Effectiveness of diabetes mellitus screening recommendations

Screening guidelines proposed by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus have been endorsed by several medical societies. However, one-third of cases are undiagnosed, and complications at the time of diagnosis indicate that disease may have been present for several years before diagnosis. This study evaluates the effectiveness of the guidelines for detecting new cases of diabetes mellitus. By using a cross-sectional, representative sample of the United States (National Health and Nutritional Examination Survey, NHANES III), the guidelines are tested on adults, 20 years and older without a prior diagnosis of diabetes. Individuals are classified as nondiabetics (n = 6,241) or as having undiagnosed diabetes (n = 274) based on their blood glucose. Screening when one risk factor is present, as stated in the guidelines, has a true-positive rate of 100% and would require that 83% of the population be tested. Screening when two risk factors are present is more efficient, with a comparable true-positive rate (98%), but requires that only 59% of the population be tested. A notable finding is the earlier age of onset among minorities, which may be associated with other health disparities. Because diabetes occurs at younger ages in minorities, screening whites who are > or =40 and minorities > or =30 years of age has a high true-positive rate (95%) and also reduces testing (60%). The screening guidelines would be effective, if followed, and would essentially eliminate undiagnosed cases of diabetes.     

White Matter Changes in Dementia: Role of Impaired Drainage of Interstitial Fluid

White matter abnormalities on magnetic resonance imaging (MRI) are associated with dementia and include white matter hyperintensities (WMH; also termed leukoaraiosis) and visible perivascular spaces (PVS). We review the potential role of impaired drainage of interstitial fluid in the pathogenesis of WMH and PVS. Whereas the volume of extracellular space in the grey matter is tightly controlled, fluid accumulates and expands the extracellular spaces of the white matter in acute hydrocephalus, vasogenic edema and WMH. Although there are no conventional lymphatic vessels in the brain, there is very effective lymphatic drainage for fluid and solutes along restricted pathways in the basement membranes of cerebral capillaries and arteries in young individuals. Lymphatic drainage of the brain is impaired with age and in association with apolipoprotein E ε4, risk factors for Alzheimer's disease and cerebral amyloid angiopathy (CAA). Deposition of proteins in the lymphatic drainage pathways in the walls of cerebral arteries with age is recognized as protein elimination failure angiopathy (PEFA), as in CAA and cerebral autosomal dominant arteriopathy and leukoencephalopathy (CADASIL). Facilitating perivascular lymphatic drainage from the aging brain may play a significant role in the prevention of CAA, WMH and Alzheimer's disease and may enhance the efficacy of immunotherapy for Alzheimer's disease.     

2-Methoxyestradiol overcomes drug resistance in multiple myeloma cells

2-Methoxyestradiol (2ME2) an estrogen derivative, induces growth arrest and apoptosis in leukemic cells and is also antiangiogenic. In this study, we demonstrate that 2ME2 inhibits growth and induces apoptosis in multiple myeloma (MM) cell lines and patient cells. Significantly, 2ME2 also inhibits growth and induces apoptosis in MM cells resistant to conventional therapies including melphalan (LR-5), doxorubicin (Dox-40 and Dox-6), and dexamethasone (MM.1R). In contrast to its effects on MM cells, 2ME2 does not reduce the survival of normal peripheral blood lymphocytes. Moreover, 2ME2 enhances Dex-induced apoptosis, and its effect is not blocked by interleukin-6 (IL-6). We next examined the effect of 2ME2 on MM cells in the bone marrow (BM) milieu. 2ME2 decreases survival of BM stromal cells (BMSCs), as well as secretion of vascular endothelial growth factor (VEGF), and IL-6 triggered by the adhesion of MM cells to BMSCs. We show that apoptosis induced by 2ME2 is mediated by the release of mitochondrial cytochrome-c (cyto-c) and Smac, followed by the activation of caspases-8, -9, and -3. Finally, 2ME2 inhibits MM cell growth, prolongs survival, and decreases angiogenesis in a murine model. These studies, therefore, demonstrate that 2ME2 mediates anti-MM activity directly on MM cells and in the BM microenvironment. They provide a framework for the use of 2ME2, either alone or in combination with Dex, to overcome drug resistance and to improve outcome in MM.     

Clinical, biochemical, serological, histological and ultrastructural features of liver disease in drug abusers

Heroin abusers are frequently found to have abnormal liver function tests and hepatic histology. Hepatitis viruses A, B, and NANB, other drugs or drug contaminants and excessive alcohol consumption are factors thought to contribute. One hundred and sixteen heroin abusers attending a London treatment centre were studied. Sixty two (53%) had a raised aspartate transaminase. This was not explained by current infection with hepatitis A and B, cytomegalo or Epstein-Barr viruses, excessive alcohol consumption (greater than 80 g/day) or concomitant drug taking. Abnormal liver function tests were as frequent in those with markers of current or past HBV infection as those without and there was evidence that both HBV infection and the cause of the abnormal liver function tests were acquired in the first few years of intravenous drug abuse. Liver biopsies from eight patients showed chronic hepatitis with a mild lobular and portal inflammatory infiltrate, fatty change and prominent sinusoidal cells. Electron microscopy showed cytoplasmic trilaminar tubular structures and dense fused membranes in dilated endoplasmic reticulum. These clinical, biochemical, serological, and histological features would suggest a major role for NANB virus infection in the aetiology of hepatitis in heroin abusers.     

Fibrinogen Longmont: a dysfibrinogenemia that causes prolonged clot-based test results only when using an optical detection method

A new fibrinogen variant was discovered as a result of discrepancies found in routine laboratory screening. The patient, a healthy 37-year-old woman, had a mild bleeding history. Initial coagulation studies on the patient revealed a prolonged prothrombin time (PT) and a normal activated partial thromboplastin time (APTT). Further investigation on the patient and her mother demonstrated both had a PT with no end point using an optical detection method (ACL3000+) and a normal PT using an electromechanical detection method (ST4 Clot Detection System). The APTT for both the patient and her mother were essentially normal with both optical and mechanical detection methods. The patient and her mother also had markedly prolonged thrombin time and reptilase time results on the ACL3000+, but they were normal on the ST4. Coagulation test results on the patient's father were all normal. We believe the fibrinogen defect in this family may affect fibrin polymerization only enough to effect light scatter interpretation, while there is enough polymerization to increase plasma viscosity and yield an end point using an electromechanical analyzer. This report should alert pathologists and clinicians to possible discrepancies between mechanical and spectrophotometric clot testing methods.     

Extended stereotactic brain biopsy in suspected primary central nervous system angiitis: good diagnostic accuracy and high safety

Journal of Neurology - To evaluate the diagnostic accuracy and safety of extended stereotactic brain biopsy (ESBB) in a single center cohort with suspected primary angiitis of the central nervous...     

Derman necrosis due to thrombosis in severe secondary hyperparathyroidism.

Two patients had gangrenous dermal necrosis associated with chronic renal disease and secondary hyperparathyroidism. Thromobosed and heavily calcified small arteries were underlying the infarcted areas. One patient had severe hypotension secondary to hemorrhage, which immediately preceded the appearance of dermal lesions. Both patients had notably elevated serum parathyroid hormone and serum alkaline phosphatase levels, as well as severe hyperphosphatemia. Therapy with phosphate binders and calcium and vitamin D supplementation corrected the hyperphosphatemia and reduced serum alkaline phosphatase levels. One patient died; the other patient's dermal lesions healed completely. Localized thrombosis, rather than obliterative intimal proliferation, represents a unique cause of dermal necrosis in this condition.     

Mental pain as a mediator of suicidal tendency: A path analysis

Background

This study used path-analysis to examine the assumption that the presence of mental pain in adults mediates the relationship between self-destruction, number of losses experienced in one’s life, and suicidal tendency.

Methods

Fifty suicidal inpatients, 50 non-suicidal inpatients and 50 healthy volunteers were assessed for self-destruction, losses experienced, depression, suicidal tendency, and mental pain.

Results

Self-destruction was found to have both a direct effect on suicidal tendency as well as one mediated by the presence of mental pain. Number of losses effected suicidal tendency only indirectly, mediated by the presence of mental pain. Overall, self-destruction was a more significant determinant of suicidal tendency than were the number of losses experienced during one’s life. A competing model, with depression replacing mental pain as the mediator, was also found to fit the data.

Discussion

These findings provide evidence that the presence of mental pain is a mediator in the relationships between both self-destruction and number of losses experienced, and between suicidal tendencies. More studies are needed in order to further differentiate between mental pain and depression as mediators in suicidal tendency.     

Nociceptin receptor signaling in sympathetic neurons from septic rats

Background

The endogenous opioid peptide, nociception (Noc), contributes to the regulation of systemic blood pressure and regional blood flow. Recent clinical and animal studies have reported that Noc and its receptor (nociceptin/orphanin FQ [NOP]) are involved in inflammation and sepsis. The purpose of the present study was to examine the modulation of Ca²⁺ channels by Noc in acutely isolated stellate ganglion (SG) neurons from control and septic rats.

Materials and methods

Sepsis was induced in male Sprague–Dawley rats via cecal ligation and puncture. SG neurons were isolated 24 and 72 h after sepsis induction. Thereafter, the concentration–response relationships for the Noc-stimulated NOP receptor Ca²⁺ current inhibition were determined using the whole-cell patch clamp technique. In addition, the Noc precursor (prepronociceptin [PNOC]) and NOP receptor messenger RNA (mRNA) levels were determined by quantitative real-time polymerase chain reaction, and PNOC protein levels were measured by Western blot analysis.

Results

Comparison of the Noc concentration–response relationships in SG neurons from control and septic rats 24 h after sepsis revealed similar potency and efficacy. Moreover, 72 h after sepsis, neurons from control and septic rats exhibited an increased potency compared with both groups at the 24-h time point—an effect that was more pronounced in neurons from septic rats. PNOC mRNA levels were significantly greater in SG neurons isolated from septic rats compared with control neurons, but NOP receptor mRNA levels remained unchanged during the 72-h period.

Conclusions

Our study demonstrates the cecal ligation and puncture model–induced temporal upregulation of components within the NOP receptor signaling pathway in rat sympathetic neurons. As SG neurons provide the main sympathetic input to the heart, an increased Noc release and potency during sepsis may compromise cardiovascular function.