Response to treatment with rosiglitazone in familial partial lipodystrophy due to a mutation in the LMNA gene

Background Familial partial lipodystrophy (FPLD) is a monogenic form of diabetes characterised by a dominantly inherited disorder of adipose tissue associated with the loss of subcutaneous fat from the limbs and trunk, with excess fat deposited around the face and neck. The lipodystrophy causes severe insulin resistance, resulting in acanthosis nigricans, diabetes, dyslipidaemia, and increased risk of cardiovascular disease. Preliminary results from animals and man suggest that increasing subcutaneous fat by treatment with thiazolidinediones should improve insulin resistance and the associated features of this syndrome. Case report We report a 24-year-old patient with FPLD caused by a mutation in the LMNA gene (R482W) treated with 12 months of rosiglitazone. Subcutaneous fat increased following rosiglitazone treatment as demonstrated by a 29% generalised increase in skin-fold thickness. Leptin levels increased from 5.8 to 11.2 ng/ml. Compared with treatment on Metformin, there was an increase in insulin sensitivity (HOMA S% 17.2–31.6) but no change in glycaemic control. The lipid profile worsened during the follow-up period. Conclusion This initial case suggests that, for modification of cardiovascular risk factors, there are no clear advantages in treating patients with FPLD with rosiglitazone despite increases in subcutaneous adipose tissue. Larger series will be needed to identify moderate beneficial effects and treatment may be more effective in patients with generalised forms of lipodystrophy.     

Preventing vaginal stenosis after brachytherapy for gynaecological cancer: an overview of Australian practices.

Despite advances in brachytherapy techniques in recent years, patients still experience a variety of treatment-related complications. Vaginal stenosis is a recognised toxicity of brachytherapy for the treatment of gynaecological cancer. It can result in long-term sexual dysfunction and painful vaginal examinations; however, it is generally accepted that it may be prevented by regular sexual intercourse or the use of vaginal dilators. The incidence of vaginal stenosis is variably reported in the literature, while preventative strategies and compliance are infrequently described and rarely evaluated. A telephone survey of radiation oncology centres in Australia was undertaken as a quality improvement activity to determine best practice for the use of vaginal dilators for the prevention of vaginal stenosis, by way of identifying similarities of practice. The results revealed a lack of consistency for all variables, including which patients are advised to use vaginal dilators, the time to initiate use, frequency of use, insertion time and duration of use. These findings suggest that current methods for preventing radiation-induced vaginal stenosis warrant formal evaluation in order to establish an evidence base for practice.     

Lofepramine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy in depressive illness

Lofepramine is a tricyclic antidepressant that is structurally similar to imipramine and is extensively metabolised to desipramine. In the absence of other major pharmacological effects it appears that its antidepressant activity stems from the facilitation of noradrenergic neurotransmission by uptake inhibition, and possibly by the additional facilitation of serotoninergic neurotransmission. The overall therapeutic efficacy of lofepramine is comparable to that of imipramine, amitriptyline, clomipramine, maprotiline and mianserin in patients with depression of varying severity, and coexisting anxiety. Dry mouth is the most commonly reported side effect of usual therapeutic doses of lofepramine, but the incidence of this and other anticholinergic side effects is less among patients treated with lofepramine than with imipramine. Lofepramine has not been associated with adverse effects on cardiac function even in cases of attempted suicide by overdose. Thus, providing its apparent favourable side effect profile is confirmed in practice, lofepramine may be a valuable alternative for treatment of the depressed patient where a tricyclic is indicated.     

Effectiveness of training health professionals to provide smoking cessation interventions: systematic review of randomised controlled trials.

OBJECTIVE--To assess the effectiveness of interventions that train healthcare professionals in methods for improving the quality of care delivered to patients who smoke. DESIGN--Systematic literature review. SETTING--Primary care medical and dental practices in the United States and Canada. Patients were recruited opportunistically. SUBJECTS--878 healthcare professionals and 11,228 patients who smoked and were identified in eight randomised controlled trials. In each of these trials healthcare professionals received formal training in smoking cessation, and their performance was compared with that of a control group. MAIN MEASURES--Point prevalence rates of abstinence from smoking at six or 12 months in patients who were smokers at baseline. Rates of performance of tasks of smoking cessation by healthcare professionals, including offering counselling, setting dates to stop smoking, giving follow up appointments, distributing self help materials, and recommending nicotine gum. METHODS--Trials were identified by multiple methods. Data were abstracted according to predetermined criteria by two observers. When possible, meta-analysis was performed using a fixed effects model and the results were subjected to sensitivity analysis. RESULTS--Healthcare professionals who had received training were significantly more likely to perform tasks of smoking cessation than untrained controls. There was a modest increase in the odds of stopping smoking for smokers attending health professionals who had received training compared with patients attending control practitioners (odds ratio 1.35 (95% confidence interval 1.09 to 1.68)). This result was not robust to sensitivity analysis. The effects of training were increased if prompts and reminders were used. There was no definite benefit found for more intensive forms of counselling compared with minimal contact strategies. CONCLUSIONS--Training health professionals to provide smoking cessation interventions had a measurable impact on professional performance. A modest, but non-robust, effect on patient outcome was also found, suggesting that training alone is unlikely to be an effective strategy for improving quality of care, unless organisational and other factors are also considered.     

Sex differences in pattern of drinking.

Drinking patterns of male and female Long-Evans rats were compared during a 15-day drinking period. All animals were tested for preference for alcohol for 24 h during which food, water, and beer containing 5% ethanol were freely available. Animals drinking 50 ml or more of beer were chosen for the experiments. On days 1-5, animals were offered food, water, and beer containing 5% ethanol (v/v). On days 6-15, the concentration of ethanol in the beer was doubled to 10% (v/v). Preference ratios (beer/total fluid) were higher for females than males, and females consumed more grams of alcohol per unit of body weight. When alcohol concentration was doubled, females increased alcohol intake (g/kg), while males tended to titrate alcohol intake to levels consumed at 5% concentration. Female patterns of drinking differed from male patterns of drinking.     

Closed interlocking nailing of the femur complicated by an intramedullary calcified lesion

The interlocking intramedullary nail has greatly expanded the indications for closed intramedullary nailing of the femur. We describe a complication caused by the presence of a calcified lesion located at the proximal metaphyseal-diaphyseal junction of the femur. This lesion could not be penetrated by hand reamers. We used a long 3.5-mm drill bit to place a hole in the infarct, which then allowed passage of the hand reamer. The operation then proceeded in the standard fashion without complications.     

Issues surrounding chiropractic fee negotiations in Saskatchewan

Chiropractic fee negotiations in Saskatchewan utilize the Chiropractic Compensation Review Committee with recourse to the Chiropractic Consultation Committee. Health care professionals who practise on a fee for service basis provide the government with a budgetary problem. Although the fees are set, the health care provider can determine his own income by deciding how many visit services he/she wishes to provide. In the fiscal years 1981-82 to 1990-91, chiropractors earned $699.00 per year more than one would expect given the increases in fee schedules. Each chiropractor earned $2,329.00 per year more than was necessary to make up for losses due to inflation. The allegation that unnecessary treatments were performed on patients is countered by analysis of the services per discrete patient values by mode of practice. The increased earnings of chiropractors was accomplished by treating an increasing percentage of the population who sought health care. Comparative information was obtained from the four western provinces.     

Practical application of comfort theory in the perianesthesia setting.

Comfort management is a priority for patients in all settings. Comfort theory provides a foundational and holistic approach to comfort management. This article reviews comfort theory and presents the application of comfort theory in the perianesthesia setting. OBJECTIVES: -Based on the content of the following article, the reader will be able to (1) define comfort; (2) identify comfort interventions; and (3) discuss the importance of a goal for enhanced comfort in patients.