All-cause and cardiovascular mortality in diabetic subjects increases significantly with reduced estimated glomerular filtration rate (eGFR): 10 years' data from the South Tees Diabetes Mortality study.

AIMS: To investigate the association between estimated glomerular filtration rate (eGFR) and total and cardiovascular mortality in a population-based cohort of diabetic subjects. METHODS: A longitudinal study using a population-based district diabetes register comprising 3288 subjects in South Tees, UK. The eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Patients were stratified by baseline eGFR into five stages as per the National Kidney Foundation guidelines: Stage 1, eGFR > 90; Stage 2, eGFR 60-89; Stage 3, eGFR 30-59; Stage 4, eGFR 15-29; and Stage 5, eGFR < 15 ml/min per 1.73 m(2). Main outcome was all-cause and cardiovascular mortality between 1 January 1994 and 31 July 2004. RESULTS: At baseline, mean age (58.4 years) differed between groups. Persons with lower eGFR were older (P < 0.001). Thirty-six percent (n = 1193, males 56%) had died by 10 years (cardiovascular cause in 60%). Median follow-up was 10.5 years amounting to 28 342 person years. Stages 4 and 5 (eGFR

The Evolving Role of the Acute Assessment Unit - from inpatient to outpatient care.

Acute Assessment Units (AAUs) have been developed to meet the demand for emergency care. Traditionally, AAUs have been an admission route to secondary care but the role is now evolving to assessment. AAUs are complex and have many interactions both in hospitals and the community. The effective functioning of an AAU requires excellent clinical leadership, appropriate facilities, timely access to diagnostics and input from the multi-disciplinary team. Increasingly, AAUs will have to develop services which are not dependent on using hospital beds. A variety of emergency medical presentations can, with the appropriate resources, be delivered in an out-patient setting.

Four pedigrees of the cation-leaky hereditary stomatocytosis class presenting with pseudohyperkalaemia. Novel profile of temperature dependence of Na+-K+ leak in a xerocytic form.

We report four pedigrees of the group of Na(+)-K(+)-leaky red cell disorders of the 'hereditary stomatocytosis' class. Each showed pseudohyperkalaemia because of temperature-dependent loss of K(+) from red cells on storage of whole blood at room temperature. All pedigrees showed an abnormality in the temperature dependence of the 'passive leak' of the membrane to K(+). Two pedigrees, both of which showed a compensated haemolytic state with dehydrated red cells and target cells on the blood film, showed a novel pattern, in which the profile was flat between 37 degrees C and about 32 degrees C then dropped as the temperature was reduced to zero. The third showed the 'shallow slope' profile, with stomatocytes on the blood film and very markedly abnormal intracellular Na(+) and K(+) levels. Minimal haemolysis was present. The fourth pedigree, of Asian origin, showed the shoulder pattern (minimum at 32 degrees C, maximum at 12 degrees C) with essentially normal haematology. Both of these latter two forms have previously been seen in other pedigrees. The first variant represents a novel kind of temperature dependence of the passive leak found in these pedigrees presenting with pseudohyperkalaemia.

Knowledge and practice of foot care in people with diabetes.

AIM: To determine knowledge and practice of foot care in people with diabetes. METHODS: A questionnaire was completed by patients in Middlesbrough, South Tees, UK. A knowledge score was calculated and current practice determined. Practices that put patients at risk of developing foot ulcers and barriers to good practice were identified. Patients at high risk of ulceration were compared to those at low risk. RESULTS: The mean knowledge score was 6.5 (S.D. 2.1) out of a possible 11. There was a positive correlation between the score and having received advice on foot care (6.9 versus 5.4, P = 0.001). Deficiencies in knowledge included the inability to sense minor injury to the feet (47.3%), proneness to ulceration (52.4%) and effect of smoking on the circulation (44.5%). 24.6% (20.1-29.2) never visited a chiropodist, 18.5% (14.2-22.7) failed to inspect their feet and 83% (79.1-86.9) did not have their feet measured when they last purchased shoes. Practices that put patients at risk included use of direct forms of heat on the feet and walking barefoot. Barriers to practice of foot care were mainly due to co-morbidity. Those with high risk feet showed a higher (6.8) but not significant knowledge score compared to those at low risk (6.5) and their foot care practise was better. CONCLUSION: The results highlight areas where efforts to improve knowledge and practice may contribute to the prevention of foot ulcers and amputation.

HOPE for patients with Type 2 diabetes: an application of the findings of the MICRO-HOPE substudy in a British hospital diabetes clinic.

AIMS: The MICRO-HOPE substudy demonstrated that when ramipril treatment was added to people with Type 2 diabetes and additional cardiovascular risk factors cardiovascular events were reduced by 25% in 4.5 years. We wished to determine the proportion of people with Type 2 diabetes and additional cardiovascular risk factors registered with a hospital diabetes service. METHODS: Non-proteinuric people (n = 1370) with Type 2 diabetes identified on our diabetes register were subject to analysis. Anticipated reductions in cardiovascular events due to ramipril treatment were based on reductions observed in the MICRO-HOPE substudy. RESULTS: Non-proteinuric people (n = 1075 (78%)) with Type 2 diabetes had at least one additional cardiovascular risk factor. Twenty-nine percent were already taking an angiotensin-converting enzyme inhibitor. The remaining 764 patients were similar to ramipril-treated participants in the MICRO-HOPE substudy. Treatment with ramipril for 4.5 years would be anticipated to reduce cardiovascular deaths by 26, revascularization procedures by 19 and admissions for myocardial infarction and stroke by 18 and 26, respectively. CONCLUSIONS: Of non-proteinuric people with Type 2 diabetes, 78% have additional cardiovascular risk factors. Only a small proportion currently receive treatment with an angiotensin-converting enzyme inhibitor. The incidence of cardiovascular events could be reduced if more patients were treated with ramipril and other cardiovascular risk factors were addressed.

A new variant of Carney's triad: phaeochromocytoma and chondrosarcoma.

A 61 year old hypertensive woman presented in 1986 with a right scapular chondrosarcoma. She developed type 1 diabetes mellitus in 1991 and suffered a stroke in 1991. Chest radiography showed pulmonary metastases in 1997. Further radiological staging detected a right sided phaeochromocytoma, which was subsequently removed in 1998. Before this, repeated urine estimations of vanillylmandelic acid had been normal. Her diabetes was cured by adrenalectomy. It is believed that the combination of phaeochromocytoma and extrapulmonary chondrosarcoma represents a new variant of Carney's triad.

Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study.

OBJECTIVES: To establish the age and sex specific mortality for people with diabetes in comparison with local and national background populations; to investigate the relationship between mortality and material deprivation in an unselected population with diabetes. DESIGN: Longitudinal study, using a population based district diabetes register. SETTING: South Tees, United Kingdom. PARTICIPANTS: All people known to have diabetes living in Middlesbrough and Redcar and Cleveland local authorities on 1 January 1994. MAIN OUTCOME MEASURE: Death, from any cause, between 1 January 1994 and 31 December 1999. RESULTS: Over the six years of the study 1205 (24.9%) of 4842 participants died. All cause standardised mortality ratios for type 1 diabetes were 641 (95% confidence interval 406 to 962) in women and 294 (200 to 418) in men, and those for type 2 diabetes were 160 (147 to 174) in women and 141 (130 to 152) in men. Cause specific standardised mortality ratios were increased for ischaemic heart disease, cerebrovascular disease, and renal disease; no reductions in mortality from other causes were seen. The risk of premature death increased significantly with increasing material deprivation (P<0.001). CONCLUSIONS: Diabetes is associated with excess mortality, even in an area with high background death rates from cardiovascular disease. This excess mortality is evident in all age groups, most pronounced in young people with type 1 diabetes, and exacerbated by material deprivation. Aggressive approaches to the management of cardiovascular risk factors could reduce the excess mortality in people with diabetes.

Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas.

OBJECTIVE: To establish the relation between socioeconomic status and the age-sex specific prevalence of type 1 and type 2 diabetes mellitus. The hypothesis was that prevalence of type 2 diabetes would be inversely related to socioeconomic status but there would be no association with the prevalence of type 1 diabetes and socioeconomic status. SETTING: Middlesbrough and East Cleveland, United Kingdom, district population 287,157. PATIENTS: 4313 persons with diabetes identified from primary care and hospital records. RESULTS: The overall age adjusted prevalence was 15.60 per 1000 population. There was a significant trend between the prevalence of type 2 diabetes and quintile of deprivation score in men and women (chi 2 for linear trend, p < 0.001). In men the prevalence in the least deprived quintile was 13.4 per 1000 (95% confidence intervals (95% CI) 11.44, 15.36) compared with 17.22 per 1000 (95% CI 15.51, 18.92) in the most deprived. For women the prevalence was 10.84 per 1000 (95% CI 9.00, 12.69) compared with 15.48 per 1000 (95% CI 13.84, 17.11) in the most deprived. The increased prevalence of diabetes in the most deprived areas was accounted for by increased prevalence of type 2 diabetes in the age band 40-69 years. There was no association between the prevalence of type 1 diabetes and socioeconomic status. CONCLUSION: These data confirm an inverse association between socioeconomic status and the prevalence of type 2 diabetes in the middle years of life. This finding suggests that exposure to factors that are implicated in the causation of diabetes is more common in deprived areas.

Socio-economic status and membership of the British Diabetic Association in Scotland.

Socio-economic status is an important predictor of mortality and morbidity in the diabetic and non-diabetic population. Improving the representation of people from deprived areas in vocal pressure groups may foster practical ideas which would improve health outcome. The general public may be represented through a variety of local and national organizations. The British Diabetic Association (BDA) represents people with diabetes mellitus, their relatives, and their health care professionals. Assuming a uniform diabetes prevalence of 1.5%, there would be 75484 diabetic people in Scotland, of which only 5649 (7.5%) are currently members of the BDA. Using area based codes of socio-economic status, it was calculated that the odds ratios of BDA membership in the most affluent category (1) to the most deprived category (7) were 1.00, 0.81, 0.68, 0.57, 0.45, 0.43 and 0.21, respectively (p < 0.00001). Studies reporting on patient cohorts derived from the BDA membership files will include a higher proportion of patients from the most affluent categories, thus, these studies may underestimate overall morbidity and mortality. By promoting membership in the deprived categories it may be possible to develop a clearer picture of diabetes mellitus and new ideas which would help to narrow the health divide.

An ovarian lipid cell tumour causing virilization and Cushing's syndrome.

We report a 73-year-old woman with rapidly developing symptoms and signs of Cushing's syndrome and high urinary free cortisol. She was virilized and hirsute with testosterone levels which became exceptionally high. ACTH was suppressed and CT scan of the adrenals and pelvis showed no abnormality. Ultrasound scanning showed enlargement of the left ovary. Venous catheter studies suggested a left ovarian source. A 2-cm diameter lipid cell tumor was removed from the left ovary laparoscopically. Histology was initially benign, and clinical and biochemical cure of Cushing's syndrome was rapid. However, the neoplastic nature of the ovarian tumour was demonstrated 12 months later when peritoneal metastases were detected and there was then clinical and biochemical relapse.

Metformin treatment in NIDDM patients with mild renal impairment.

Metformin is contraindicated in patients with renal failure because of the risk of lactic acidosis. This study assessed the complications of metformin treatment in patients with non-insulin-dependent diabetes mellitis with normal and raised serum creatinine. Subjects using metformin with serum creatinine above the upper reference range (120 mu mol/l) were identified (n = 17) from a hospital diabetes register; those with abnormal liver function, cardiac failure, peripheral vascular disease or recent severe illness were excluded. Reference plasma lactate levels were established, mean 1.742 mu mol/l (SD 0.819) using age-matched non-diabetic subjects. Age-matched patients treated with metformin with normal serum creatinine levels formed the control group (n = 24). Details of gastrointestinal disturbance were recorded, and plasma lactic acid and vitamin B12 levels measured. The median total daily dose of metformin in both groups was 1700 mg. The mean plasma lactate in subjects with serum creatinine 80-120 mu mol/l (2.640 mmol/l (SD 1.434) p < 0.02) was higher than non-diabetic control levels while diabetic subjects with serum creatinine 120-160 mumol/l had a mean of 2.272 mmol/l (SD 0.763) p < 0.05. There was no significant difference between the two groups taking metformin, nor any significant difference in the reporting of gastrointestinal symptoms between the groups on metformin (11.76% vs 12.5%). Plasma lactic acid levels are higher in diabetic subjects taking metformin compared with healthy volunteers but, within the diabetic groups, the small elevation of serum creatinine was not associated with higher plasma lactate levels.

Socioeconomic status and clustering of cardiovascular disease risk factors in diabetic patients.

OBJECTIVE: Correction of cardiovascular risk factors is an essential component of good diabetes care. Our goal was to examine the relationship of socioeconomic status in five risk factors: obesity, hypertension, high cholesterol, smoking, and high HbA1c. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional prevalence study of all patients with diabetes (n = 1,553) attending a clinic in Glasgow, U.K. Area-based codes were used to measure socioeconomic status; these ranged from 1, the most affluent, to 7, the most deprived. RESULTS: Comparing patients with NIDDM from the seven categories of socioeconomic status, we found that those from deprived categories experienced a higher prevalence of obesity. In the most affluent groups, 30% had a BMI > 30 kg/m2 compared with 47% in the most deprived categories (P < 0.002). With regard to smoking, 13% in the most affluent category smoked compared with 33% in the most deprived (P < 0.001). In patients with IDDM from affluent categories, 13% smoked compared with 34% from deprived categories (P < 0.001). The proportion of patients with no cardiac risk factors fell by 30.6% from deprived category 1 to 7 (P < 0.001), and the proportion of patients with three or more risk factors rose from 8.6% in category 1 to 20.2% in category 7. CONCLUSIONS: Diabetic patients from areas of low socioeconomic status are at increased risk of cardiovascular disease. To counter this, specific health education programs should be evolved and resources should be directed toward these areas.

Battered granny or spontaneous fractures? A legal dilemma.

A 70-year-old woman was admitted from a local nursing home with extensive bruising and bilateral hip discomfort. The referring doctor had reported the possibility of elder abuse to the police. Full examination showed that osteomalacia, precipitated by a poor diet and lack of exposure to sunlight, was sufficient to explain the patient's condition. Caution is recommended in diagnosing elder abuse until other possibilities have been excluded.

A study of fluoxetine in obese elderly patients with type 2 diabetes.

In order to establish the safety and efficacy of fluoxetine in subjects over 60 years of age with Type 2 diabetes, a randomized, double-blind, parallel study of 30 obese subjects was undertaken, comparing the use of fluoxetine 60 mg daily with placebo. Subjects were diet controlled with an HbA1 < 14% (reference range 6-9%) and BMI > 29 kg m2. Those taking fluoxetine had a median weight loss of 2.6 kg at 3 months (p < 0.001) and 3.9 kg at 6 months (p < 0.02), compared with weight loss in the placebo group of 0.1 kg and 0.0 kg at 3 and 6 months, respectively. Improved glycaemic control was also demonstrated in the fluoxetine group compared with placebo, initial HbA1 levels of 8.0% vs 8.7% (NS) falling at 4 months by 0.9% (p < 0.02) and at six months by 0.9% (p < 0.02). No sustained improvement in fasting blood glucose levels was demonstrated. Reporting of adverse events was similar in both groups. Fluoxetine in the short term aids weight loss and improves glycaemic control without a significant increase in adverse events in elderly Type 2 diabetic subjects.

Paternal inheritance of mitochondria and chloroplasts in Festuca pratensis-Lolium perenne intergeneric hybrids.

Organelle inheritance in intergeneric hybrids of Festuca pratensis and Lolium perenne was investigated by restriction enzyme and Southern blot analyses of chloroplast DNA (cpDNA) and mitochondrial DNA (mtDNA). All F1 hybrids exhibited maternal inheritance of both cpDNA and mtDNA. However, examination of backcross hybrids, obtained by backcrossing the intergeneric F1 hybrids to L. Perenne, indicated that both uniparental maternal organelle inheritance and uniparental paternal organelle inheritance can occur in different backcross hybrids.