Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with Type 2 diabetes mellitus: results from the Patient Empowerment Programme.

AIM: To assess whether a structured diabetes education programme, the Patient Empowerment Programme, was associated with a lower rate of all-cause hospitalization and emergency department visits in a population-based cohort of patients with Type 2 diabetes mellitus in primary care. METHODS: A cohort of 24 250 patients was evaluated using a linked administrative database during 2009-2013. We selected 12 125 patients with Type 2 diabetes who had at least one Patient Empowerment Programme session attendance. Patients who did not participate in the Patient Empowerment Programme were matched one-to-one with patients who did, using the propensity score method. Hospitalization events and emergency department visits were the events of interest. Cox proportional hazard and negative binomial regressions were performed to estimate the hazard ratios for the initial event, and incidence rate ratios for the number of events. RESULTS: During a median 30.5 months of follow-up, participants in the Patient Empowerment Programme had a lower incidence of an initial hospitalization event (22.1 vs 25.2%; hazard ratio 0.879; P < 0.001) and emergency department visit (40.5 vs 44%; hazard ratio 0.901; P < 0.001) than those who did not participate in the Patient Empowerment Programme. Participation in the Patient Empowerment Programme was associated with a significantly lower number of emergency department visits (incidence rate ratio 0.903; P < 0.001): 40.4 visits per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 36.2 per 100 patients annually in those who did. There were significantly fewer hospitalization episodes (incidence rate ratio 0.854; P < 0.001): 20.0 hospitalizations per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 16.9 hospitalizations per 100 patients annually in those who did. CONCLUSIONS: Among patients with Type 2 diabetes, the Patient Empowerment Programme was shown to be effective in delaying the initial hospitalization event and in reducing their frequency.

Patient Empowerment Programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study.

AIMS: To assess whether a structured diabetes education programme, the Patient Empowerment Programme (PEP), was associated with a lower risk of first cardiovascular disease (CVD) event and all-cause mortality in a population-based cohort of patients with type 2 diabetes mellitus (T2DM) in primary care. METHODS: A Chinese cohort of 27 278 patients with T2DM and without previous CVD events on or before the baseline study recruitment date was linked to the Hong Kong administrative database from 2008 to 2013. The PEP was provided to patients with T2DM treated at primary care outpatient clinics through community trained professional educators. PEP non-participants were matched one-to-one with the PEP participants using a propensity score method with respect to their baseline covariates. Cox proportional hazard regression was performed to estimate the associations of the PEP with the occurrence of first CVD event, coronary heart disease, stroke, heart failure and death from any cause, controlling for baseline characteristics. RESULTS: During a median of 21.5 months follow-up, 795 (352 PEP participants and 443 PEP non-participants) patients experienced a first CVD event. After adjusting for confounding variables, PEP participants had a lower rate of all-cause mortality [hazard ratio (HR) 0.564, 95% confidence interval (CI) 0.445-0.715; p < 0.001], first CVD (HR 0.807, 95% CI 0.696-0.935; p = 0.004) and stroke (HR 0.702; 95% CI 0.569-0.867; p = 0.001) than those without PEP. CONCLUSIONS: Enrolment in the PEP was associated with lower all-cause mortality and a lower number of first CVD events among patients with T2DM. The CVD benefit of PEP might be attributable to improving metabolic control through empowerment of self-care and the enhancement of quality of diabetes care in primary care.

Prospective study on serum metal levels in patients with metal-on-metal lumbar disc arthroplasty.

PURPOSE: Metal-on-metal total disc replacement is a recent alternative treatment for degenerative disc disease. Wear and corrosion of these implants can lead to local and systemic transport of metal debris. This prospective longitudinal study examined the serum chromium and cobalt levels in 24 patients with cobalt-chromium alloy metal-on-metal lumbar disc replacements. METHODS: Serum was assayed for chromium (Cr) and cobalt (Co) using high-resolution inductively-coupled plasma-mass spectrometry. Detection limits were 0.015 ng/mL for Cr and 0.04 ng/mL for Co. RESULTS: Median serum Co levels at pre-op, 3, 6, 12, 24, and 36-months post-op were 0.10, 1.03, 0.96, 0.98, 0.67, and 0.52 ng/mL, respectively. Median serum Cr levels were 0.06, 0.49, 0.65, 0.43, 0.52, and 0.50 ng/mL, respectively. CONCLUSION: In general, these results indicated that serum Co and Cr levels are elevated at all postoperative time points and are of the same order of magnitude as those observed in well-functioning metal-on-metal surface replacements of the hip and in metal-on-metal total hip replacements at similar postoperative time points.

Reduced bone mineral density in male Severe Acute Respiratory Syndrome (SARS) patients in Hong Kong.

During the Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong in 2003, patients were treated with very high doses of corticosteroid and ribavirin. The detrimental effects of such treatment on the bone mineral density (BMD) of SARS patients are unknown. To compare the BMD of SARS patients with normal range data, a cross-sectional survey was conducted. The bone mineral density of 224 patients with SARS, who were treated with an average of 2753 mg (SD = 2152 mg) prednisolone and 29,344 mg (SD = 15,849 mg) of ribavirin was compared to normal data. Six percent of men had a hip BMD Z score of < or =-2 (P = 0.057 for testing the hypothesis that >2.5% of subjects should have a Z score of < or =-2). Moreover, there was a negative association (r = -0.25, P = 0.023) between the duration of steroid therapy and BMD in men. We conclude that male SARS patients had lower BMD at the hip than normal controls, and this could be attributed to prolonged steroid therapy.

Is INR between 2.0 and 3.0 the optimal level for Chinese patients on warfarin therapy for moderate-intensity anticoagulation?

AIM: To examine the optimal range of International Normalized Ratio (INR) for Chinese patients receiving warfarin for moderate-intensity anticoagulation. METHODS: This was a retrospective cohort study conducted at the ambulatory setting of a 1400-bed public teaching hospital in Hong Kong. The INR measurements and occurrence of serious or life-threatening haemorrhagic and thromboembolic events among patients newly started on warfarin from 1 January 1999 to 30 June 2001 for indications with target INR 2-3 were analysed. The INR-specific incidence of bleeding and thromboembolism were calculated. RESULTS: A total of 491 patients were included, contributing to 453 patient-years of observation period. Forty-seven of the 491 patients experienced 25 haemorrhagic events (5.5 per 100 patient-years) and 27 thromboembolic events (6.0 per 100 patient-years). The percentage of patient-time spent within therapeutic INR range (2-3), INR <2 and INR >3 were 50, 44 and 6%, respectively. The incidence of either haemorrhagic or thromboembolic events was lowest (< or =4 events per 100 patient-years) at INR values between 1.8 and 2.4. CONCLUSIONS: An INR of 1.8-2.4 appeared to be associated with the lowest incidence rate of major bleeding or thromboembolic events in a cohort of Hong Kong Chinese patients receiving warfarin therapy for moderate-intensity anticoagulation.

The Otto Aufranc Award. Wear and lubrication of metal-on-metal hip implants.

The implication of polyethylene wear particles as the dominant cause of periprosthetic osteolysis has created a resurgence of interest in metal-on-metal implants for total hip arthroplasty because of their potential for improved wear performance. Twenty-two cobalt chromium molybdenum metal-on-metal implants were custom-manufactured and tested in a hip simulator. Accelerated wear occurred within the first million cycles followed by a marked decrease in wear rate to low steady-state values. The volumetric wear at 3 million cycles was very small, ranging from 0.15 to 2.56 mm3 for all implants tested. Larger head-cup clearance and increased surface roughness were associated with increased wear. Independent effects on wear of material processing (wrought, cast) and carbon content were not identified. Implant wear decreased with increasing lambda ratio, a parameter used to relate lubricant film thickness to surface roughness, suggesting some degree of fluid film lubrication during testing. This study provided important insight into the design and engineering parameters that affect the wear behavior of metal-on-metal hip implants and indicated that high quality manufacturing can reproducibly lead to very low wear.

Kinematics of the MATCO hip simulator and issues related to wear testing of metal-metal implants.

Metal-metal hip implants have been used clinically in Europe to reduce the risk of wear particle induced osteolysis. Joint simulator devices could provide useful information for design improvement of the modern generation of metal-metal hip implants. Early wear results for metal-metal hip specimens were obtained using a MATCO hip simulator. A detailed kinematic analysis was developed for the MATCO simulator and applied to two of the wear experiments to predict the starting surface motion, contact zone and lubricant film thickness. It was shown that points on cup surfaces were not subjected to a reciprocating interaction with the head during wear at the beginning of testing but as wear proceeded, it was suggested that, in some cases, reciprocating interaction did occur on the cup surface. Comparison between simulator and in vivo kinematics suggested a more realistic representation for cup than for head wear. In the simulator, the Hertzian contact zone moved in a circular path over the cup surface and changed in size in correspondence with the applied load. Elastohydrodynamic lubrication was considered to be possible in the simulator, with estimated fluid film thickness as great as 0.1 micron. However, such thick films were not likely to have occurred at the start of the two wear tests which were examined in detail, although some mixed film lubrication might have accounted for the relatively low wear of one of the specimens. The inclusion of kinematic details, contact mechanics and elastohydrodynamic lubrication analysis in simulator testing protocols and in design of metal metal hip implants was recommended.

Engineering issues and wear performance of metal on metal hip implants.

A major concern in total hip arthroplasty is the generation of polyethylene wear particles at the articulating surfaces and resulting macrophage mediated periimplant osteolysis. There is renewed interest in metal on metal bearings as a solution to this problem in view of their potential for greatly improved wear performance. Using a commercially available hip simulator, the wear performance of metal on metal femoral head and acetabular cup combinations was evaluated and various parameters affecting metal on metal implant wear were identified. Nine implants custom manufactured from 2 medical grades of CoCrMo alloy (ASTM F1537-95 and F75-92) were tested within bovine serum as the lubricant to 3 million cycles (equivalent to approximately 3 years of service in vivo). The progressive wear of the components was determined by gravimetric methods at approximately every 300,000 cycles. The wear rates were characterized by an initial period of accelerated wear after which a lower steady state wear rate was observed for subsequent cycles. The presence of calcium phosphate films on the component surfaces, the microstructure of the lower carbon, wrought alloy, and increased effective radii (decreased diametral clearances) were identified as factors that may be favorable to improved wear performance. The extent of the effect on wear of each parameter, however, cannot be discerned at this point and necessitates a study in which parametric changes are more tightly controlled. The present study suggests that the use of metal on metal articulating surfaces may mitigate the problem of osteolysis by offering improved wear performance.

Comparison of alloys and designs in a hip simulator study of metal on metal implants.

Previous studies of metal on metal hip implants have shown that it is possible to obtain substantially lower volumetric wear than with metal on polyethylene pairings. To work toward design optimization, the gravimetric wear of serum lubricated, metal on metal implants was examined in a hip simulator apparatus. Seventeen implant specimens were fabricated from 3 alloys in various combinations of diameter and clearance and wear tested as many as 3 million cycles. Theory was developed to predict the thickness of elastohydrodynamic lubricant films, the linear wear, and wear zone geometry. To help interpret the data, implant diameter and clearance were combined into a single parameter called effective radius. Implants with larger effective radii (6-11 m) tended to experience lower wear, and theory suggested that this was a result of the correspondingly thicker elastohydrodynamic lubricant films providing an enhanced mixed film lubrication. As in most wear testing, the results were scattered but, overall, a low carbon, wrought alloy had lower wear than either a high carbon, cast alloy or a low carbon, commercial alloy. Because of the small number of specimens tested and possible variations in tribologic parameters such as calcium phosphate film formation and surface microgeometry, there was low statistical reliability of the results.

Cell kinetic analysis in pediatric brain and spinal tumors: a study of 117 cases with Ki-67 quantitation and flow cytometry.

We present cell kinetic data including Ki-67 quantitation and flow cytometry on 117 pediatric brain/spinal cord tumors and review the literature. Although, in general, these proliferation indices are in agreement with the histologic grade, they are useful in prognostication in some instances when the histological features of malignancy are equivocal. Specific examples in which flow cytometry may prove particularly useful in this context are childhood ependymomas, which do not show frank anaplasia but have cellular foci with focal increase in mitoses, and choroid plexus neoplasms, where elevated S phase fractions have been associated with an adverse outcome. Thus Ki-67 quantitation and flow cytometry not only serve as useful adjuncts to conventional histologic grading but also in specific instances may provide new information on tumor prognosis.

The effect of post adaptation in the root canal on retention of posts cemented with various cements.

This laboratory study compared the retention of prefabricated posts in well-fitting and loose-fitting post canals using different cement materials. Eighty-three human teeth were prepared for post placement. One of zinc phosphate cement, polycarboxylate cement, glass ionomer cement or resin cement was used to cement each post in place. A tensile force was applied to remove each post and the separation force was recorded. Posts cemented with the resin cement were the most difficult to dislodge. Posts cemented into loose-fitting canals exhibited greater resistance to dislodgment than posts cemented into well-fitting canals irrespective of the type of cements used.

Puppet-like syndrome of Angelman: a pathologic and neurochemical study.

We present the first pathologic descriptions of the puppet-like syndrome of Angelman based on autopsy studies of a 21-year-old woman. The noteworthy findings were a small brain with mild cerebral atrophy but normal gyral development. There was marked cerebellar atrophy with loss of Purkinje and granule cells and extensive Bergmann's gliosis. Study of dendrite morphology using Golgi impregnations of the visual cortex revealed a prominent decrease in dendritic arborization of layer 3 and layer 5 pyramidal neurons. Quantitative Golgi analysis also revealed a significant decrease in the numbers of dendritic spines in apical layer 3 dendrites and both apical and basal layer 5 dendrites. Neurochemical studies of frozen brain tissue demonstrated markedly reduced gamma-aminobutyric acid content in the cerebellar cortex, as well as elevated glutamate content in the frontal and occipital cortices. Although there are no definite morphologic correlates of many of the clinical signs, the pronounced dendritic pathology and neurochemical abnormalities in cerebral cortex may provide a physiologic basis for mental retardation.

Dendritic arborization in the human fetus and infant with the trisomy 18 syndrome.

Dendritic arborization patterns of visual cortical neurons in four cases of trisomy 18 syndrome were compared with those in 8 neurologically asymptomatic age-matched controls. The trisomy cases included a 20-week-old fetus, a term infant, a 3-month-old infant, and 6-month-old infant. Quantitative Golgi analysis showed a decrease in the mean total dendritic length of apical dendrites in layer 5 pyramidal neurons in the term infant with trisomy 18. In layer 3, an attenuated dendritic tree was observed in the earlier age groups with increased dendritic extent at 6 months. Although not conclusive, due to the small number of subjects, this preliminary study showed definitive dendritic abnormalities in the trisomy 18 syndrome.

Golgi and computer morphometric analysis of cortical dendrites in metabolic storage disease.

Golgi and computer morphometric analysis of neuronal dendrites was done on four cases, one each of Tay-Sachs disease, infantile type 2 sialidosis, Hurler's syndrome, and Sanfilippo's syndrome. There were large meganeurites on pyramidal neurons in Tay-Sachs disease, and small ones in Hurler's and Sanfilippo's syndromes. All the meganeurites in these three diseases were predominantly distal to the soma in layer 3, but close to it in layer 5. These findings may be accounted for by different rates of ganglioside accumulation and cortical neuronal morphogenesis. Computer morphometric analysis revealed atrophic or less developed layer 5 dendritic length and branching in Tay-Sachs disease, sialidosis, and Hurler's syndrome compared with tissues from control patients. These dendritic changes may be secondary to ganglioside accumulation or due to abnormal surface membrane production during dendritic development. This study contributes to an understanding of how enzyme deficiency is translated into abnormal cell structure and, presumably, function.

Retardation of neuronal maturation in premature infants compared with term infants of the same postconceptional age.

Neuronal morphologic development and the number of soma and spines in the visual cortex were investigated. Ten premature infants surviving at least three weeks were compared with control infants who had been born at term gestation and had the same postconceptional age. In six cases of sudden infant death syndrome, bronchopulmonary dysplasia, or patent ductus arteriosus, neuronal development was similar to that in the control cases. The persistence of immature neurons in two of the remaining four cases suggested a developmental neuronal delay or arrest.