Multiple Cerebral Haematomata and Peripheral Nerve Palsies Associated with a Case of Juvenile Diabetic Ketoacidosis

A 15-year-old girl presented de novo in diabetic ketoacidosis having been comatose for 24 h (day 1). A CT scan and lumbar puncture performed on admission were normal and her conscious level slowly improved over several days. On day 7 she had central neurological signs of bilateral knee clonus and an extensor plantar response. In addition, she had developed lower motor neurological signs of an ulnar nerve palsy of the left forearm, and ulnar, median, and radial nerve palsies of the right forearm. Magnetic resonance imaging (MRI), performed on day 12, showed multiple small cerebral haematomata with appearances at least several days of age. The scattered lesions were localized particularly to the parieto-occipital region, with sparing of the basal ganglia and without cerebral oedema, a novel feature not previously described in juvenile ketoacidosis. Four months later there was minimal residual disability of her right arm. The clinical findings together with the MRI images suggested that the peripheral nerve and central lesions were temporally related, suggesting a common aetiology. However, it is likely that MRI showed cerebral lesions which may have been missed by the conventional CT scanning performed initially.     

International cancer patterns in men: geographical and temporal variations in cancer risk and the role of gender

The comparison of disease risk in populations stratified by certain demographic variables provides important clues as to the underlying causes of disease. There are fundamental variations in the risk of occurrence of different cancers by gender, area of residence, and time of diagnosis. Men are, for instance, at considerably higher risk of developing most of the common cancers that occur in both sexes, and there are substantial variations in the occurrence of particular cancers in different regions of the World. This paper attempts to highlight some of these remarkable variations using cancer incidence data by sex, area of residence and year of diagnosis, emphasising the strong evidence that many of the contrasts can be appropriated to a number of modifiable “environmental” factors.Rates of cancer occurrence in the developed world are double that of less developed regions, although risk patterns are of very different magnitude and direction depending on the cancer site examined. Lung cancer is the most common neoplasm in men globally, but is overshadowed by prostate cancer in certain westernised countries, notably in the U.S. Cancers of the colon and rectum are important in the developed world, whereas stomach and liver cancer are common in developing areas.Men have systematically higher rates than women for the vast majority of the tumours that develop in both sexes, with the exception of thyroid cancer. There are also huge variations in the extent of the inequality: men have notably elevated risks, relative to women, of developing tumours of the head and neck, bladder, lung, oral cavity and liver.In Europe, incidence trends of lung cancer tend to be declining in men, although there is substantial between-country variation. In women, lung cancer rates are systematically on the increase in most Western, Southern and European countries. Trends in prostate cancer are increasing, as are trends in colorectal cancer (in both sexes), although more noticeably in Southern and Eastern Europe. Stomach cancer continues to fall in most European areas. Bladder cancer is decreasing in both men and women, apart from in Eastern Europe, whereas cancers of the kidney and non-Hodgkin lymphoma are steadily increasing in both sexes.We have estimated that men have better and more readily achievable prospects of avoiding death from cancer since they have lower rates of gender specific cancers, that are probably hormonal in origin, then women. Tobacco consumption plays a dominating role in the excess risk of cancer in men but it is apparent that the male excess disease burden can be effectively reduced by various prevention measures. As well as avoiding (or quitting) smoking, these include, moderating alcohol consumption, avoiding obesity, undertaking regular physical exercise, and maintaining a diet high in fruit and vegetables. The adoption of a healthier lifestyle will be of considerable benefit to the general health of both men and women, with an expectation of a major reduction in the burden of cancer, as well as other major diseases.     

The expression of somatostatin receptors 1 and 2 in benign,pre‐malignant and malignant laryngeal lesions

The expression of somatostatin receptors 1 and 2 in benign, pre‐malignant and malignant laryngeal lesions The role of chemotherapy in squamous cell carcinoma of the larynx has not been clearly defined. Whilst toxic chemotherapy regimes may confer a marginal improvement in survival, surgery and radiotherapy remain the mainstay of treatment. Somatostatin is a naturally occurring peptide, which exerts antiproliferative and antiangiogenic effects via five membrane‐bound receptor subtypes. The expression of somatostatin receptor subtypes (SSTRs) 1 and 2 was studied in benign, pre‐malignant and malignant laryngeal specimens. Epithelial expression of SSTR1 was detected in 4/6 (67%) Reinke's oedema, 5/6 (83%) pre‐malignant and 8/12 (67%) malignant specimens, with virtually no stromal or vascular expression. High levels of epithelial SSTR2 expression were noted in all Reinke's oedema specimens, compared with low‐to‐moderate levels in only 2/6 (33%) pre‐malignant and 3/12 (25%) malignant specimens (P < 0.01). This ‘loss’ of epithelial SSTR2 expression may provide a growth advantage in pre‐malignant and malignant laryngeal lesions. Vascular expression of SSTR2 was ubiquitous in all groups, with scant stromal expression. Overall, most (>80%) pre‐malignant and malignant laryngeal specimens expressed at least one of the two SSTR subtypes studied. Somatostatin analogues may have a therapeutic role in squamous cell carcinoma of the larynx.     

Should surgeons repair symptomatic,clinically occult,radiologically evident,inguinal hernias? A case–control study of patient-reported outcomes

Hernia - Patients who present with symptomatic, clinically occult, radiologically evident (SCORE) inguinal hernia represent diagnostic and therapeutic challenge with a wide differential diagnosis...     

Diet composition and body composition in preschool children

BACKGROUND: In studies of adult humans and in animal models, dietary intakes of the macronutrients, particularly fat, are related to body composition; however, data on children are more scarce. OBJECTIVE: We sought to determine whether diet composition is related to percentage body fat in children aged 1.5-4.5 y. DESIGN: In 77 preschool children, a 4-d weighed-food record was used to determine intakes of total energy and energy from each macronutrient. An oxygen-18 dilution method was used to calculate percentage body fat. Habitual physical activity level was determined by calculating the ratio of total energy expenditure (from stable isotope analyses) to predicted basal metabolic rate. Dietary intake and body-composition data were analyzed to evaluate whether diet composition was related to body fat. Further analyses incorporating physical activity level were performed. RESULTS: Percentage body fat was not significantly correlated with dietary intake variables (total energy or percentage of energy from fat, carbohydrate, or protein) and did not differ significantly among 3 increasing levels of each dietary intake variable by analysis of variance. In multiple regression analysis, physical activity level was related to body fat whereas diet composition was not. CONCLUSIONS: We found no relations between dietary intakes of total energy, fat, carbohydrate, or protein and percentage body fat in children. The relation between fat intake and body fat may develop over time and may not be evident in preschool children. Energy expenditure, in particular physical activity level, may have a greater influence on body composition in early childhood.     

Biological variation of cardiovascular risk factors in patients with diabetes

Biological variation refers to the natural fluctuations found when repeated measurements are made in a biological system. Generally, biological variation remains within narrow boundaries in health, but may differ in pathological states, with implications for the diagnosis and monitoring of disease processes. In disease, biological variation may alter such that any subsequent measurement may need to have a greater difference compared with a healthy control to be biologically relevant. Treatments such as insulin or anti‐hypertensive therapy have been shown to reduce biological variability closer to normal levels and theoretically this may help prevent complication development or progression in conditions such as diabetes. This article reviews how biological variation can influence our identification and assessment of vascular risk factors in a person with diabetes. The role of biological variation in the diagnosis of diabetes (glucose and HbA_1c) is then examined. Finally, the influence that common treatments in diabetes have in modifying biological variation is described.     

The school environment and adolescent physical activity and sedentary behaviour: a mixed‐studies systematic review

There is increasing academic and policy interest in interventions aiming to promote young people's health by ensuring that the school environment supports healthy behaviours. The purpose of this review was to summarize the current evidence on school‐based policy, physical and social‐environmental influences on adolescent physical activity and sedentary behaviour. Electronic databases were searched to identify studies that (1) involved healthy adolescents (11–18 years old), (2) investigated school‐environmental influences and (3) reported a physical activity and/or sedentary behaviour outcome or theme. Findings were synthesized using a non‐quantitative synthesis and thematic analysis. Ninety‐three papers of mixed methodological quality were included. A range of school‐based policy (e.g. break time length), physical (e.g. facilities) and social‐environmental (e.g. teacher behaviours) factors were associated with adolescent physical activity, with limited research on sedentary behaviour. The mixed‐studies synthesis revealed the importance of specific activity settings (type and location) and intramural sport opportunities for all students. Important physical education‐related factors were a mastery‐oriented motivational climate and autonomy supportive teaching behaviours. Qualitative evidence highlighted the influence of the wider school climate and shed light on complexities of the associations observed in the quantitative literature. This review identifies future research needs and discusses potential intervention approaches to be considered.