A randomized controlled trial of an intervention designed to improve the care given in general practice to Type II diabetic patients: patient outcomes and professional ability to change behaviour

AIM: Our objective was to evaluate the effect of training in a patient- centred intervention for GPs and practice nurses on outcomes for patients with Type II diabetes. METHODS: We carried out a randomized controlled trial within general practices as the basis for randomization and a before-and-after design for measures of patient outcome. A parallel process study examined the use of the method by professionals. The study was carried out in 29 general practices in South Glamorgan who had participated for at least 2 years in a local scheme of audit and CME in relation to Type II diabetes care. The subjects were 252 Type II diabetic patients recruited by 15 experimental and 14 control practices. The main outcome measures were changes in glycosylated haemoglobin, patient satisfaction with care and treatment, functional health status and professional ability to apply the intervention. RESULTS: Professionals adopted the innovative method with enthusiasm, but after 2 years only 19% continued to apply the method systematically. The trial was, therefore, unable to demonstrate significant biochemical or functional improvements. This highlights the need to understand the factors associated with professional uptake and subsequent ability to sustain changes in behaviour. CONCLUSIONS: The efficacy of this behavioural intervention remains unproved, despite its acceptability to professional staff. Detailed and prolonged development and testing of behavioural interventions is an essential first step before embarking on randomized controlled trials which involve complex behavioural changes in professionals or patients.      

Validity of testing alanine aminotransferase in refrigerated whole blood

Alanine aminotransferase (ALT) was tested in the sera and plasma of in-line segments as well as the main bags of whole blood units collected from blood donors. The purpose of this study was to evaluate the stability of enzyme activity during blood storage when the analysis of ALT is postponed over weekends or holidays. In addition, when validation of a particular result is requested, an in-line segment may be convenient for confirmatory testing. While a dilutional effect was found, the anticoagulant in the main collection bag was not shown to have affected enzyme activity. During storage the mean enzyme concentration decreased. Appropriate plasma ALT cutoffs for respective time periods during storage were calculated to compensate for downward drift. This correction prevented the use of the blood units (40% of total) that would erroneously have appeared transfusable if the serum cutoff had been used. If the Day 0 plasma cutoff was used throughout the total storage time period, 14 percent of the blood would erroneously have appeared transfusable.     

Social relations and extent and severity of coronary artery disease: The Stockholm Female Coronary Risk Study

Aims Social relations have been repeatedly linked to coronary heartdisease in men, even after careful control for standard riskfactors. Women have rarely been studied and results have notbeen conclusive. We investigated the role of social supportin the severity and extent of coronary artery disease in women. Methods and Results One hundred and thirty-one women, aged 30 to 65 years, who werehospitalized for an acute coronary event and were included inthe Stockholm Female Coronary Risk Study, were examined withcom-puter assisted quantitative coronary angiography. Angio-graphicmeasures included presence of stenosis greater than 50% in atleast one coronary artery (severity) and the number of stenosesgreater than 20% within the coronary tree (extent). Social factorsincluded two measures of social support, which were previouslyshown to predict coronary disease in prospective studies ofmen. After adjustment for age, lack of social support was associatedwith both measures of coronary artery disease. With furtheradjustment for smoking, education, meno-pausal status, hypertension,high density lipoprotein and body mass index, the risk ratiofor stenosis greater than 50% in women with poor as comparedto those with strong social support was 2·5 (95% confidenceinterval 1·2 to 5·3;P=0·003). Also, womenwith poor social support had more stenoses obstructing at least20% of the coronary lumen with multivariate adjustment, butthe difference from women with strong support was only of borderlinesignificance (P=0·09). Conclusion The findings suggest that lack of social support contributesto the severity of coronary artery disease in women, independentof standard risk factors.The European Society of Cardiology     

Identifying Chinese populations in the UK for epidemiological research: experience of a name analysis of the FHSA register

Definition of Chinese. For the purposes of this study, Chinese refers to residents of the UK who either on the basis of name (face-to-face contact not made), or self-definition and appearance (contact made) had origins in China and included those born in the UK and others migrating to the UK via a third country (for example Vietnam, Singapore, Hong Kong etc). This is a pragmatic definition.There is a paucity of research on health in the UK Chinese community partly due to the difficulties of identifying and accessing study populations. For a survey of cardiovascular disease we aimed to identify and recruit all Chinese adults aged 25–64 y living in Newcastle-upon-Tyne, UK. One thousand, eight hundred and sixty-five potential subjects were identified using a variety of methods. Of the 1702 potential subjects identified from a name analysis of the 1991 FHSA register (FHSA group), 638 students in halls of residence were excluded and the remaining 1064 were invited to participate. Non-respondents were followed up. Of the 1064, 658 (65.5%) addresses were no longer valid, 21 (2%) were reclassified as non-Chinese and no contact was made with 18 individuals (1.6%). A further 163 subjects (non-FHSA group) came forward in response to publicity, giving a total of 530 Chinese actually identified in Newcastle. Three hundred and eighty subjects took part in the study. Compared to the 1991 Census, the recruitment procedure underestimated the total population size, particularly for men and younger ages. In the FHSA group, men were significantly more likely to be current drinkers, and women were more likely to smoke and have a lower educational attainment that the non-FHSA group. There were no other important differences in the distribution of CHD risk markers in the two groups. Our experience indicates that the FHSA register is suitable for identifying Chinese but should be used alongside other complementary methods to augment samples for ethnicity and health research.     

蛇床子素对去卵巢大鼠近侧胫骨代谢影响的定量研究

切除3月龄SD大鼠双侧卵巢12周后,其骨形成的参数值明显增加(%L.Pm+58%,BFR/BV+105%,BFR/BS+74%,%O.Pm+188%),同时骨吸收的参数值增加(%Er.Pm+155%),荧光标记周长与吸收周长的比率-41%,由于骨吸收大于骨形成,骨质丢失(%Tb.Ar-59%,Tb.Th-14%),出现高转换型骨质疏松。分别用蛇床子素(osthole)6.7mg·kg^-1ig,每周6次,尼尔雌醇(nilestri-ol) 1 mg·kg^-1ig,每周1次,持续12周,均能明显抑制去卵巢诱导的骨高转换,防止骨质丢失。但蛇床子素抑制骨高转换的效应比尼尔雌醇低(蛇床子素治疗组比尼尔雌醇治疗组%Tb.Ar-55%)。     

The Use of Automobile Safety Restraint Systems during Pregnancy

The American Medical Association's Committee on Medical Aspects of Automobile Safety recommends that pregnant women use seat belts. Currently, all military installations, 39 states, and the District of Columbia mandate varying degrees of seat belt usage. A survey was conducted to evaluate seat belt usage in the antepartum population at the Wilford Hall United States Air Force Medical Center. Eighty-eight percent of the respondents used automobile safety restraints 100% of the time when driving, and 90% of the respondents used automobile safety restraints 100% of the time when riding as a passenger. Twenty-three percent, however, were uniformed or misinformed about seat belt safety procedures and practices during pregnancy. Increased education regarding seat belt safety would be beneficial to this population.     

Comparison of vasa vasorum after intravascular stent placement with sirolimis drug‐eluting and bare metal stents

The cytostatic drug, sirolimis has shown prevention in neointimal hyperplasia after stent placement. Recent studies have shown persistent inflammation seen with drug‐eluting stents (DES) may result in late stent thrombosis. The aim of this study is to compare effects of bare metal stents (BMS) and sirolimis DES on the neointima and vasa vasorum in stented rabbit aortas. Stents were implanted in eight New Zealand rabbits for 9 weeks. Group I rabbits received BMS. Group II rabbits received sirolimis DES. A balloon‐mounted BMS or DES was placed in the infrarenal aorta. Following euthanasia, aortas were perfused with barium sulfate and sectioned for histology. After 9 weeks the qualitative intrastent luminal diameter was fairly uniform in both the DES and the BMS. The thickness of neointima was similar in both groups. The number of vasa vasorum in the sirolimis DES increased compared with the BMS (P < 0.05). An increased number of vasa vasorum produced by the DES when compared with the BMS shows a difference in response to local vessel injury in rabbits. This result suggests that vasa vasorum may play a role in the persistent inflammation generated by sirolimis‐coated stents.     

Antidepressant therapy in epilepsy: can treating the comorbidities affect the underlying disorder?

There is a high incidence of psychiatric comorbidity in people with epilepsy (PWE), particularly depression. The manifold adverse consequences of comorbid depression have been more clearly mapped in recent years. Accordingly, considerable efforts have been made to improve detection and diagnosis, with the result that many PWE are treated with antidepressant drugs, medications with the potential to influence both epilepsy and depression. Exposure to older generations of antidepressants (notably tricyclic antidepressants and bupropion) can increase seizure frequency. However, a growing body of evidence suggests that newer (‘second generation’) antidepressants, such as selective serotonin reuptake inhibitors or serotonin-noradrenaline reuptake inhibitors, have markedly less effect on excitability and may lead to improvements in epilepsy severity. Although a great deal is known about how antidepressants affect excitability on short time scales in experimental models, little is known about the effects of chronic antidepressant exposure on the underlying processes subsumed under the term ‘epileptogenesis’: the progressive neurobiological processes by which the non-epileptic brain changes so that it generates spontaneous, recurrent seizures. This paper reviews the literature concerning the influences of antidepressants in PWE and in animal models. The second section describes neurobiological mechanisms implicated in both antidepressant actions and in epileptogenesis, highlighting potential substrates that may mediate any effects of antidepressants on the development and progression of epilepsy. Although much indirect evidence suggests the overall clinical effects of antidepressants on epilepsy itself are beneficial, there are reasons for caution and the need for further research, discussed in the concluding section.     

腹腔镜门静脉高压症贲门周围血管离断术的风险评估

目的 探讨腹腔镜在外科治疗门静脉高压症手术风险及手术技巧.方法 自 2011 年 6 月以来,46 例诊断为肝炎肝硬变、门静脉高压症、食管胃底静脉曲张,肝功能分级 Child A 级 32 例,B 级 14 例.术前胃镜检查了解食管胃底静脉曲张;门静脉彩超,了解门静脉有无血栓;上腹部 CT 增强扫描,了解脾脏大小,脾动、静脉走行,二级脾蒂分叉部位,脾门以及胃底、贲门周围曲张静脉分布情况.采用 4 孔法,取脐上 10 mm 戳孔为腹腔镜观察孔,左锁骨中线约与脐平线 12 mm 戳孔,为主操作孔;剑突左侧肋缘下 2 cm 处 5 mm 戳孔、左腋前线约与脐平线 12 mm 戳孔为辅操作孔,术者、一助均位于患者右侧.LS 技术操作我们采用前入路与侧入路结合方法,离断脾动脉、胃短血管时用前入路,游离脾肾、脾膈韧带,离断脾蒂时运用侧入路;贲门周围血管离断采用前入路.结果 全腹腔镜成功实施 38 例肝硬化门静脉高压症脾切除加贲门周围血管离断术,7 例术中出现不可控出血中转,1 例慢性胰腺炎术中无法分离出脾动脉中转.手术时间 142 ～ 218 min,平均（ 167 ± 44 ） min,术中出血80 ～ 280 ml,平均（ 113 ± 76 ） ml.采用预先结扎脾动脉,Endo Cut 闭合切割一级脾蒂或二级脾蒂,无出血、胰漏并发症,无死亡病例.术后第 2 天拔除胃管,第 3 天拔除腹腔引流管,术后 7 ～ 12 d 出院.结论 通过上腹部 CT,谨慎进行贲门周围血管离断术手术风险评估,正确的操作步骤,准确的分离层面,娴熟的腹腔镜下分离技巧,处理脾蒂血管动作精细,预防出血,保持视野清晰,尽管风险很大,腹腔镜手术治疗门静脉高压症还是安全、可行的.