Suspected malignant cord compression - improving time to diagnosis via a 'hotline': a prospective audit.

The aim of the study was to achieve earlier diagnosis of malignant cord compression (MCC) using urgent magnetic resonance imaging (MRI) for selected patients. A comparison was carried out of the current prospective audit of 100 patients referred by a general practitioner or a consultant over 32 months with both a previous national Clinical Research and Audit Group (CRAG) prospective audit (324 cases of MCC) and an earlier retrospective audit of 104 patients referred with suspected MCC. A telephone hotline rapid-referral process for patients with known malignancy and new symptoms (severe nerve root pain +/- severe back pain) was designed. Patients were considered for urgent MRI after discussion with a senior clinician responsible for the hotline. Appropriate referrals were discussed with radiology and oncology ensuring timely MRI reporting and intervention. The main outcome measures are as follows: time from referral to diagnosis; time from the onset of symptoms to diagnosis; and mobility at diagnosis. A total of 50 patients (52%) of those scanned had either MCC (44) or malignant nerve root compression (6) compared with the earlier rate of 23 out of 104 patients (22%). Ten out of 44 MCC patients (23%) were paralysed at diagnosis, compared with 149 out of 324 (46%) in the CRAG audit. Time from reporting pain to diagnosis was 32 days compared with 89 days in the CRAG audit. Median time from referral to diagnosis was 1 day, again considerably shorter than the CRAG audit time of 15 days (interquartile (IQ) range: 3-66). In patients at risk of MCC, fast-track referral with rapid access to MRI reduces time between symptom onset and diagnosis, improves mobility at diagnosis and reduces the number of negative MRI scans.

A clinical MRI investigation of the relationship between kidney volume measurements and renal function in patients with renovascular disease.

Recent improvements in MR image acquisition and post-processing techniques have allowed quantitative kidney volume measurements to be derived from patient studies. These morphological indices can provide "snapshot" assessments that may be related to kidney function. The study objective was to measure cortical and total kidney volumes in patients with renovascular disease (RVD) using contrast-enhanced MR angiography (CE-MRA) in order to assess the reproducibility of the technique and to investigate associations between volumes and renal function as measured by glomerular filtration rate (GFR) calculations. 50 patients with RVD were scanned using CE-MRA. Kidney lengths, volumes and renal artery stenoses (RAS) were evaluated, and GFR was calculated using clinical formulae and nuclear medicine isotope renography. Mean MRI kidney lengths were 10.3+/-0.2 cm, and mean MRI volumes were 74.9+/-3.6 cm3 (cortical) and 128.5+/-5.3 cm3 (total). Kidneys supplied by moderately stenosed arteries had enlarged lengths and volumes, whilst those supplied by severely stenosed arteries had significantly smaller lengths (p<0.001) and volumes (p<0.001). There was a clear association between MRI cortical volume and GFR (r = 0.74, p<0.001, n = 48), but less so between kidney length and GFR (r = 0.54, p<0.001, n = 48). For individual patients, left/right cortical volume differences were small provided that severe RAS was not present, but large left/right volume differences and a GFR reduction were noted when severe RAS was present. The cortical volume distribution provides a useful single-timepoint indication of kidney function as defined by GFR, with no additional data acquisition required other than that of standard CE-MRA examination.

Reduced prevalence of impaired glucose tolerance and no change in prevalence of diabetes despite increasing BMI among Aboriginal people from a group of remote homeland communities.

OBJECTIVE: To examine trends in glucose tolerance and coronary risk among Aboriginal people from a group of homeland communities in central Australia during a 7-year follow-up period. RESEARCH DESIGN AND METHODS: Community-based screenings of adult volunteers were performed in 1988 (n = 437; 93% response rate) and in 1995 (n = 424; 85% response rate). A health promotion intervention program commenced after the 1988 survey that focused on the benefits of exercise and appropriate diet. RESULTS: Mean (95% CI) BMI increased significantly from 22.8 kg/m2 (22.3-23.2) to 24.2 kg/m2 (23.8-24.7) during the follow-up period (P < 0.001). This increase was similar for men and women and across all age-groups. The increase in BMI was greater among subjects residing adjacent to a store compared with those residing in communities located far from a store (P < 0.001). Decreases were evident in the prevalence of impaired glucose tolerance (IGT) (from 22.5 to 10.1% among women, P < 0.001; from 12.2 to 6.5% among men, P = 0.074) and hypercholesterolemia (from 36.7 to 25.8% among women, P < 0.01; from 52.4 to 44.0% among men, P = 0.147), but no change was evident in the prevalence of diabetes. Smoking remained rare among women (<4%) and decreased among men (from 52.9 to 40.8%, P < 0.05). CONCLUSIONS: The trends in glucose intolerance were clearly better than have been observed in other Aboriginal communities. The institution of an intervention program corresponded with reductions in the prevalence of IGT, hypercholesterolemia, and smoking. The prevalence of diabetes remained unaltered despite a significant increase in mean BMI, possibly because of the promotion of increased physical activity levels.

Abnormal glucose tolerance and other coronary heart disease risk factors in an isolated aboriginal community in central Australia.

OBJECTIVE: To determine the age- and sex-specific prevalence of diabetes, impaired glucose tolerance (IGT), and coronary heart disease risk factors in a remote central Australian Aboriginal community maintaining some degree of traditional lifestyle, living in homeland communities on their ancestral land. RESEARCH DESIGN AND METHODS: A cross-sectional survey of 437 subjects > or = 15 years of age (189 men, 248 women), representing 80% of the adult population residing in the community at the time of the survey, was performed and the following parameters measured: BMI, glucose tolerance, circulating insulin and lipids, and blood pressure. RESULTS: The mean BMI for this population was 22.9 +/- 4.8 kg/m2. The prevalence of diabetes in the age group of 15-34 years (103 men and 140 women) was 2 and 6% for men and women, respectively. In the 35-years-and-older age group (86 men and 108 women), diabetes prevalence was 19 and 13% for men and women, respectively. Over half the diabetic subjects did not exhibit fasting hyperglycemia. IGT occurred in 8 and 15% of younger men and women, respectively, and in 17 and 32% of older men and women, respectively. Smoking was common among men (53% current smokers) but rare among women (2% current smokers). The prevalence of hypercholesterolemia, hypertriglyceridemia, hypertension, and overweight rose with increasing degrees of glucose intolerance. The two communities adjacent to the only store in the area had a higher prevalence of abnormal glucose tolerance than did the more remote homeland communities (odds ratio for abnormal glucose tolerance: 2.92; 95% CI 1.51-5.63). CONCLUSIONS: Despite their relative leanness, this Aboriginal population exhibited relatively high prevalences of IGT and diabetes without fasting hyperglycemia. The data suggest a protective effect of a decentralized mode of living, as opposed to a more urbanized lifestyle, on the occurrence of glucose intolerance. Abnormal lipid profiles (particularly high triglycerides and low HDL cholesterol) and the high prevalence of smoking in men indicated a high-risk profile for coronary heart disease in this population.