The association between carotid disease, arterial stiffness and diabetic retinopathy in type 2 diabetes: the Fremantle Diabetes Study Phase II.

AIM: To determine whether macrovascular disease assessed by carotid ultrasonography and arterial stiffness by pulse wave velocity are independently associated with diabetic retinopathy in type 2 diabetes. METHODS: A random subgroup of surviving participants with type 2 diabetes from the Fremantle Diabetes Study Phase II were invited to take part in this sub-study in 2018-2019. In addition to standardized questionnaires, a physical examination and fasting biochemical tests, each underwent dilated colour fundus photography, carotid arterial ultrasonography with measurement of the intima-media thickness (IMT) and quantification of the degree of stenosis, and pulse wave analysis calculation of the carotid-femoral pulse wave velocity (cfPWV). The cross-sectional association between arterial disease parameters and diabetic retinopathy was assessed using generalized estimating equation models which enabled both eyes to be included in the analysis. RESULTS: Some 270 participants [mean ± sd age 72 ± 9 years, 153 (57%) men and median (IQR) diabetes duration 15 (11-22) years] were included in analysis. Of 524 assessable eyes, 82 (16%) had diabetic retinopathy. In multivariable analysis, significant independent associates of diabetic retinopathy were age at diabetes diagnosis (inversely), HbA1c , insulin treatment and urinary albumin to creatinine ratio (all P ≤ 0.022), as well as cfPWV [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.03, 1.23 per 1 m/s increase; P = 0.008] and common carotid artery (CCA) IMT ≥1 mm (OR 2.95, 95% CI 1.21, 7.23; P = 0.018). CONCLUSIONS: The association between diabetic retinopathy and CCA IMT suggests that carotid disease may share cardiovascular risk factors with diabetic retinopathy. The association between diabetic retinopathy and cfPWV may reflect the consequences of altered intravascular haemodynamics.

Incidence and precipitants of hospitalization for pancreatitis in people with diabetes: the Fremantle Diabetes Study.

AIMS: To determine the relative risk of pancreatitis in diabetes, and to establish whether diabetes-related as well as recognized risk factors contribute. METHODS: We studied 1426 participants [mean (SD) age 62.1 (13.3) years, 49.6% male, 90.9% type 2 diabetes, median (interquartile range) diabetes duration 4.0 (1.0-10.0) years] from the community-based Fremantle Diabetes Study Phase I and 5663 matched residents without diabetes from the same geographical area. Pancreatitis hospitalizations between 1982 and 2010 were ascertained using validated data linkage. For Fremantle Diabetes Study Phase I participants, chart review provided data on the likely causes of pancreatitis. RESULTS: A total of 21 Fremantle Diabetes Study Phase I participants (1.5%) were hospitalized for pancreatitis before study entry vs 29 (0.5%) of contemporaneous residents without diabetes. During a mean (SD) of 12.1 (5.4) years of follow-up from entry, 22 (1.6%) Fremantle Diabetes Study Phase I participants were hospitalized for a first-ever episode of pancreatitis on 37 occasions (1.31/1000 person-years) compared with 58 (1.0%) residents without diabetes on 81 occasions during a mean (SD) 13.6 (4.8) years (0.75/1000 person-years). The age- and sex-adjusted hazard ratio (95% CI) for first-ever pancreatitis hospitalization in Fremantle Diabetes Study Phase I participants was 1.73 (1.06-2.83; P=0.029). Chart review of 17 of the 22 Fremantle Diabetes Study Phase I participants (77%) with incident pancreatitis and available case notes revealed that four (24%) presented without objective evidence of pancreatitis, seven (41%) presented with cholelithiasis, three (18%) with excessive alcohol consumption, two (12%) as a complication of elective endoscopic retrograde cholangiopancreatography, and one (6%) with hypertriglyceridaemia. CONCLUSION: Consistent with previously published data, the risk of pancreatitis was higher in community-dwelling Fremantle Diabetes Study Phase I participants but conventional precipitants accounted for confirmed cases. These data question whether diabetes-specific risk factors cause or contribute to pancreatitis.

Modification of eating attitudes and behavior in adolescent girls: A controlled study.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a school-based eating disorder prevention program designed to reduce dietary restraint and concern about shape and weight among adolescent girls. METHOD: A total of 474 girls aged 13-14 years received the program as part of their normal school curriculum. An assessment-only control group included 386 pupils. Measures of eating disorder features, self-esteem, and knowledge were administered before and after the intervention and at 6-month follow-up. RESULTS: Immediately following the intervention, there was a small reduction in dietary restraint and attitudes to shape and weight in the index group, whereas there was no change in the control group. This reduction was not maintained at 6-month follow-up although the dietary restraint scores of the index group remained lower than those of the control group. DISCUSSION: This prevention program achieved change in eating attitudes and behavior, although the change was modest in size and not sustained. Focusing on a high-risk subgroup of dieters might be a more fruitful primary prevention strategy.

Assumptions and beliefs in adolescents with anorexia nervosa and their mothers.

A pilot study examined the specific cognitive content of female adolescents with anorexia nervosa. The relationship between daughter and mother concerns, and concerns in mothers, also were investigated. All participants completed a measure of assumptions and negative self-beliefs related to eating disorders. Adolescents with anorexia nervosa scored more highly on all subscales of the measure than nonclinical adolescent controls. There were significant daughter-mother relationships on two subscales in the clinical, but not the nonclinical, group. However, the two groups of mothers did not differ on any subscale. Possible explanations for the findings, and implications for treatment and research, are briefly considered.

Hypothalamo-pituitary abnormalities in adult patients with langerhans cell histiocytosis: clinical, endocrinological, and radiological features and response to treatment.

Langerhans cell histiocytosis (LCH) is a rare disorder in which granulomatous deposits occur at multiple sites within the body, but which often involves the hypothalamo-pituitary axis (HPA). Although diabetes insipidus (DI) is a well recognized complication, the frequency of anterior pituitary and other nonendocrine hypothalamic (NEH) involvement has not been well defined, particularly in adult patients with the disease. We have evaluated the frequency and progression of LCH-related anterior pituitary and other NEH dysfunction and their responses to treatment in 12 adult patients with histologically proven LCH and DI. They were followed up for a median of 11.5 yr (range, 3-28 yr) after the diagnosis of DI was made. Study evaluations comprised clinical (including formal psychometric assessment where appropriate), basal and dynamic pituitary function tests, and radiology with computed tomography and/or magnetic resonance imaging scanning. Eleven patients received systemic treatment, and 5 patients received external beam radiotherapy confined to the HPA. The median age at diagnosis of DI was 34 yr (range, 2-47 yr); DI was the presenting symptom in four patients, whereas the remaining eight each developed DI 1-20 yr (median, 2 yr) after the diagnosis of LCH. Eight patients developed one or more anterior pituitary hormonal deficiencies at a median of 4.5 yr (range, 2-22 yr) after the diagnosis of DI: GH deficiency developed in eight patients (median, 2 yr; range, 2-22 yr), FSH-LH deficiency in 7 patients (median, 7 yr; range, 2-22 yr), and TSH and ACTH deficiency in five patients (median, 10 yr; range, 3-16 and 3-19 yr), respectively; five patients developed panhypopituitarism. In addition, seven patients with anterior pituitary dysfunction also developed symptoms of other NEH dysfunctions at a median of 10 yr (range, 1-23 yr): five morbid obesity (body mass index, >35), five short term memory deficits, four sleeping disorders, two disorders of thermoregulation, and one adipsia. All patients developed disease outside of the hypothalamus during the course of the study, and no fluctuation of disease activity in the HPA region was noted. Radiological examination of the HPA was abnormal in each of the eight patients with anterior pituitary involvement and in the seven patients with NEH dysfunction (one or more abnormalities): seven had thickening of the infundibulum, and one had hypothalamic and thalamic signal changes. All patients who had a magnetic resonance imaging scan had absence of the bright spot of the posterior pituitary on the T1-weighted sequences, and in four patients with DI and normal anterior pituitary function this was the only abnormality. The five patients who received radiotherapy to the HPA achieved a partial or complete radiological response, and there was no evidence of tumor progression in this region. No form of therapy, including chemotherapy, improved any established hormonal deficiencies or symptoms of NEH. In summary, in our adult patients with hypothalamic LCH and DI, anterior pituitary hormonal deficiencies developed in 8 of 12 patients; these occurred over the course of 20 yr. They were frequently accompanied by structural changes of the HPA, although these were often subtle in nature. In addition, symptoms of NEH dysfunction developed in up to 90% of such patients and complicated management. Radiotherapy may be useful in achieving local control of tumor, but established anterior, posterior pituitary, and other NEH dysfunctions do not improve in response to current treatment protocols. Patients with LCH and DI, particularly those with multisystem disease and a structural lesion on radiology, should undergo regular and prolonged endocrine assessment to establish anterior pituitary deficiency and provide appropriate hormonal replacement.

Drug use, binge drinking and attempted suicide among homeless and potentially homeless youth.

In order to assess the need for drug-related services for at-risk youth, a survey was conducted among young people aged 12-17 years who, owing to severe family discord, were currently living away from home (homeless) or had experienced periods away from home in the past 12 months (potentially homeless). Prevalence of use and of potentially harmful levels of use of alcohol and other licit and illicit drugs were higher than in a comparative population. Of the 155 people interviewed, 54% reported past physical abuse, 28% reported past sexual abuse, and 73% had a family alcohol or other drug history. Of the total, 62% had been in a youth refuge at some time in the past 12 months. Twenty four per cent had been to hospital as a result of alcohol or other drug use and 45% had attempted suicide. Female sex and an interaction between sexual abuse and binge drinking predicted suicide attempts. This study points to the need for a comprehensive approach to interventions for troubled youth which gives greater recognition to mental health issues related to family circumstances, including abuse.

Patient readiness for scheduled therapies: nursing's positive contribution.

In this era of cost accountability and containment, scheduling issues have increasing importance. The authors monitored the readiness of patients in one institution for morning therapy appointments. The purpose of the study, which lasted for a period of 5 days, was to obtain an accurate picture of patient readiness for therapy and to determine whether nurses were able to have patients ready for therapy on time.

Who should measure quality of life, the doctor or the patient?

The extent to which a doctor or health professional can make a valid assessment of a patient's quality of life, anxiety and depression was investigated in a series of cancer patients. Doctors and patients filled out the same forms, viz. the Karnofsky, Spitzer, Linear Analogue Self Assessment Scales and a series of simple scales designed for this study, at the same time. Correlations between the two sets of scores were poor, suggesting that the doctors could not accurately determine what the patients felt. A further study examining the reproducibility of these scales demonstrated considerable variability in results between different doctors. It is concluded that if a reliable and consistent method of measuring quality of life in cancer patients is required, it must come from the patients themselves and not from their doctors and nurses.

Cerebral function before and after extra-intracranial carotid bypass.

Thirty-eight patients had their cerebral function measured before and after extra-intracranial carotid bypass surgery using the Halstead-Reitan neuropsychology test battery. Two composite indices of cerebral function for each patient showed them to be impaired before operation. There was no improvement in the composite measures after operation to match that previously demonstrated after carotid endarterectomy. This may reflect the greater pre-operative cerebral impairment of the extra-intracranial group.

Cerebral function before and after carotid endarterectomy.

Twenty men had their cerebral function measured preoperatively and three months after carotid endarterectomy using the Halstead-Reitan neuropsychological test battery. Thirteen patients were cerebrally impaired preoperatively, but 12 of them improved appreciably after surgery. Changes in internal carotid arterial blood flow measured preoperatively showed no significant correlation with the improvement in neuropsychological status. We think that carotid endarterectomy carries an even better prophylaxis for the brain as a whole than had been thought.

Method for measuring cerebral dysfunction in patients with liver disease.

Objective tests of cerebral function were undertaken in 64 outpatients after portal decompression for intrahepatic portal hypertension. These involved scoring the errors in constructing a five-pointed star, and a simple modification of the Reitan trail making test. The first test was found to be less discriminating than the second. There was some correlation between the results and the presence or absence of overt encephalopathy, which-though generally mild-was present in 30 (47%) of the 64 patients.

Relationship between breathlessness and anxiety in asthma and bronchitis: a comparative study.

Two personality testing forms, the Eysenck Personality Inventory Form A and the Cattell Self Analysis Form, were completed on 471 hospital patients who fell within the general diagnostic range of asthma, bronchitis, or both. Respiratory diagnoses were based on the standard M.R.C. questionary. All categories of patients showed a tendency towards neuroticism, anxiety, and introversion, and the scores were slightly higher for bronchitics than for asthmatics. Neuroticism and anxiety increased with increasing respiratory disability. Variations in these scores with age of onset of symptoms and length of history were small.