Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines

Patients with advanced cancer and diabetes mellitus present a challenge to healthcare professionals. To establish how diabetes is currently being managed in these patients, we audited the care of patients who died in Cheltenham General Hospital over the previous 12 months with diagnoses of both diabetes mellitus and cancer. Management and monitoring of the diabetes was variable and there was little record of discussion between healthcare professionals and the patient or family regarding the diabetes. Thirty-two out of 42 patients continued to have blood sugar monitoring up to and including the day they died. We review the literature on this topic and suggest guidelines to help professionals to appropriately manage diabetes in the palliative setting at the end of life.     

Association of polymorphism in the transforming growth factor {beta}1 gene with disease outcome and mortality in rheumatoid arthritis

OBJECTIVE: To investigate whether polymorphism in the transforming growth factor beta1 (TGFbeta1) gene is associated with disease outcome in rheumatoid arthritis. METHODS: 208 patients with established rheumatoid arthritis were genotyped for the TGFbeta1 T869C polymorphism using an amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) method. Disease severity was assessed by measuring radiographic damage by Larsen score and functional outcome by the health assessment questionnaire (HAQ). Patients were tracked on the NHS central register for notification of death, and the relation between TGFbeta1 polymorphism and mortality was analysed using Cox proportional hazards regression. RESULTS: Patients carrying a TGFbeta1 T allele had a higher mean HAQ score than those without this allele (1.60 v 1.22, p = 0.04). The T allele was also associated with higher five year mean area under the curve (MAUC) erythrocyte sedimentation rate (ESR), and nodular disease. Larsen score was higher in patients with the TT genotype compared with CC + CT genotypes, although this was not significant after correction for disease duration. There was a trend of increasing mortality risk with T allele dose after adjustment for age, sex, and disease duration (hazard ratio = 1.6 (95% confidence interval, 1.1 to 2.4), p = 0.01). CONCLUSIONS: TGFbeta1 T869C gene polymorphism is associated with disease outcome in rheumatoid arthritis. Carriage of the T allele (putatively associated with decreased TGFbeta1 production) was associated with increased inflammatory activity and poor functional outcome, while increasing T allele dose was associated with worse survival.     

The ethical implications of Paul Meehl's work on comparing clinical versus actuarial prediction methods

Paul E. Meehl's work comparing statistical versus actuarial prediction-and the large body of research that followed by others on the same topic-was mainly theoretical and empirical. Meehl also suggested that this work led to a "practical" conclusion, which was quite strong. The author argues that, in addition, it leads to an ethical conclusion, equally strong. Whether the scientific findings are combined with an overarching ethical principle that the best predictions possible should be made for clients, or whether these findings are framed as delineating what can be done for clients-and that clinicians ought not to attempt to do what they cannot-the conclusion is the same. Whenever statistical prediction rules (SPR's) are available for making a relevant prediction, they should be used in preference to intuition. Any modification of these rules should be systematic and subject to the same type of evaluation originally used to assess the SPR's themselves. It is even possible to develop near-optimal rules in new situations. Providing service that assumes that clinicians "can do better" simply based on self-confidence or plausibility in the absence of evidence that they can actually do so is simply unethical.     

How we do it: Modified Wehrs incus ossiculoplasty

• ? Ossiculoplasty is commonly performed as part of tympanoplasty. Hydroxyapatite is a favoured material for ossicular protheses.
• ? A modification to the Wehrs incus prosthesis^® is described.
• ? Twenty‐one procedures were performed on 20 patients and the results are reported.
• ? On average there was a 4–5 dB closure of the air–bone gap (ABG), with patients having a hearing gain procedure averaging 11 dB closure. Air–bone gap closure to ≤20 dB was achieved between 78% (0.5, 1, 2 kHz average) and 60% (0.5, 1, 2, 4 kHz average) of patients and this was stable during long‐term follow‐up of the ABG.
• ? Wehrs incus prosthesis^® ossiculoplasty provides a reliable result following ossiculoplasty when autograft incus is not available.

     

Salivary status in patients treated for head and neck cancer

The objective of this study was to compare unstimulated salivary flow rate and residual salivary volume (the volume of saliva retained in the mouth after swallowing) in a group of 23 control subjects and a group of 25 patients who had received radiation treatment or had undergone removal of the salivary glands (or both) for head and neck cancer. As expected, the mean flow rate (+/- 0 standard deviation) in the patient group was significantly less than that in the control group (0.07 +/- 0.11 and 0.45 +/- 0 0.27 mL/min, respectively). However, the mean residual volumes were not significantly different between the 2 groups (0.70 +/- 0 0.28 and 0.82 +/- 0 0.26 mL, respectively). The 25 patients were subdivided according to their self-reported assessment of the mouth as being not dry (3), somewhat dry (12) or very dry (10); mean residual volume of saliva was significantly lower, at 71% the level in control subjects, for the group with very dry mouth (p < 0.02). These results suggest that people who report that the mouth is dry may not have a complete lack of fluid in the mouth; rather, there may be localized areas of dryness, notably on the hard palate, where the salivary film is particularly thin and subject to fluid absorption or evaporation because of mouth breathing.     

Somatization disorder--a defensive waste of NHS resources

SIR, Patients with somatization disorder are high users of healthcare and often receive expensive, unnecessary tests and treatments.Current society expects doctors to diagnose and cure specificpathology. A failure to achieve this creates a psychologicalpressure of failure upon clinicians. We present one case thatillustrates a common approach to a common condition with benignpathology which often presents to rheumatology out-patient departments. This lady initially presented at the age of fourteen to ear,nose and throat surgeons with recurrent sore throats and underwenta