001; OR = 3.268, 95%CI = 0.955–11.236, p = 0.047; and OR = 7.462, 95%CI = 0.975–55.555, p = 0.024, respectively). Considering the renal involvement and severity of proteinuria, there was no association with HLA class 1 alleles. Our results suggest that the increased frequency of HLA A2, A11, and B35 alleles in unselected pediatric HSP patient population and miscarrying of HLA A1, B49, and B50 could be considered as a risk factor for susceptibility to HSP.     

The effect of smoking after surgery for Crohn’s disease: a meta-analysis of observational studies

Objective  The aim of the study was to quantify the risk of disease recurrence associated with cigarette smoking for individuals with Crohn’s disease after disease-modifying surgery. Design  Meta-analysis of observational studies. Data sources  Medline, Embase, Ovid and the Cochrane database. Materials and methods  A literature search was performed to identify studies published between 1966 and 2007 comparing outcomes of smokers, ex-smokers and non-smokers with Crohn’s disease. Random-effect meta-analytical techniques were employed to assess the risk of medical or surgical recurrence. Results  Sixteen studies encompassing 2,962 patients including 1,425 non-smokers (48.1%), 1,393 smokers (47.0%) and 137 ex-smokers (4.6%) were included. Smokers had significantly higher clinical post-operative recurrence than non-smokers (odds ratio [OR] = 2.15; 95%CI = 1.42, 3.27; p < 0.001). Smokers were also more likely to experience surgical recurrence by 5 (OR = 1.06; 95%CI = 0.32; 3.53, p = 0.04) and 10 years of follow-up (OR = 2.56; 95%CI = 1.79, 3.67; p < 0.001) compared to non-smokers, although the crude re-operation rate was not statistically significant. When matched for operation and disease site, smokers had significantly higher re-operation rates to non-smokers (OR = 2.3; 95%CI = 1.29, 4.08; p = 0.005). There was no significant difference between ex-smokers and non-smokers in re-operation rate at 10 years (OR = 0.30; 95%CI = 0.09, 1.07; p = 0.10) or in post-operative acute relapses (OR = 1.54; 95%CI = 0.78, 3.02; p = 0.21). Conclusions  Patients with Crohn’s disease who smoke have a 2.5-fold increased risk of surgical recurrence and a twofold risk of clinical recurrence compared to non-smokers. Patients with Crohn’s disease should be encouraged to stop smoking since the risk of disease relapse is minimised upon its cessation. George E. Reese and Theodore Nanidis with equal contribution.     

Caregiver Time and Cost of Home Care for Alzheimer’s Disease: A Clinic-based Observational Study in Beijing,China

This cross-sectional study was conducted to estimate the caregiver time and calculate the cost of informal care for AD, and to explore the potential predictors of caregiver time. Seventy-one community-dwelling AD patient-caregiver dyads completed the assessment and questionnaire. AD patients were assessed with Mini-mental status examination (MMSE), activities of daily living (ADL), and Neuropsychiatric Inventory (NPI). Caregiver time was recorded using the Resource Utilization in Dementia (RUD). According to the MMSE score, subjects were classified as mild (n = 18), moderate (n = 43), and severe (n = 10) groups. The PADL care time was significantly different among three groups, with highest in severe group (172.5 ± 208.0 h/month), and least in mild group (24.9 ± 70.5 h/month) (F = 5.215, df = 2, P = 0.008). The supervision time was higher in severe group compared to mild group (F = 3.330, df = 2, P = 0.042), while there were no differences between mild and moderate groups, and between moderate and severe groups. There was no difference in IADL caregiver time among three groups. The estimated annual cost of PADL care ranged from 903 USD (mild) to 6,259 USD (severe), IADL care from 4042USD to 7645USD, and supervision from 871 USD to 6,172 USD. Stepwise logistic regression analysis showed that MMSE score was significant predictor of PADL care time. For every one unit increase in MMSE, the odds of PADL care time decrease by a factor of 0.791 (χ2 = 13.628, P = 0.000). Spouse caregivers significantly predict greater IADL care time (OR = 4.469, 95%CI = 1.248–15.999, P = 0.021), and male caregiver was a protector for IADL care time (OR = 0.157, 95%CI = 0.040–0.609, P = 0.007). The ADL score was a significant predictor of supervision time. For every one unit increase in ADL, the odds of supervision time increase by a factor of 1.132 (95%CI = 1.055–1.215, P = 0.001). Higher educational level of the patient predicted decrease in supervision time (OR = 0.888, 95%CI = 0.794–0.994, P = 0.038). Caregiver time and cost of home care for AD was substantial in China. Care time of PADL increased with the progression of cognitive decline. The IADL care time was strongly influenced by the biographical characteristics of caregivers. Supervision was mostly predicted by the functional status of the patient.     

Risk factors for mortality–morbidity after emergency–urgent colorectal surgery

Background  The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery. Materials and methods  All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database. Results  The median age of patients was 73 (range 17–98) years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500 cm³ (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63–6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score ≥3 (OR = 2.9, 95% CI 1.9–4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4–7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4–3.4, p = 0.0003). Conclusions  The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients’ ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.     

The relationship between physical activity level,anxiety, depression,and functional ability in children and adolescents with juvenile idiopathic arthritis

The aim of this study was to assess the relationships between physical activity level and anxiety, depression, and functional ability in children and adolescents with juvenile idiopathic arthritis (JIA). Cross-sectional study design including patients with JIA aged between 8 and 17 years and healthy controls was used. Sociodemographic data and clinical features were assessed. Physical activity level and energy expenditure were assessed with a 1-day activity diary. Anxiety was screened by The Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire. Depressive symptoms were assessed by the Children’s Depression Inventory (CDI). Functional ability was assessed with the Childhood Health Assessment Questionnaire (CHAQ). Pain and overall well-being were measured using a visual analog scale (VAS). Fifty-two patients and 48 controls were included with a mean age of 12.13 ± 2.92 and 11.27 ± 1.59 years, respectively. The mean disease duration was 64 months. The JIA group had significantly less time in physical activity (p = 0.000), decrease in energy expenditure (p = 0.04), and higher CHAQ scores (p = 0.000) compared with the control group. In the JIA group, significant relationships were found between the number of active joint and disease duration (r = 0.44, p = 0.000) and VAS pain (r = 0.30, p = 0.02), between SCARED and CDI (r = 0.54, p = 0.000). Significant relationships were found between VAS overall well-being and CDI (r = 0.29, p = 0.03), CHAQ (r = 0.37, p = 0.000), and VAS pain (r = 0.41, p = 0.000). Correlation between CHAQ and CDI (r = 0.34, p = 0.01) was significant. The result of our study suggested that only depression was related to anxiety, functional ability, and well-being in children and adolescents with JIA.     

An association analysis of the HLA gene region in latent autoimmune diabetes in adults

Aims/hypothesis Pathophysiological similarities between latent autoimmune diabetes in adults (LADA) and type 1 diabetes indicate an overlap in genetic susceptibility. HLA-DRB1 and HLA-DQB1 are major susceptibility genes for type 1 diabetes but studies of these genes in LADA have been limited. Our aim was to define patterns of HLA-encoded susceptibility/protection in a large, well characterised LADA cohort, and to establish association with disease and age at diagnosis. Materials and methods Patients with LADA (n = 387, including 211 patients from the UK Prospective Diabetes Study) and non-diabetic control subjects (n = 327) were of British/Irish European origin. The HLA-DRB1 and -DQB1 genes were genotyped by sequence-specific PCR. Results As in type 1 diabetes mellitus, DRB1*0301_DQB1*0201 (odds ratio [OR] = 3.08, 95% CI 2.32–4.12, p = 1.2 × 10⁻¹⁶) and DRB1*0401_DQB1*0302 (OR = 2.57, 95% CI 1.80–3.73, p = 4.5 × 10⁻⁸) were the main susceptibility haplotypes in LADA, and DRB1*1501_DQB1*0602 was protective (OR = 0.21, 95% CI 0.13–0.34, p = 4.2 × 10⁻¹³). Differential susceptibility was conferred by DR4 subtypes: DRB1*0401 was predisposing (OR = 1.79, 95% CI 1.35–2.38, p = 2.7 × 10⁻⁵) whereas DRB1*0403 was protective (OR = 0.37, 95% CI 0.13–0.97, p = 0.033). The highest-risk genotypes were DRB1*0301/DRB1*0401 and DQB1*0201/DQB1*0302 (OR = 5.14, 95% CI 2.68–10.69, p = 1.3 × 10⁻⁸; and OR = 6.88, 95% CI 3.54–14.68, p = 1.2 × 10⁻¹¹, respectively). These genotypes and those containing DRB1*0401 and DQB1*0302 associated with a younger age at diagnosis in LADA, whereas genotypes containing DRB1*1501 and DQB1*0602 associated with an older age at diagnosis. Conclusions/interpretation Patterns of susceptibility at the HLA-DRB1 and HLA-DQB1 loci in LADA are similar to those reported for type 1 diabetes, supporting the hypothesis that autoimmune diabetes occurring in adults is an age-related extension of the pathophysiological process presenting as childhood-onset type 1 diabetes. Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible to authorised users.     

Study of 18 functional hemostatic polymorphisms in mucocutaneous bleeding disorders

Hereditary disorders of primary hemostasis, characterized by mucocutaneous bleeding (MCB), are highly prevalent in children. Few cases are clearly monogenic, but the overwhelming majority are classified as mild bleeding disorders, with wide clinical and laboratory heterogeneity suggestive of complex polygenic diseases. In this framework, and by homology with venous thrombosis, some functional polymorphisms affecting the hemostatic system should be considered. We evaluated the role of 18 common hemostatic polymorphisms on the occurrence and severity of MCB in a case–control study including 269 patients and 286 matched controls consecutively recruited. FV Leiden was associated with milder bleeding severity, assessed by a standardized bleeding score (p = 0.013). Multivariate analysis revealed that three additional polymorphisms protected against MCB (F13 Leu34, OR = 0.66; 95% CI, 0.47–0.94; p = 0.024; VKORC1 1173T, OR = 0.59; 95% CI, 0.40–0.87; p = 0.009; and non-O blood group alleles, OR = 0.59; 95% CI, 0.41–0.86; p = 0.006). When combined, these polymorphisms showed an additive protection (OR = 0.24; 95% CI, 0.11–0.52), supporting the polygenic nature of MCB. Our data suggest that some common polymorphisms affecting hemostasis-related genes could protect from bleeding.     

Caspase-3 activity, response to chemotherapy and clinical outcome in patients with colon cancer

Background and aims The prognostic value of the degree of apoptosis in colorectal cancer is controversial. This study evaluates the putative clinical usefulness of measuring caspase-3 activity as a prognostic factor in colonic cancer patients receiving 5-fluoracil adjuvant chemotherapy. Materials and methods We evaluated caspase-3-like protease activity in tumours and in normal colon tissue. Specimens were studied from 54 patients. These patients had either stage III cancer (Dukes stage C) or high-risk stage II cancer (Dukes stage B2 with invasion of adjacent organs, lymphatic or vascular infiltration or carcinoembryonic antigen [CEA] > 5). Median follow-up was 73 months. Univariate analysis was performed previously to explore the relation of different variables (age, sex, preoperative CEA, tumour size, Dukes stage, vascular invasion, lymphatic invasion, caspase-3 activity in tumour and caspase-3 activity in normal mucosa) as prognostic factors of tumour recurrence after chemotherapy treatment. Subsequently, a multivariate Cox regression model was performed. Results Median values of caspase-3 activity in tumours were more than twice those in normal mucosa (88.1 vs 40.6 U, p = 0.001), showing a statistically significant correlation (r = 0.34). Significant prognostic factors of recurrence in multivariate analysis were: male sex (odds ratio, OR = 3.53 [1.13–10.90], p = 0.02), age (OR = 1.09 [1.01–1.18], p = 0.03), Dukes stage (OR = 1.93 [1.01–3.70]), caspase-3 activity in normal mucosa (OR = 1.02 [1.01–1.04], p = 0.017) and caspase-3 activity in tumour (OR = 1.02 [1.01–1.03], p = 0.013). Conclusion Low caspase-3 activity in the normal mucosa and tumour are independent prognostic factors of tumour recurrence in patients receiving adjuvant 5-fluoracil-based treatment in colon cancer, correlating with poor disease-free survival and higher recurrence rate.     

Reticulated platelet levels in patients with ulcerative colitis

Background and aims In this study, we investigated whether reticulated platelets (RP) would be useful markers in the evaluation of ulcerative colitis (UC) activity and also aimed to gain indirect information about the platelet kinetics. Materials and methods Complete blood count, C-reactive protein, erythrocyte sedimentation rate, and proportion of RP were measured in 16 active, 21 inactive UC patients, and 20 healthy blood donors. UC activity was assessed by Truelove–Witts criteria. Results Mean platelet count was increased in patients with active compared to inactive UC (p = 0.008) or healthy donors (p = 0.000). Mean platelet volume (MPV) was significantly decreased in patients with active compared to inactive (p = 0.015) and healthy donors (p = 0.001). RP values was significantly decreased in active and inactive UC groups compared to healthy donors (p = 0.000, p = 0.000, respectively), while there was no significant difference between active and inactive UC patients (p = 0.980). Significant negative correlation between platelet count and MPV in patients with active UC (r = −0.542, p = 0.030) was observed. Conclusions RP values is reduced in active and inactive UC patients compared to healthy donors. To our knowledge, this is the first study about proportion of RP with UC in literature. However, the role of low RP values have not been determined clinically. Further studies are needed to evaluate the role of platelet abnormalities and changes in megakaryopoiesis caused by inflammatory state on low MPV and RP values during the course of UC.     

IgG subclass serum levels in systemic lupus erythematosus patients

IgG subclass levels of sera from 105 patients with systemic lupus erythematosus (SLE) were determined by immunonephelometric assay. Patients were divided into two groups according to clinical activity of the disease: active disease and remission. Forty-five normal controls were also measured. We found a significant increase of IgG1 (p = 0.000), IgG2 (p = 0.000), and IgG3 (p = 0.000) in SLE sera, while IgG4 (p = 0.494) values did not differ significantly from those of controls. When patients were divided according to clinical activity, decrease of IgG3 concentration was observed in the patients in remission. In contrast, the concentrations of IgG1, IgG2, and IgG4 subclass were similar between the two groups (p > 0.05). Our data suggest that differential increase of IgG subclasses during the course of SLE may be of relevance to the pathogenesis of the disease.     

Faecal calprotectin in colonic diverticular disease: a case–control study

Background and aims  Information about faecal calprotectin (FC) in colonic diverticular disease (DD) are lacking. We assessed FC in colonic DD, comparing it with irritable bowel syndrome (IBS) patients and healthy controls. Moreover, we compared FC levels in different degrees of DD and assessed FC in symptomatic DD before and after treatment. Materials and methods  Forty-eight consecutive patients with a new endoscopic diagnosis of DD (16 with asymptomatic diverticulosis, 16 with symptomatic uncomplicated DD, 16 with acute uncomplicated diverticulitis), 16 healthy controls, and 16 IBS patients were studied. FC was assessed by semi-quantitative method and compared with histological inflammation. Moreover, FC was reassessed in symptomatic DD after 8 weeks of treatment. Results/findings  FC was not increased in healthy controls and IBS patients. No difference was found between asymptomatic diverticulosis, healthy controls, and IBS patients (p = n.s.). We found higher FC values in acute uncomplicated diverticulitis (p < 0.0005) and in symptomatic uncomplicated DD (p < 0.005) than in healthy controls and in IBS patients. FC values correlated with inflammatory infiltrate (p < 0.0005). FC decreased after treatment to normal values both in acute uncomplicated diverticulitis (p < 0.0005) and in symptomatic uncomplicated DD (p < 0.005) after treatment. Interpretations/conclusions  FC may be useful to detect colonic inflammation in DD and in distinguishing symptomatic DD from IBS, as well as in assessing response to therapy in DD.     

Community Volunteerism of US Physicians

Background  Many physicians and professional leaders agree that community participation is an important professional role for physicians. Volunteerism has also received increasing attention in the national agenda for social change. Yet little is known about physicians’ community volunteer activities. Objective  To measure levels of community volunteerism among US physicians. Design and Participants  Analysis of the 2003 Current Population Survey (CPS) Volunteer Supplement, a cross-sectional, nationally-representative, in-person and telephone survey of 84,077 adult citizens, including 316 physicians. Measurements  The primary outcome was whether the respondent had volunteered in the prior 12 months and if so the total number of hours. The level of community volunteer activity was compared between physicians, lawyers and the general public. In addition, predictors of physician volunteerism were identified. Results  According to the survey, 39% of physicians had volunteered in their community in the past 12 months compared to 30% of the general public (p = 0.002) and 57% of lawyers (p < 0.001). After multivariate adjustment, physicians were half as likely as the general public (OR = 0.52, p < 0.001) or lawyers (OR = 0.44, p < 0.001) to have volunteered. Physicians were more likely to have volunteered if they worked part-time (OR = 3.35, p = 0.03), variable hours (OR = 3.16, p = 0.03), or between 45–54 hours per week (OR = 3.15, p = 0.02) compared to a 35–44 hour work week. Conclusions  Despite highly favorable physician attitudes toward volunteerism in prior surveys, less than half of US physicians have volunteered with community organizations in the past year. Renewed attention to understanding and increasing physician engagement in community volunteer work is needed.     

Variations in the Associations Between Psychiatric Comorbidity and Hospital Mortality According to the Method of Identifying Psychiatric Diagnoses

Summary Objective Little is known about associations between psychiatric comorbidity and hospital mortality for acute medical conditions. This study examined if associations varied according to the method of identifying psychiatric comorbidity and agreement between the different methods. Patients/Participants The sample included 31,218 consecutive admissions to 168 Veterans Affairs facilities in 2004 with a principle diagnosis of congestive heart failure (CHF) or pneumonia. Psychiatric comorbidity was identified by: (1) secondary diagnosis codes from index admission, (2) prior outpatient diagnosis codes, (3) and prior mental health clinic visits. Generalized estimating equations (GEE) adjusted in-hospital mortality for demographics, comorbidity, and severity of illness, as measured by laboratory data. Measurements and Main Results Rates of psychiatric comorbidities were 9.0% using inpatient diagnosis codes, 27.4% using outpatient diagnosis codes, and 31.0% using mental health visits for CHF and 14.5%, 33.1%, and 34.1%, respectively, for pneumonia. Agreement was highest for outpatient codes and mental health visits (κ = 0.51 for pneumonia and 0.50 for CHF). In GEE analyses, the adjusted odds of death for patients with psychiatric comorbidity were lower when such comorbidity was identified by mental health visits for both pneumonia (odds ratio [OR] = 0.85; P = .009) and CHF (OR = 0.70; P < .001) and by inpatient diagnosis for pneumonia (OR = 0.63; P ≤ .001) but not for CHF (OR = 0.75; P = .128). The odds of death were similar (P > .2) for psychiatric comorbidity as identified by outpatient codes for pneumonia (OR = 1.04) and CHF (OR = 0.93). Conclusions The method used to identify psychiatric comorbidities in acute medical populations has a strong influence on the rates of identification and the associations between psychiatric illnesses with hospital mortality.     

Low hepatic stearoyl-CoA desaturase 1 activity is associated with fatty liver and insulin resistance in obese humans

Aims/hypothesis Stearoyl-CoA desaturase 1 (SCD1) is the rate-limiting enzyme in monounsaturated fatty acid synthesis. It is imperative for the assembly of VLDL particles, which transport triacylglycerol (TG) from liver to adipose tissue and other sites. We aimed to determine the role of hepatic SCD1 activity in human glucose and lipid metabolism. Methods We studied 54 people participating in a lifestyle intervention programme with diet modification and increased physical activity. Insulin sensitivity was determined during a euglycaemic–hyperinsulinaemic clamp and estimated from an OGTT. Liver fat was quantified by ¹H-magnetic resonance spectroscopy at baseline and after 9 months of intervention. The pattern of fatty acids in serum VLDL-TGs was determined by ultracentrifugation followed by thin layer and gas chromatography, with the 18:1 n-9: 18:0 ratio providing an index of hepatic SCD1 activity. Results The hepatic SCD1 activity index correlated negatively with liver fat (r = −0.29, p = 0.04) and positively with insulin sensitivity, both OGTT-derived (r = 0.42, p = 0.003) and clamp-derived (r = 0.27, p = 0.07). These correlations depended on overall adiposity. They were absent in leaner participants (n = 27, liver fat: p = 0.34, insulin sensitivity [OGTT]: p = 0.75, insulin sensitivity [clamp]: p = 0.24), but were strong in obese individuals (n = 27, p = 0.004, p = 0.0002 and p = 0.006, respectively). Furthermore, during intervention a high SCD1 activity index at baseline predicted a decrease in liver fat only in obese participants (r = −0.46, p = 0.02). Conclusions/interpretation Our data suggest that high hepatic SCD1 activity may regulate fat accumulation in the liver and possibly protects from insulin resistance in obesity. N. Stefan and A. Peter contributed equally to this work.     

Pregnancy plasma glucose levels exceeding the American Diabetes Association thresholds,but below the National Diabetes Data Group thresholds for gestational diabetes mellitus,are related to the risk of neonatal macrosomia,hypoglycaemia and hyperbilirubinaemia

Aims/hypothesis Gestational diabetes mellitus (GDM) is a risk factor for perinatal complications. In several countries, the criteria for the diagnosis of GDM have been in flux, the American Diabetes Association (ADA) thresholds recommended in 2000 being lower than those of the National Diabetes Data Group (NDDG) that have been in use since 1979. We sought to determine the extent to which infants of women meeting only the ADA criteria for GDM are at increased risk of neonatal complications. Materials and methods In a multiethnic cohort of 45,245 women who did not meet the NDDG criteria and were not treated for GDM, we conducted nested case–control studies of three complications of GDM that occurred in their infants: macrosomia (birthweight >4,500 g, n = 494); hypoglycaemia (plasma glucose <2.2 mmo/l, n = 488); and hyperbilirubinaemia (serum bilirubin ≥342 μmol/l (20 mg/dl), n = 578). We compared prenatal glucose levels of the mothers of these infants and mothers of 884 control infants. Results Women with GDM by ADA criteria only (two or more glucose values exceeding the threshold) had an increased risk of having an infant with macrosomia (odds ratio OR = 3.40, 95% CI = 1.55–7.43), hypoglycaemia (OR = 2.61, 95% CI = 0.99–6.92) or hyperbilirubinaemia (OR = 2.22, 95% CI = 0.98–5.04). Glucose levels 1 h after the 100-g glucose challenge that exceeded the ADA threshold were particularly strongly associated with each complication. Conclusions/interpretation These results lend support to the ADA recommendations and highlight the importance of the 1-h glucose measurement in a diagnostic test for GDM.     

Long-term follow-up of allogeneic HSCT for CML reveals significant improvement in the outcome over the last decade

Allogeneic hematopoetic stem cell transplantation (HSCT) is still the only curative therapeutic option for chronic myelogenous leukemia (CML). To examine the development of allogeneic HSCT at our center over the past two decades (decade 1: 1984–1994; decade 2: 1995–2005), all CML patients transplanted in first chronic phase (n = 234) were analyzed with respect to patient characteristics, overall survival, transplant-related mortality (TRM), and relapse incidence. The median follow up time was 54 months (range 1–218). The incidence of acute graft vs host disease (GvHD) °II–IV and extensive chronic GvHD were not different between the two decades (p = 0.894 and p = 0.422, respectively). There was also no difference in the relapse incidence (23 vs 26%, p = 0.869). One-year TRM and overall survival were improved in the later decade (33 vs 18%, p = 0.011 and 62 vs 73% at 5 years, p = 0.063, respectively). The major reason for improved outcome in decade 2 was the improved management of acute GvHD and infections in the early phase after transplantation (p = 0.026). In conclusion, the past decade has seen significant improvement in the performance of allogeneic HSCT for CML.     

Abnormal surface markers expression on bone marrow CD34<Superscript>+</Superscript> cells and correlation with disease activity in patients with systemic lupus erythematosus

Defects of hematopoietic stem cells (HSCs) have been suggested to contribute to the development of systemic lupus erythematosus (SLE). The aim of this study was to investigate the phenotypic characteristics of bone marrow (BM) CD34⁺ cells in patients with SLE and its relationship with SLE disease activity. Ten SLE patients and 10 healthy subjects were recruited and their BM CD34⁺ cells were analyzed by flow cytometric analysis with CD45/SSC gating for the expression of CD90, CD95, CD117, CD123, CD164, CD166, FAS-L, and HLA-DR. The percentage of BM CD34⁺ cells was significantly decreased in active SLE patients (1.48 ± 0.41%, n = 7) compared to the healthy controls (2.31 ± 0.75%, n = 10, p < 0.01), but no significant difference was found between the inactive patients (2.04 ± 0.44%, n = 3) and the controls. The expression of CD95, CD123, and CD166 on BM CD34⁺ cells were significantly increased in SLE patients (48.31 ± 10.59%, 44.9 ± 21.5%, 30.9 ± 19.54%, respectively, n = 10) when compared with the control subjects (24.33 ± 11.1%, 19.5 ± 4.4%, 10.7 ± 5.5%, respectively, n = 10, p < 0.05). The increased CD123 expression was negatively correlated with the number of peripheral white blood cells (r = −0.700, p < 0.05, n = 10). The percentage of CD166 expression was found significantly correlated with the index of SLE disease activity (r = 0.472, p < 0.05, n = 10) and 24 h proteinuria (r = 0.558, p < 0.05, n = 10), but negatively correlated with serum C3 level (r = −0.712, p < 0.01, n = 10). Our study found that the surface marker expression of CD95, CD123, and CD166 on BM CD34⁺ cells were significantly increased in patients. This supports the hypothesis that there are abnormalities of the HSC in SLE. Since CD166 and CD123 correlated with the overall lupus activity, their role as a biomarker of inflammatory disease activity also requires further study.