The effectiveness of the ‘2‐week wait’ referral service for colorectal cancer

Introduction: The UK government target expects all suspected cancer patients to be seen within 2 weeks of referral made by general practitioners. This has significant impact on the workload for colorectal surgeons. The aim of this study was to investigate the effectiveness of this colorectal service. Method: A retrospective study of all patients referred to a 2‐week wait colorectal clinic over a 12‐month period was assessed, documenting diagnosis and staging. Comparison of patients diagnosed with colorectal cancer (CRC) presenting via other routes in the same period was made. Results: Over the 12‐month period, all 1100 patients were seen in the 2‐week wait clinic; 938 (85%) patients fulfilled the referral criteria, but only 81 (7.3%) were diagnosed with cancer. Conversely, 136 CRC patients presented to the surgeons via urgent referrals (n = 86), emergency (n = 13), routine colorectal clinic (n = 19) and bowel screening (n = 18). The 2‐week cohort had more advanced staging than those referred by standard letter and pilot screening. Cancers in the symptomatic population are predominantly Dukes’ B and Dukes’ C whereas in pilot screening group predominantly Dukes’ A. Conclusion: The effectiveness of 2‐week wait referral was poor, confirming its lack of validity. Further work is required to offer primary care stricter inclusion and exclusion referral criteria.     

A Clinical Study of Type 2 Neurofibromatosis

The clinical features, age at onset of symptoms and survivalof 150 patients with type 2 neurofibromatosis were studied.The mean age at onset was 21.57 years (n = 110) and no patientspresented after 55 years of age. Patients presented with symptomsattributable to vestibular schwannomas (acoustic neuroma), cranialmeningiomas and spinal tumours. In 100 patients studied personallyby the authors 44 per cent presented with deafness and thiswas unilateral in the majority (35/44). Deafness was accompaniedby tinnitus in a further 10 per cent and muscle weakness orwasting was the first symptom in 12 per cent. Less common presentingsymptoms were seizures (8 per cent), vertigo (8 per cent) numbnessand tingling (2 per cent) and blindness (1 per cent). Elevenpatients were diagnosed asymptomatically through screening.Café au lait spots occurred in 43 per cent (n = 43) butonly one case had six. Skin tumours were detected in 68 percent (68/100) and 38 per cent (34/90) had and identifiable lensopacity or cataract. The mean age at death in 40 cases was 36.25years and all but one death was a result of a complication ofneurofibromatosis. There are marked inter-family differencesin disease severity and tumour susceptibility.     

Presenting characteristics as predictors of duration of treatment in sarcoidosis

Background: Some sarcoidosis patients never need therapy, butmany still require therapy more than 2 years after initial diagnosis. Aim: To determine what features at initial presentation areassociated with treatment 2 years later. Methods: Patients with biopsy-confirmed sarcoidosis enrolledin the ACCESS (A Case Control Etiologic Study of Sarcoidosis)study were initially evaluated within 6 months of diagnosis.Pulmonary function, chest X-ray and dyspnoea score were measured,and systemic therapy for the sarcoidosis recorded. Organ involvementwas assessed using a standardized instrument. A subset (n =215) were seen 18–24 months later for follow-up, and thesepatients constitute our study group. Results: Ten patients had only received therapy before the firstvisit, with no further therapy, and were excluded from analysis.Of the remaining 205, 95 were not on therapy at the initialvisit and 75 (79%) of these were never treated during follow-up.Of the 110 initially on therapy, 52 (47%) remained on therapyat follow-up. Other initial features associated with continuedtherapy were the level of dyspnoea and predicted vital capacity.On logistic regression, only dyspnoea and therapy at initialvisit remained significant. Patients on systemic therapy atinitial evaluation were more likely to be on therapy at follow-up(OR 3.6, p = 0.003). Neither ethnicity nor gender independentlypredicted therapy at follow-up. Discussion: This study group represents a sample of newly diagnosedsarcoidosis patients. However, this is a referral population,and there was no set protocol for treatment. Use of systemictherapy within the first 6 months after diagnosis appears tobe strongly associated with continued use of therapy 2 yearslater.     

Screening for Adolescent Depression in a Pediatric Emergency Department

Objectives: To describe the prevalence of depressive symptoms in adolescents presenting to the emergency department (ED) and to describe their demographics and outcomes compared with adolescents endorsing low levels of depressive symptoms. Methods: The Beck Depression Inventory–2nd edition (BDI‐II) was used to screen all patients 13–19 years of age who presented to the ED during the period of study. The BDI‐II is a 21‐item self‐report instrument used to measure the presence and severity of depressive symptoms in adolescents and adults. Demographics and clinical outcomes of screening‐program participants were abstracted by chart review. Patients were categorized into one of four severity categories (minimal, mild, moderate, or severe) and one of three presenting complaint categories (medical, trauma, mental health). Results: Four hundred eighty‐seven patients were approached, and 351(72%) completed the screening protocol. Participants endorsed minimal (n= 192, 55%), mild (n= 52, 15%), moderate (n= 41, 11%), or severe depressive symptoms (n= 66, 19%). Those with moderate or severe depressive symptoms were more likely to be hospitalized. Of patients completing the BDI‐II, 72% with psychiatric, 12% with traumatic, and 19% with medical chief complaints endorsed either moderate or severe depressive symptoms. Conclusions: Depressive symptoms are prevalent in this screening sample, regardless of presenting complaint. A substantial proportion of patients with nonpsychiatric chief complaints endorsed moderate or severe depressive symptoms. A screening program might allow earlier identification and referral of patients at risk for depression.     

Progression of Diabetic Autonomic Neuropathy over a Decade in Insulin-Dependent Diabetics

The prognosis for diabetics with autonomic neuropathy is littleknown. We therefore studied the progress of young insulin-dependentdiabetics, first identified as having abnormal autonomic function10–15 years ago. We have shown that the mortality of diabeticswith symptomatic authonomic neuropathy is increased, but isless than previously reported. Mortality in asymptomatic diabeticswith an isolated abnormality in autonomic function tests isnot increased. The heart rate variability declines at 1.02±0.47(SD) per annum in diabetics with an initially normal heart ratevariability. While symptoms of autonomic neuropathy do not usuallyremit even over a decade, they do not commonly progress. Three groups of young insulin-dependent diabetics had heartrate variability tested between 1972 and 1977 and have beenreviewed 10–15 years later. Group A (n=49) had symptomaticautonomic neuropathy and an abnormal heart rate variability(<12), Group B (n=24) were asymptomatic yet had an abnormalheart rate variability and Group C (n=38) were asymptomaticand had a normal heart rate variability (16–26). The 10-yearsurvival in Group A (73.4 per cent) was less (P<0.05) thanin Groups B (91.7 per cent) or C (89.5 per cent) which did notdiffer from each other. The 18 Group A deaths were due predominantlyto renal failure (n=4), myocardial infarction in patients withnephropathy (n=3) and sudden unexpected death (n=3). The chiefsymptoms of autonomic neuropathy-diarrhoea, postural hypotensionand gustatory sweating, were very persistent but did not necessarilydeteriorate or become disabling in the majority of patients.The development of autonomic symptoms in asymptomatic patientswith abnormal heart rate variability was uncommon over a decade.     

Psychiatric outcome in alcoholic liver transplant patients

We investigated drinking behaviour and psychiatric outcome ofpatients with alcoholic liver disease after liver transplantation,to help assess the advisability of the procedure in these patients.English-speaking patients (n = 20) transplanted for alcoholicliver disease and informants, and patients transplanted fornon-alcoholic liver disease (n = 54), were assessed by semi-structuredinterviews and standardized questionnaires 1–6 years followingtransplantation. All alcoholics were abstinent for several monthsafter transplantation, but only one patient remained totallyabstinent. Sixteen of the 20 alcoholics later returned to regulardrinking; the mean daily alcohol consumption was 3.5 units.Forty percent of the group were drinking above the recommendedsafe levels for the general population and over 50% were ‘binge’drinking intermittently. The alcoholic liver transplant patientsdid not have higher levels of psychiatric or physical morbiditythan controls. Patients with alcoholic liver disease returnto drinking after a period of abstinence following liver transplantation,although at lower levels than before. Their vulnerability toalcohol abuse is not explained by higher levels of physicalor psychiatric morbidity.     

Hyperthyroidism in the Land of Graves: Results of Treatment by Surgery, Radio-iodine and Carbimazole in 837 Cases

A review of the outcome of treatment by subtotal thyroidectomy,radio-iodine and carbimazole of 837 patients with hyperthyroidismseen consecutively over the period 1954–78 inclusive ispresented. The age and sex distribution, the male to femaleratio, the ABO blood group distribution and the prevalence ofpernicious anaemia and diabetes mellitus in these patients wasalso analysed. Life-table data showed that the five-year andten-year cumulative relapse rates following a two-year courseof carbimazole (n = 162) were 56 per cent and 62 per cent; followingsurgery (n = 266), 6 per cent and 10 per cent and followingradio-iodine (n = 43), 3 per cent and 14 per cent. Five-yearand ten-year cumulative hypothyroid rates after surgery were10 per cent and 18 per cent, and after radio-iodine 10 per centand 30 per cent. Hypothyroidism did not occur after carbimazoletherapy. Of 31 patients who took carbimazole for less than twoyears (mean 11 months, range 6–19 months), 91 per centhad relapsed at five years. Of 79 patients treated for longerthan two years (mean 3.8 years, range 2–14 years), relapserates at five and eight years were 49 per cent and 62 per cent.Nine patients (3.4 per cent) suffered permanent vocal cord paralysisand five (1.9 per cent) had permanent hypocalcaemia. The male/female ratio was 9.9 to 1, with a peak female prevalencebetween 25 and 30 years and a peak male prevalence between 40and 45 years. The ABO blood group distribution among patients did not differsignificantly from the distniution in the general population(x² = 13.4, p = 0.2). Forty-seven patients (5.6 per cent) had diabetes mellitus andthyrotoxicosis whilst two patients (0.23 per cent) had diabetes,thyrotoxicosis and pernicious anaemia.     

Percutaneous Transluminal Angioplasty Improves Blood Pressure and Renal Function in Renovascular Hypertension

Thirty-three patients with renal angiographic evidence of significantrenal artery stenosis were referred for percutaneous transluminalangioplasty. The indications were poorly controlled hypertension(n=13) or hypertension associated with deteriorating renal function(n=20). Their mean age was 56 (23–73) years (12 males,21 females). Causes of the renal artery stenosis were fibromusculardysplasia (n=8) and atheromatous changes (n=25). Four patientswere excluded, three due to technical failure. Forty-five angioplastieswere performed in 29 patients with a mean observation periodafter angioplasty of 18 (one to 60) months. During this periodeight patients (28 per cent) had a diastolic blood preasureof less than 90 mnHg without antihypertensive drugs, a further15 patients (52 per cent) had improved blood pressure controlwith a significant reduction in the number and amount of antihypertensivedrugs, but six patients (20 per cent) showed no improvementin blood pressure. Hypertension associated with the stenosisof fibromuscular dysplasia responded better to angioplasty thanhypertension associated with atheromatous renal artery stenosis.Improvement in renal function was noted in eight patients withno change in 16 patients. Two patients with end-stage renalfailure and atheromatous intrarenal vascular disease becamedialysis dependent within four weeks of the procedure. One majorand four minor complications occurred but there were no deathsrelated to angioplasty. Together with results from other centresthis study indicates that percutaneous transluminal angioplastyshould be considered the initial treatment choice for all patientswith renovascular hypertension due to fibromuscular dysplasiaand atheromatous renal artery stenosis     

Barrett's Oesophagus: A Clinical Study of 52 Patients

This paper reports a series of 52 patients with Barrett's (orcolumnar-lined) oesophagus from one medical unit diagnosed overa six-year period. The commonest associated symptoms were heartburn,regurgitation and dysphagia but 10 patients had no oesophagealsymptoms and two had no symptoms at all. Gastrointestinal bleeding(overt or occult) was observed in almost one-third of patients.At diagnosis, 26 patients had oesophagitis, 23 had oesophagealulceration and 10 had benign oesophageal strictures. An associationbetween oesophageal ulceration and non-steroidal anti-inflammatorydrug ingestion was suggested by the data and patients with oesophagealulceration were significantly older than patients with uncomplicatedBarrett's oesophagus. No patient had adenocarcinoma of the oesophagusat diagnosis and neither carcinoma nor dysplasia were seen duringa mean period of 16.4 months. However, 17 per cent of patientsin the series had malignancies in other sites. Most patientsdid well on medical treatment and only two were referred foranti-reflux surgery (both for non-healing oesophageal ulcers).Barrett's oesophagus was seen in 10 per cent of patients withgastro-oesophageal reflux at endoscopy. Oesophageal ulcerationin patients with Barrett's oesophagus made up 21 per cent ofoesophageal ulcers seen and benign oesophageal stricture inpatients with Barrett's oesophagus constituted 13 per cent ofall benign strictures seen. Barrett's oesophagus is common inour population and despite complications, it can be managedsuccessfully, at least in the short term, by conservative means.     

Clinical Features and Natural History of von Hippel-Lindau Disease

The Clinical features, age at onset and survival of 152 patientswith von Hippel-Lindau disease were studied. Mean age at onsetwas 26.3 years and 97 per cent of patients had presented byaged 60 years. Retinal angioma was the first manifestation in65 patients (43 per cent), followed by cerebellar haemangioblastoma(n = 60, 39 per cent) and renal cell carcinoma (n = 15, 10 percent). Overall, 89 patients (59 per cent) developed a cerebellarhaemagioblastoma, 89 (59 percent) a retinal angioma, 43 (28percent)renal cell carcinoma, 20 (13 per cent) spinal haemangioblastomaand 11 (7 per cent) a phaeochromocytoma. Renal, pancreatic andepididymal cysts were frequent findings but their exact incidencewas not accurately assessed. Mean age at diagnosis of renalcell carcinoma (44.0±10.9 years) was significantly olderthan that for cerebellar haemangioblastoma (29.0±10.0years) and retinal angioma (25.4±12.7 years). The probabilityof a patient with von Hippel-Lindan disease developing a cerebellarhaemangioblastoma, retinal angioma or renal cell carcinoma byage 60 years was 0.84, 0.7 and 0.69, respectively. A comprehensivescreening protocol for affected patients and at-risk relativesis presented, based on detailed analysis of age at onset datafor each of the major complications. Median actuarial survivalwas 49 years, with renal cell carcinoma the leading cause ofdeath.     

The Association of Autoimmune Disorders with Inflammatory Bowel Disease

Medical records of patients with ulcerative colitis (n= 858),Crohn's disease (n= 378) and coeliac disease (n = 148) wereexamined to determine the prevalence of associated autoimmunedisorders. Of outpatient controls (n= 300), 2 per cent had atleast one autoimmune disorder, compared to 7 per cent with ulcerativecolitis, 2 per cent with Crohn's disease and 6 per cent withcoeliac disease. Inclusion of primary sclerosing cholangitiswith the autoimmune disorders increased the overall prevalencein ulcerative colitis to over 9 per cent The results providefurther indirect evidence of involvement of autoimmune mechanismsin the pathogenesis of ulcerative colitis.     

Final Outcome of Ursodeoxycholic Acid Treatment in 126 Patients with Radiolucent Gallstones

One hundred and twenty-six patients with radiolucent gallstonesin ‘functioning’ gallbladders were treated with8–10 mg ursodeoxycholic acid (UDCA) Kg/day and followedto a treatment conclusion. Complete or partial gallstone dissolutionwas achieved in 74 (59 per cent). However, only 22 achievedcomplete gallstone dissolution, as judged by two normal oralcholecystograms; ultrasonograms were performed in 16 of thesepatients, and all were normal. UDCA was stopped in 76 patients:because of cystic duct obstruction (n=12), severe biliary pain(n=13), non-response (n=25) or partial stone dissolution witharrested progress (n=26). Life-table analysis showed that completegallstone dissolution rates at four years were 25–30 percent. (two normal oral cholecystograms) and 17–19 percent (two normal oral cholecystograms plus one ultrasonogram).All patients with complete gallstone dissolution had shown partialstone dissolution at 6–12 months; of those with partialstone dissolution at six months, only 25 per cent went on tocomplete gallstone dissolution, and then always within two years.Efficacy correlated inversely with stone size but not with age,sex, obesity or on-treatment saturation indices. Acquired surfacegallstone calcification developed in 13 patients (life-tableanalysis 22±7 per cent at four years); none of thesepatients achieved complete gallstone dissolution and only fiveachieved partial stone dissolution. Thus, despite relativelyhigh partial gallstone dissolution rates, the ultimate efficacyof UDCA in achieving complete gallstone dissolution is low.     

Elderly Patients with Suppressed Serum TSH but Normal Free Thyroid Hormone Levels Usually Have Mild Thyroid Overactivity and are at Increased Risk of Developing Overt Hyperthyroidism

The clinical and biochemical characteristics of 15 elderly patientswith low levels of thyrotrophin (TSH) (<0.1 mU/L) but normalfree tri-iodothyronine, (T3) and free thyroxine (T4) (groupS) were compared with 10 euthyroid subjects (group E) and 10hyperthyroid patients (group T). Free T3 and free T4 were significantlyhigher (p<0.05) in group S(6.3±0.5 and 18.6±1.0pmol/l, respectively) than in group E(4.6±0.3, 12.6+0.6).In common with elderly hyperthyroid patients (group T)patientsin group S had few signs or symptoms of thyrotoxocosis, butthe Wayne score (clinical index of hyperthyroidism) was higherin group S than in euthyroid subjects (p<0.05). Thyroid microsomal,thyrogolobulin or thyrotrophin receptor antibodies were commonin group T (n=9)but not in groups S(n=2) or E(n=1). This suggestsa low prevalence of Graves' disease in group S compared to groupT. Combined thyrotrophin releasing hormone (TRH; 200 µgi.v.) and gonadotrophin releasing hormone GnRH; 100 µgi.v.) tests were performed; no cases of low TSH due to hypopituitarismwere identified in group S. During a mean of 7.9 (4–12)months of observation TSH reverted to the normal range (>0.2mU/L)in 7 of 15 patients in group S; thyroid hormone concentrationsrose above the normal range in four, however, only two patientsrequired treatment for hyperthyroidism. It is unlikely thatthe suppressed TSH of patients in group S was due to mild thyroidhormone excess; although this is often a transitory phenomenon,these patients are at increased risk of developing overt hyperthyroidism.     

Age dependency of coagulation parameters during childhood and puberty

Summary. Background: Use of age‐adjusted reference values is crucial for correct diagnosis and management of thrombotic and hemorrhagic disease in children. They vary with utilized reagents and analyzers. Objectives: We established reference values with the Sysmex CA‐1500 System and in parallel with the Behring BCS System using reagents from Siemens Healthcare Diagnostics Products GmbH. Methods: After informed consent, blood samples were obtained from 218 healthy children and 52 healthy adults, grouped as 1–6 months (n = 29), 7–12 months (n = 25), 1–5 years (n = 57), 6–10 years (n = 57), 11–18 years (n = 50) and > 19 years (n = 52). Results: Most coagulation parameters demonstrate good comparability between analyzers with the exception of PT and APTT. Single coagulation factors fibrinogen, factor (F) II, FIX, FXI and XII were significantly decreased in the youngest children; the strongest age dependency was found for coagulation inhibitors Protein C and S, both significantly decreased in infancy and young childhood. We confirmed that high levels of von Willebrand factor are found in the youngest children without increased levels of FVIII followed by decreased von Willebrand levels in the subsequent age group. In children with blood group O a less distinct increase in time was found, compared with individuals with one of the other blood groups. Conclusions: The correlation between the CA‐1500 and the BCS system was remarkable. Differences were most pronounced between children < 12 months and older children and adults, confirming the phenomenon of developmental hemostasis. The rationale for age‐related changes in the hemostatic system remains unraveled. Our results underline the need for age‐specific reference ranges.     

Wilson's disease presenting with features of hepatic dysfunction: a clinical analysis of eighty-seven patients

An analysis has been made of presenting symptoms and course in 87 patients with predominantly hepatic Wilson's disease. In 30 patients, in whom the diagnosis was made relatively quickly, response to treatment was excellent and all recovered although two had severe haemolytic crises. Mean age of onset was 11 years (range five to 22). Nine patients suffered toxic reactions to penicillamine and were then treated with trientine. In 22 patients the diagnosis was made after neurological symptoms had supervened; in 20 the signs of hepatic damage had disappeared despite the lack of treatment but in two hepatic signs persisted until the central nervous system was affected. In the 20 patients in whom signs of liver disease resolved spontaneously there was a time interval of from one to eight years before neurological signs developed. All 22 patients in a third group died of hepatic disease without central nervous system involvement. In 19 cases duration of the illness was brief and the diagnosis was made very late or at post-mortem examination. One patient survived with chronic progressive liver damage for 20 years; diagnosis was also made at post-mortem examination. Mean age at death was 15 years. The diagnosis was made retrospectively in 13 patients who died. In two of these the diagnosis was confirmed by determination of the liver copper concentration on tissue saved at postmortem examination; in the other 11 the diagnosis is probable since other siblings developed a similar illness, proven to be Wilson's disease. Age range for these patients was eight to 13 years. Duration of the illness from onset to death was nine days to four years (mean 10 weeks). There was no example of primary carcinoma of the liver in this series.     

Pyogenic Liver Abscess in Crohn's Disease

We describe six cases of pyogenic liver abscess occurring among1227 Crohn's disease patients admitted to The Mount Sinai Hospitalfrom 1960 through 1982, and review the features of the sevensimilar cases that have been previously reported. Mechanismsof formation of liver abscess in these 13 patients includeddirect extension of intraabdominal abscess (three cases), propagationvia the portal vein (eight cases), biliary complications (onecase), or metastatic cancer (one case). Five of the 13 patients died. All five deaths occurred amongthe eight patients with multiple abscesses; all five patientswith solitary abscess survived. The mean age of the patientswho died was 56 years, versus 37 years for the survivors. Threeof the four patients treated with antibiotics only died; onlytwo of the nine patients who underwent some form of drainagesuccumbed. Mortality was usually attributable to failure in making thediagnosis, especially as liver function test abnormalities wereoften subtle. Furthermore, the generally nonspecific clinicalsigns and symptoms were often obscured by underlying bowel disease.If a high index of suspicion is maintained, CT scanning andultrasonography should reveal the lesion at an early stage,so that the necessary drainage procedure can be carried out,with or without concomitant resection of affected bowel anddrainage of intraabdominal abscess.     

Pregnancy-associated osteoporosis

The clinical features, investigation and outcome in 24 patientswith pregnancy-associated osteoporosis, followed for up to 24years from the first pregnancy are described. Symptoms occurredmost often in the first pregnancy (17 patients) at a mean ageof 27 years (range 21–36); the most frequent was backpain in late pregnancy or post partum (n=18); less common waship (n= 5) or ankle (n= 1) pain. In most, symptoms improvedsoon after delivery. Four subjects had pre-existing disordersknown to reduce bone density (corticosteroid therapy, heparintreatment, mild osteogenesis imperfecta and previous anorexianervosa). Radiographs showed vertebral collapse or localizedosteoporosis of the hip, with MRI evidence of oedema. Forearmbone mineral density (BMD) was sometimes normal, but spinalBMD (measured by DXA) was low. Bone biopsies in eleven patientsshowed features compatible with osteoblast failure. Except forthe patient with mild osteogenesis imperfecta, cultured dermalfibroblasts synthesized and exported normal Type I collagen.In 14 subsequent pregnancies (10 patients) there was no recurrencein ten and mild symptoms in the remainder. Excluding one patientwho had repeated osteoporotic fractures and vertebral collapse,the long-term prognosis was good.     

Influence of symptoms,lung function,mood, and social support on level of functioning of patients with COPD

To explain how symptoms, lung function, mood, and social support affect level of functioning, patients (N = 143) with chronic obstructive pulmonary disease (COPD) completed measures assessing their symptoms (Bronchitis-Emphysema Symptom Checklist), mood (Profile of Mood States), social support (Personal Resource Questionnaire), and functioning (Sickness Impact Profile). Those who were receiving oxygen therapy (n = 52) had significantly lower FEV, scores and experienced significantly poorer functioning than those who were not receiving oxygen therapy (n = 91). Results of path analyses indicated that symptoms and mood directly, and social support indirectly, influenced the functioning of those who were not receiving oxygen. For those who were receiving oxygen, only symptoms directly, and FEV, indirectly, influenced their functioning. These models need to be confirmed using other samples of patients with COPD. ©1995 John Wiley & Sons, Inc.     

Use of bisphosphonates and dual-energy X-ray absorptiometry scans in the prevention and treatment of glucocorticoid-induced osteoporosis in rheumatology

Background: Patients treated with steroids are at risk of glucocorticoid-inducedosteoporosis. Appropriate investigations and therapeutic agentscan decrease rate of bone loss and fracture. Aim: To review adherence to current UK guidelines for the preventionof glucocorticoid-induced osteoporosis in rheumatology outpatientclinics. Design: Retrospective case note review. Methods: The management of patients taking glucocorticoids whoattended outpatient rheumatology clinics at a Teaching HospitalNHS Trust over a 4-week period was reviewed against currentUK recommendations for prevention and treatment of osteoporosis(Bone and Tooth Society, National Osteoporosis Society, RoyalCollege of Physicians. Glucocorticoid-induced osteoporosis:guidelines for prevention and treatment. London: Royal CollegePhysicians, 2002). Results: Over the study period, 519 patients attended rheumatologyoutpatient clinics, amongst whom 104 were current glucocorticoidusers. Most patients had been taking oral steroids for over12 months (n = 79, 76%). The majority had also received steroidsby at least one other route (n = 67, 64.4%). According to theguidelines, 51 patients, at relatively low risk of osteoporosis(<65 years, no previous fragility fracture) should have beenreferred for bone density assessment; of these, 27 (53%) hadreceived a DEXA scan. In total, 58 subjects fulfilled criteriafor bisphosphonates (>65 years, fragility fracture, T-score<–1.5) and, of these, 51 (87.9%) were appropriatelytreated. In 21 cases, a DEXA scan had been performed when guidelinesrecommended that treatment could commence without further assessment. Discussion: The findings indicate a high level of awarenessof glucocorticoid-induced osteoporosis amongst UK rheumatologists.Most patients identified to be at high risk of bone loss wereoffered treatment. Although encouraging, current practice couldpotentially be improved, particularly through more targeteduse of DEXA scanning.     

The association between glycemic, lipids and blood pressure control among Israeli diabetic patients

Background: It is recommended that in diabetes mellitus patientsall risk factors for cardiovascular disease should be controlled. Aim: To evaluate the rate of reaching all glycemic, lipids andblood pressure target levels among diabetic patients in Israeland to analyze demographic and clinical parameters associatedwith it. Design: A cross-sectional study. Methods: The study was conducted in Maccabi Healthcare Services,Israel's second largest health maintenance organization. Allpatients (n = 41 936), older than 20 years, who were listedon Maccabi Healthcare Service's diabetes mellitus computerizeddatabase and had all three study parameters (HbA1c, LDL-C andblood pressure levels during 2005) were eligible for the study.The rate of reaching HbA1c <7.0%, LDL-C <100 mg/dl andblood pressure <130/85 mmHg, as well as its association withvarious demographic and clinical parameters were analyzed. Results: Only 13% of all study patients achieved all three targetlevels. The parameters which were significantly associated withgoal achievement were compliance to medical treatment for allthree parameters (OR 1.56, 95% CI 1.44–1.69, P = 0.0001),male gender (OR 1.42, 95% CI 1.31–1.54, P = 0.0001), comorbiditywith ischemic heart disease (OR 1.23, 95% CI 1.13–1.34,P = 0.0001), and >12 visits per year to family physician(OR 1.10, 95% CI 1.02–1.19, P = 0.012). Conclusion: Non-compliance with treatment and sub-optimal follow-upby family physicians are associated with increased risk of failureto control major risk factor among diabetic patients.