Prevalence and characteristics of brittle diabetes in Britain

We investigated the prevalence and characteristics of 'brittle diabetes', defined as insulin-dependent diabetes mellitus associated with glycaemic instability of any type, leading to life disruption with recurrent and/or prolonged hospitalizations. A questionnaire was sent to all physicians and paediatricians running diabetic clinics in the UK, from lists held at the British Diabetic Association. A total of 414 brittle patients were reported (72% questionnaire return). Most were young (mean age +/- SD was 26 +/- 15 years), though there was a small peak at ages 60-70 years. There was an excess of females (66%) and overall clinic prevalence was 1.2 per 1000 diabetic patients and 2.9 per 1000 insulin-treated diabetic patients. On average, there was 1.0 brittle patient per diabetic clinic. The most common form of brittleness was recurrent ketoacidosis (59%), with 17% having predominant hypoglycaemia, and 24% mixed instability. Female excess was highest and mean age lowest in the recurrent ketoacidosis group, whilst the reverse was true for those with recurrent hypoglycaemia. Causes of brittleness were offered by 58% of consultants, and most (93%) considered various psychosocial problems as likely underlying factors. We conclude that brittle diabetes is a small but significant problem, currently affecting about 1 per 1000 diabetic patients. Most, but by no means all, are young females--often with recurrent ketoacidosis. Older age groups are more likely to have recurrent hypoglycaemic or mixed types of brittleness. Perceived causes of brittleness are usually psychosocial.      

Patterns of Insulin Dependence in an African Diabetic Clinic

SUMMARY Analysis of the age of onset of diabetes amongst insulin-treatedpatients in a large African diabetic clinic revealed a bimodaltype of distribution, 23 per cent having an age of onset before30 years and 77 per cent with onset at 30 years of age. All66 of the young insulin-treated group (21.7±4.8 years(mean±1 SD)), and a random selection of 50 older insulin-treatedpatients (49.7±10 years), were studied. The older groupwere better controlled (HbA₁ 8.4±1.7 per cent vs. 10.8±2.6per cent, p<0.001), on lower doses of insulin (49±23vs. 71±23 u/day, p<0.001) and had higher body massindex (26.0±5.6 vs. 21.8±3.5, p<0.001). SerumC-peptide (0.24±0.15 vs. 0.07±0.10 nmol/l, p<0.0001),and C-peptide/glucose ratio (2.57±2.65 vs. 0.56+0.98nmol/mmolx 10², p<0.001) were very significantly higher inolder patients. Patients with later onset disease thus had betterpreservation of pancreatic function, higher body mass indexand better glycaemic control on lower doses of insulin. Thesefeatures suggest that older insulin-treated patients could infact be ‘Type 2’ or non-insulin dependent patients,and the condition may be controllable with diet and/or oralhypoglycaemic agents, at least in some.     

Are drains required following a routine primary total joint arthroplasty?

The purpose of this study was to evaluate the benefits of suction drainage following primary total joint arthroplasty. We reviewed primary total hip and knee replacements separately and together in 126 consecutive patients. There were 63 patients each in the drainage and no drainage groups. Sex distribution and anticoagulant use were similar in the two groups. All patients underwent the same operative technique and method of closure. The mean postoperative fall in haemoglobin was 3.2 and 3.3 gm/dl in the drainage and no drainage groups respectively. There was no statistically significant difference between the two groups with regard to blood transfusion requirements, rehabilitation time, postoperative complications such as hypotension and wound infections (p>0.05). The average rehabilitation time in both groups was 8–9 days. The routine use of a suction drain is unnecessary after an uncomplicated total joint arthroplasty.

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Résumé Le sujet de cette étude était d’évaluer les bénéfices du drainage aspiratif après arthroplastie primaire. Nous avons revus 126 cas consécutifs d’arthroplastie totale de la hanche et du genou. Il y avait 63 patients dans chacun des groupes, drainés ou non drainés. La technique opératoire était la même chez tous les patients et le genre ainsi que le traitement anti-coagulant étaient similaires dans les deux groupes. La chute de l’hémoglobine était respectivement de 3,2 et 3,3 g/dl dans les groupes drainés et non drainés. Il n’y avait pas de différence significative entre les deux groupes pour la nécessité de transfusion, le temps de récupération, et les complications post-opératoires (p>0,05). Le temps moyen de récupération dans les deux groupes était de 8–9 jours. Le drainage aspiratif n’est pas nécessaire après une arthroplastie totale non compliquée.

     

Correlation of drug sensitivity in vitro with clinical responses in childhood acute myeloid leukemia

Clonogenic cells from 41 children with newly diagnosed acute myeloid leukemia (AML) were tested in vitro for their sensitivity to cytarabine (Ara-C) and daunorubicin (DNR). The findings were then compared with the patients' responses to induction chemotherapy that uniformly included Ara-C and DNR. Light-density marrow cells were incubated with either or both drugs for one hour and cultured over leukocyte feeder layers; clusters and colonies were scored on days 7, 10, and 14. Only the percentage of cell kill in the presence of 1.8 mumol/L DNR was significantly associated with responses to induction therapy: median of 45% (range, 0% to 98%) for patients achieving complete remission v 16% (range, 4% to 23%) for nonresponders (P = .007). The relationship between clonogenic cell kill less than or equal to 23% and clinical responses was striking. Of the 11 evaluable patients with in vitro findings in this category, ten either failed induction therapy or relapsed within 1 year after attaining remission. Kaplan-Meier analysis of relapse-free survival times indicated longer durations of remission for patients whose blast cells showed increased sensitivity in vitro to Ara-C alone, DNR alone, or a combination of the two agents. Seven of 11 patients with cell kills of greater than or equal to 49% in the presence of 1.25 mumol/L Ara-C remain free of leukemia, compared with only one of 12 whose cells were less sensitive to the drug (P = .006). We conclude that the in vitro sensitivity of clonogenic leukemic progenitors to DNR and Ara-C correlates with treatment outcome in children with newly diagnosed AML.     

Synthesis and bioactivity of novel caffeic acid esters from Zuccagnia punctata

Synthesis of novel caffeic acid esters (1 and 2) was accomplished starting from appropriately substituted benzaldehydes (3 and 9). While compound 2 exhibited potent anti-oxidative activity in both the nitroblue tetrazolium and 1,1-diphenyl-2-picrylhydrazyl radical-scavenging models, compound 1 showed moderate 5-lipoxygenase inhibitory activity.     

Clinical and user-friendly classification of traumatic digital nerve injuries of hand

INTRODUCTION: Surgical findings of traumatic neurapraxia and neurotmesis in digital nerve injuries of hand have significantly different prognosis and surgeons managing such injuries must be able to provide the expected incidence of these injuries along with decision on surgical exploration. There is a paucity of data in the literature defining the incidence of traumatic neurapraxia and neurotemesis in lacerated hand injuries with clinical features of digital nerve injury. MATERIALS AND METHODS: We carried out a study in an urban practice to understand this problem on 81 consecutive patients with 82 digital nerve injuries over 1.5 years. Seventy-two percent of the injuries were caused mainly in the domestic accidents by glass and knife. All patients had clinical features of digital nerve injury. RESULTS: Operative findings revealed nerve damage in 76 patients (confidence interval at 95% = 91-97). Seventy-one had severed nerves and underwent repair (CI at 95% = 80-95). There were 7% patients with operative findings of normal looking nerves and 6% of bruised but intact nerves. All of these 13% patients who did not require surgical repair were grouped as traumatic neurapraxia and showed complete clinical recovery. CONCLUSION: Traumatic neurapraxia in digital nerve injuries of the hand are not uncommon, as previously thought, following lacerated injuries to hand and have favourable prognosis. This information is important for clinicians in getting more informed consent and patient education. The classification of digital nerve injuries into traumatic neurapraxia and neurotemesis appears logical for its practical application in routine clinical practice.     

Effect of rifampicin in the treatment of pruritus in hepatic cholestasis

Pruritus in hepatic cholestasis has been suggested to be secondary to a high concentration of serum bile acids. Rifampicin, which inhibits the uptake of bile acids by hepatocytes, has been used to treat pruritus. To determine the efficacy of rifampicin as a treatment for refractory pruritus, the medical records of 33 children (median age 25 months, range 4-135; 19 boys) with chronic cholestasis liver disease (21 with Alagille's syndrome, eight with progressive intrahepatic cholestasis, one with extrahepatic biliary atresia, one with an inborn error of bile acid metabolism, and one with cryptogenic cirrhosis) were reviewed retrospectively. The median dose of rifampicin was 5(4-10) mg/kg/day. The median duration of intake was 36(4-120) weeks. Complete relief of pruritus was noted in five (15%) patients and a partial response in 12 (36%). Overall, no significant difference was noted in the laboratory parameters before and after treatment with rifampicin. In the 21 patients with Alagille's syndrome, however, a significant decrease in alkaline phosphatase was seen before and after one and six months of starting treatment. No adverse side effects were seen. Rifampicin appears to be effective in the treatment of refractory pruritus. A prospective study is warranted to assess further the effect of rifampicin treatment in children with hepatic cholestasis.