Mothers', fathers', and children's perceptions of parental diabetes responsibility in adolescence: examining the roles of age, pubertal status, and efficacy

OBJECTIVES

To examine how perceptions of parental responsibility for diabetes management are associated with age, pubertal status, adolescents' self-efficacy, and parental perceptions of adolescents' efficacy, and if parental responsibility is associated with better metabolic control as a function of adolescents' self-efficacy and parental perceptions of adolescents' efficacy.

METHODS

Questionnaires assessing parental responsibility, pubertal status, adolescents' self-efficacy, and parental perceptions of adolescents' efficacy were given to 185 adolescents with type 1 diabetes, 185 mothers, and 145 fathers.

RESULTS

Greater parental responsibility was negatively associated with age, perceptions of pubertal status, and efficacy for all reporters. Interactions between parental responsibility and parental perceptions of adolescents' efficacy indicated that parental responsibility was associated with better metabolic control when adolescents were perceived to have lower efficacy.

CONCLUSIONS

Adolescents' and parents' perceptions of parental responsibility are related to multiple factors. Metabolic control is best when high parental responsibility is maintained among adolescents with lower efficacy.

Congenital hyposomatotropism in a domestic shorthair cat presenting with congenital corneal oedema

A six-month-old, female, domestic shorthair cat was presented with a history of failure to grow and bilateral corneal opacity caused by corneal oedema. Congenital hyposomatotropism and possible secondary hypothyroidism were diagnosed on the basis of fasting serum levels of insulin-like growth factor-1 and thyroxine levels, respectively. These endocrinopathies are rare in the cat and have not been reported to cause ocular signs. The cat died during investigation of these diseases, and histopathological examination of the eyes showed significantly reduced corneal endothelial cell density and number of corneal epithelial cell layers when compared with age-matched healthy control corneas. These changes were implicated in the development of the corneal oedema.

Role of parental monitoring in understanding the benefits of parental acceptance on adolescent adherence and metabolic control of type 1 diabetes

OBJECTIVE

This study examined 1) whether the benefits of mothers' and fathers' accepting relationships with their adolescents regarding diabetes control were due to parental monitoring and 2) how parents together may provide sufficient acceptance and monitoring for diabetes management.

RESEARCH DESIGN AND METHODS

Adolescents aged 10-14 years with type 1 diabetes (n = 185) and their mothers (n = 185) and fathers (n = 145) completed assessments of parental acceptance and monitoring of diabetes tasks. Adolescents completed a modified version of the Self-Care Inventory (1) to measure adherence. A1C scores were used as a marker of glycemic control.

RESULTS

Mediational analyses revealed that the benefits of adolescents' reports of fathers' acceptance on A1C and mothers' and fathers' acceptance on better adherence were partially mediated by monitoring. Both mothers' and fathers' monitoring and fathers' acceptance had independent effects in predicting adherence. However, only fathers' monitoring had an independent effect on A1C. The effect of fathers' monitoring on A1C occurred as fathers were monitoring at a lower level than mothers. Mothers' and fathers' reports of their own acceptance and monitoring were not associated with A1C or adherence.

CONCLUSIONS

Results reveal the importance of fathers' acceptance and monitoring in diabetes management, a role that should be encouraged, despite the little attention it has received.

Physician recommendations about maternal involvement in adolescent diabetes management

OBJECTIVE

The purpose of this study was to examine whether perceptions of physician recommendations about maternal involvement in adolescent diabetes management are associated with children's reports of mothers' involvement during the subsequent week.

RESEARCH DESIGN AND METHODS

Youth with type 1 diabetes (aged 10-15 years) and mothers completed scales measuring perceptions of physician recommendations about maternal involvement. At their appointment, and again 1 week later, children reported mothers' involvement in diabetes over the preceding week.

RESULTS

A total of 53 dyads provided usable data at both time points. Perceived recommendations to increase involvement were associated with children's reports of increased maternal collaboration during the subsequent week (B = 0.81, P < 0.05), an effect that was stronger among boys (B = -1.21, P < 0.005). Increased maternal collaboration correlated with better A1C (r = -0.39, P < 0.005).

CONCLUSIONS

Physicians may facilitate adaptive forms of maternal involvement during adolescence by conveying messages about involvement to patients and families.

Abstract 874: MLN1202, a Novel CCR2 Antagonist, Decreases C-reactive protein in Patients at Risk for Atherosclerotic Cardiovascular Disease in a Double Blind Placebo Controlled study

Background: Macrophages play a central role in atherosclerotic plaque formation. The CC chemokine receptor 2 (CCR2), expressed on the surface of circulating monocytes, and its ligand MCP-1 (CCL2), are present in atherosclerotic plaques and may play a critical part in endothelial monocyte recruitment and activation. MLN1202 is a humanized monoclonal antibody with high specificity to CCR2, which interrupts MCP-1 binding to CCR2. MLN1202 is being developed for the treatment of immune mediated diseases.

Hypothesis: We tested the hypothesis that MLN1202 significantly influences disease activity in patients at risk for ASCVD as measured by a reduction in circulating levels of high sensitivity C-reactive protein (hsCRP), an established biomarker of inflammation.

Trial Design: In this double-blind placebo controlled study patients with at least 2 or more risk factors for ASCVD, no history or symptoms of ASCVD disease, and circulating levels of hsCRP > 3mg/L, were randomized 1:1 to receive a single infusion of 10 mg/kg MLN1202 (n 56) or placebo (n = 56). Subjects with hypercholesterolemia on stable doses of lipid-lowering agents were included. Circulating levels of hsCRP were determined every 2 weeks, and clinical examination performed every 4 weeks for 16 weeks following treatment.

Results and Conclusion: Patients were recruited from nine centers in the US. The study population had a mean age of 60.9 years and included subjects with hypertension (59%), hypercholesterolemia (70%), significant smoking history (28%), and type 2 diabetes (16%). At screening the median value CRP was 6.8 mg/L with interquartile range from 4.7–9.3 mg/L. PK/PD results showed that the plasma level of MLN1202 required for > 90% receptor saturation was maintained for 6 to 8 weeks. A between-group difference in reduction of hsCRP was statistically significant from week 4 through week 8 following dosing. The maximum difference in absolute median reduction was observed at week 8 and it was 1.6 mg/L (p = 0.0275; Wilcoxon); the observed median percent reduction of hsCRP was 24.2% for MLN1202 group versus 2.5% increase for placebo group at 8 weeks (p = 0.0089; Wilcoxon). These data indicate that blockade of CCR2 reduces a biomarker related to inflammation in patients at risk for ASCVD.

Acute lead poisoning associated with backyard lead smelting in Jamaica

Long-term backyard smelting of lead in a district known as Mona Commons, Kingston, Jamaica, has produced lead burdens as high as 30 000 mg/kg in soils near to the smelter, and indoor dust loadings of 373 microg/f2 in the residents' home. The blood lead levels (BPb) of 107 children from the district were in the range 2.2-202 microg/dL. Fifty-nine per cent of these had BPb levels above 10 microg/dL and the population mean was an unacceptably high 25.1 microg/dL. The highest levels were observed for five siblings, two of whom presented with lead encephalopathy. This severe chronic exposure to lead was exacerbated by a significant history of pica, and chronic nutritional anaemia. Chelation therapy significantly reduced the BPb levels but due to lead storage in other organs, the values after several months were still higher than desirable. This study emphasizes the importance of reducing the exposure of children to lead.

Value of electrocardiographically gated single-photon emission computed tomographic myocardial perfusion scintigraphy in a cohort of symptomatic postmenopausal women

The aim of this study is to prospectively evaluate the clinical value of electrocardiographically gated single-photon emission computed tomographic myocardial perfusion scintigraphy (MPS) imaging in a cohort of postmenopausal women with symptoms suggestive of ischemic heart disease. Forty-six postmenopausal women with no history of coronary artery disease (CAD), but with typical or atypical angina and >or=1 risk factor for CAD, were enrolled and underwent both coronary angiography and technetium-99m sestamibi MPS with exercise (n = 36) or pharmacologic stress (n = 10). All women were followed up for 5.0 +/- 3 years for the occurrence of hospitalization for acute coronary syndrome, myocardial infarction, and/or new-onset or worsening angina. CAD prevalence (>or=50% diameter stenosis) was 62% (26 of 42 patients). Fifteen patients (36%) had 1-vessel disease, 7 (17%) had 2-vessel disease, and 4 (10%) had 3-vessel disease. Diagnostic sensitivity and specificity of the exercise electrocardiogram were 67% and 69%, respectively. By comparison, sensitivity of MPS was 88% and specificity was 87.5% (p <0.0001). Cox survival analysis showed 3- and 5-year cumulative event-free survival rates of 97% and 94% for patients with normal MPS results compared with 60% and 48% for those with abnormal MPS findings (p <0.001). In conclusion, results of this study indicate high diagnostic and prognostic accuracy for MPS in symptomatic postmenopausal women.

Clinical Predictors of Appropriate Implantable-Cardioverter Defibrillator Discharge

BACKGROUND

The implantable cardioverter-defibrillator (ICD) is the mainstay of treatment for ventricular tachyarrhythmias due to its impact on mortality. ICD discharges may be appropriate or inappropriate, and identification of patients at risk for ICD discharge is essential. We sought to determine the predictors of appropriate ICD discharge.

METHODS

We analyzed data from 591 ICD recipients (mean age 67.9 +/- 13.0 years; 474 men; mean follow-up 10.9 +/- 13.8 months). The association between ICD discharges and multiple clinical variables, including age, gender, hypertension, diabetes, coronary artery bypass graft (CABG) surgery, syncope, atrial fibrillation (AF), prior coronary intervention, left ventricular ejection fraction (LVEF), left ventricular end diastolic dimension, left ventricular end systolic dimension (LVESD), and ambient drug therapy was examined.

RESULTS

The rates of appropriate or inappropriate discharges, delivered to 155 patients, were 0.49 per follow-up year (F/Y). The median time-to-first appropriate discharge was 3.4 years. Among the discharges delivered, 97(63%) were appropriate and 58(37%) were inappropriate. Risk factors associated with a trend toward earlier appropriate discharges included age </= 65 years, and diuretic and digitalis use. By multiple variable analysis, no history of CABG and an enlarged LVESD were independent predictors of earlier appropriate ICD discharge.

CONCLUSIONS

Patients who did not have CABG revascularization were 2.8-fold more likely than those who underwent CABG, and patients with enlarged LVESD were 2.5-fold more likely than those with normal LVESD to receive appropriate ICD discharges. These patients deserve special vigilance and management in order to prevent the occurrence of ventricular tachyarrhythmias triggering ICD discharges.

Multiple limbal haemangiosarcomas in a border collie dog: management by lamellar keratectomy/sclerectomy and strontium-90 beta plesiotherapy

An eight-year-old, neutered, male border collie dog was presented with a six-week history of left ocular discomfort and a raised, red mass at the lateral limbus. The right eye had been enucleated approximately 12 months previously following suspected trauma when the eye had become red and painful. The mass was excised using superficial keratectomy/sclerectomy and the surgery site was treated with strontium-90 beta radiation. Histopathological findings were consistent with a diagnosis of haemangiosarcoma. Immunohistochemical staining showed uniform expression of CD31 in neoplastic cells, confirming their endothelial origin. Two further treatments with strontium-90 beta radiation were applied to the surgical site at weekly intervals. Twenty-six weeks after surgery, a second, raised, red limbal mass became apparent at the medial limbus of the left eye. Surgical excision and adjuvant strontium-90 beta plesiotherapy were performed as described for the initial tumour. Routine histopathological analysis confirmed haemangiosarcoma at this site. Eighty-six weeks following the initial presentation, no recurrence of ocular haemangiosarcoma was evident.

Canine limbal melanoma: 30 cases (1992-2004). Part 2. Treatment with lamellar resection and adjunctive strontium-90beta plesiotherapy - efficacy and morbidity

OBJECTIVES

To evaluate the efficacy of lamellar resection and adjunctive 90Sr-beta plesiotherapy in the management of canine limbal melanoma and the frequency and morbidity of early and late-onset side effects following treatment.

DESIGN

Retrospective study.

ANIMALS STUDIED

Thirty dogs treated for limbal melanoma at the Animal Health Trust (AHT), between 1992 and 2004.

METHODS

Medical records were reviewed and information collected on the radiation dose administered, duration of follow-up, and the frequency of early- and late-onset ocular side effects. Follow-up information was obtained by re-examination of patients or completion of a telephone interview with the referring veterinary surgeons or the owners.

RESULTS

Recurrence of limbal melanoma occurred in 1 of 30 cases (3%; 95% CI: 0.2-14%). One or more side effects occurred in 16 of 30 cases (53%; 95% CI: 28.1-74.9). The occurrence of side effects was not associated with the number of sites treated or the total surface dose of radiation. Short-term side effects were reported in 16/30 cases (53%) and included corneal scarring (12/30), corneal neovascularization (6/30), conjunctivitis with or without granulation tissue formation (5/30), lipid keratopathy (1/30), and localized bullous keratopathy (2/30). Long-term side effects were reported in 6 of 30 cases (20%) cases and included deep scleral thinning (5/30), focal scleromalacia (3/30), globe perforation (2/30), lipid keratopathy (3/30), localized bullous keratopathy (1/30), and sectoral cortical cataract (1/30).

CONCLUSIONS

Lamellar resection and adjunctive 90Sr-beta plesiotherapy is relatively easy to perform, is minimally invasive, and extremely well tolerated by patients. The treatment is highly efficacious in the management of canine limbal melanoma. Modification of the radiation dosimetry, in particular reducing the total dose of radiation and the dose per radiation fraction, is necessary to reduce the incidence of late onset side effects.

Canine limbal melanoma: 30 cases (1992-2004). Part 1. Signalment, clinical and histological features and pedigree analysis

OBJECTIVES

(1) To review the signalment, clinical, and histological features of canine limbal melanoma; (2) to perform pedigree analysis on breeds predisposed to limbal melanoma to establish if common ancestry exists; and (3) to investigate if any ancestral relationship exists between canine limbal melanoma and canine anterior uveal melanoma (CAUM).

DESIGN

Retrospective study.

ANIMALS STUDIED

Thirty dogs with limbal melanoma.

METHODS

Medical records of patients were reviewed. Follow-up information was obtained by re-examination of patients or telecommunications with the referring veterinary surgeons or the owners. Pedigrees were analyzed for common ancestry amongst affected dogs. RESULTS The mean age (+/- SD) at diagnosis was 6.2 (+/- 2.75) years with a range from 1 to 11 years. There was a bimodal distribution of ages with a peak at 3-4 years and a peak at 7-10 years. There was no eye predilection or predisposition for sex or coat color. Twenty-five (83%) of the limbal melanomas occurred within a dorsal arc from the dorsomedial to the ventrolateral limbus. Golden retrievers were four times more common in the melanoma group compared to the Animal Health Trust population (P < 0.0001). Labrador retrievers were three times more common in the melanoma group (P=0.01). Pedigree analysis on eight Golden retrievers [limbal melanoma (n=5), CAUM (n=2) and diffuse ocular melanosis (n=1)], revealed a pattern of inter-relatedness consistent with the condition(s) being caused, at least in part, by a genetic mutation(s). A similar level of inter relatedness was evident in six Labrador retrievers (limbal melanoma (n=2) and CAUM (n=4)). In 5/22 cases (23%), histological features suggestive of malignancy were present including intratumor necrosis in 4/22 cases (18%) and cellular atypia in 1/22 cases (5%).

CONCLUSIONS

In Golden and Labrador retrievers there is evidence that limbal melanomas, CAUM and ocular melanosis are at least in part heritable and that the same genetic mutation(s) may be causally associated with melanocytic disease at different ocular sites. The same genetic mutation(s) may be present in these two breeds. Histology should be performed on all cases to identify those with greater malignant potential.

Surgical management of cicatricial ectropion following scarring dermatopathies in two dogs

Two dogs were presented with severe dermatopathies leading to cicatricial ectropion and severe surface ocular pathology. In one case, idiopathic sterile pyogranuloma was diagnosed on histopathology and managed with systemic immunosuppressive therapy. In the second case, demodicosis was diagnosed on skin scrapings and successfully treated with acaricidal medication. Following control of the underlying dermatopathies, both cases developed cicatricial ectropion as a result of scarring and contracture of eyelid tissue. Wharton-Jones (V-Y) blepharoplasties were performed on the affected eyelids and resulted in improved eyelid function and reduced corneal exposure in both cases.

A single course of anti-CD3 monoclonal antibody hOKT3gamma1(Ala-Ala) results in improvement in C-peptide responses and clinical parameters for at least 2 years after onset of type 1 diabetes

Despite advances in understanding autoimmune diabetes in animal models, there has been little progress in altering the natural course of the human disease, which involves progression to insulin deficiency. Studies with immunosuppressive agents have shown short-term effectiveness, but they have not induced tolerance, and continuous treatment is needed. We studied the effects of hOKT3gamma1(Ala-Ala), a humanized Fc mutated anti-CD3 monoclonal antibody, on the progression of type 1 diabetes in patients with recent-onset disease in a randomized controlled trial. In general, the drug was well tolerated. A single course of treatment, within the first 6 weeks after diagnosis, preserved C-peptide responses to a mixed meal for 1 year after diagnosis (97 +/- 9.6% of response at study entry in drug-treated patients vs. 53 +/- 7.6% in control subjects, P < 0.01), with significant improvement in C-peptide responses to a mixed meal even 2 years after treatment (P < 0.02). The improved C-peptide responses were accompanied by reduced HbA(1c) and insulin requirements. Clinical responses to drug treatment were predicted by an increase in the relative number of CD8(+) T-cells in the peripheral blood after the lymphocyte count recovered 2 weeks after the last dose of drug. We conclude that treatment with the anti-CD3 monoclonal antibody hOKT3gamma1(Ala-Ala) results in improved C-peptide responses and clinical parameters in type 1 diabetes for at least 2 years in the absence of continued immunosuppressive medications.

Familial aggregation of juvenile idiopathic arthritis

OBJECTIVE

To estimate the degree of familial aggregation of juvenile idiopathic arthritis (JIA), determine whether the aggregation of JIA and the aggregation of type 1 diabetes mellitus (type 1 DM) overlap, and identify multiplex JIA pedigrees.

METHODS

Records of individuals with JIA or type 1 DM were probabilistically linked with records in the Utah Population Database (UPDB), a large computerized family history database. For each case of JIA or type 1 DM, 10 matched controls or 5 matched controls, respectively, were selected. All familial relationships among cases of JIA or type 1 DM were established. A familial risk score was calculated for each subject. For various levels of familial exposure to JIA or type 1 DM, one's risk (odds ratio [OR]) of developing JIA or type 1 DM was established (cases compared with controls). Recurrence risks for JIA were computed for relatives of JIA cases compared with relatives of controls. Extended JIA families were identified from a list of common ancestors.

RESULTS

Records of a total of 443 patients were linked with the UPDB. Of these, 381 (86.0%) met criteria for JIA. An increased risk for JIA was observed among relatives of probands with JIA. The prevalence of type 1 DM among JIA cases was higher than the US prevalence of type 1 DM (P < 0.003). The recurrence risk for JIA was significantly elevated among first-degree relatives of cases with JIA (OR 30.4). The overall prevalence of JIA was 28/100,000. Four extended JIA pedigrees were identified.

CONCLUSION

There is familial aggregation of JIA in the Intermountain West region of the US. We have demonstrated that multiplex JIA pedigrees can be identified using a genealogic database.

Quantification and analysis of pain in nonsurgical scaling and/or root planing

BACKGROUND

Three efficacy studies, comprising a database of 337 subjects, were conducted as part of the clinical evaluation of the noninjectable anesthetic gel Oraqix (AstraZeneca, Södertälje, Sweden). The authors discuss some of the challenges encountered when they interpreted the results of the clinical studies and present the results from an alternative analysis of the anesthetic efficacy.

METHODS

The three multicenter studies were double-blind, randomized and placebo-controlled. Clinicians applied gel in the subjects' periodontal pockets before scaling and/or root planing, or SRP. Subjects recorded overall pain on a 100-millimeter visual analog scale, or VAS. In the studies, the evaluation of the anesthetic efficacy was based on absolute treatment difference (active-placebo). Investigators used an alternative post hoc approach to evaluate the effect expressed as a ratio (active:placebo).

RESULTS

The studies demonstrated consistent and significant lower pain scores for the anesthetic gel versus the placebo gel, with point estimates of absolute treatment difference being 8, 4 and 10 mm. The alternative analysis verified that the estimated treatment effect in terms of a ratio was close to 50 percent in all three studies.

CONCLUSIONS

Treatment effects of the anesthetic gel relative to the placebo gel were described more appropriately by means of ratios instead of absolute differences. In this sample of 337 subjects, it was shown that pain was reduced by 50 percent when the anesthetic gel was used compared with when the placebo gel was used.

CLINICAL IMPLICATIONS

The authors found that the anesthetic periodontal gel is effective in reducing pain resulting from SRP.

Neural correlates of temporal context discrimination

This study investigated event-related potential (ERP) effects when judgments about temporal context (recency judgments) required the retrieval of different amount of information. Subjects studied two consecutively presented word lists and at test made recency judgments to word pairs composed of two previously studied words, one drawn from each list ('Old + Old different' pairs), both drawn from the same list ('Old + Old same' pairs), or two unstudied words ('New + New' pairs). A frontopolar old/new effect was elicited by correct recency judgments which did not differ between both 'Old + Old' pairs. This finding suggests that the generators of the frontopolar old/new effect are not sensitive to the differing retrieval demands required here. However, an old/new effect over left inferior temporal electrodes was larger for 'Old + Old same' than for 'Old + Old different' pairs. The significance of these old/new effects are discussed in relation to the broader pattern of old/new effects seen in standard tests of declarative memory retrieval.

Insulin secretion in type 1 diabetes

Type 1 diabetes, a chronic autoimmune disease, causes destruction of insulin-producing beta-cells over a period of years. Although many markers of the autoimmune process have been described, none can convincingly predict the rate of disease progression. Moreover, there is relatively little information about changes in insulin secretion in individuals with type 1 diabetes over time. Previous studies document C-peptide at a limited number of time points, often after a nonphysiologic stimulus, and under non-steady-state conditions. Such methods do not provide qualitative information and may not reflect physiologic responses. We have studied qualitative and quantitative insulin secretion to a 4-h mixed meal in 41 patients with newly diagnosed type 1 diabetes and followed the course of this response for 24 months in 20 patients. Newly diagnosed diabetic patients had an average total insulin secretion in response to a mixed meal that was 52% of that in nondiabetic control subjects, considerably higher than has been described previously. In diabetic patients there was a decline of beta-cell function at an average rate of 756 +/- 132 pmol/month to a final value of 28 +/- 8.4% of initial levels after 2 years. There was a significant correlation between the total insulin secretory response and control of glucose, measured by HbA(1c) (P = 0.003). Two persistent patterns of insulin response were seen depending on the peak insulin response following the oral meal. Patients with an early insulin response (i.e., within the first 45 min after ingestion) to a mixed meal, which was also seen in 37 of 38 nondiabetic control subjects, had a significantly accelerated loss of insulin secretion, as compared with those in whom the insulin response occurred after this time (P < 0.05), and significantly greater insulin secretory responses at 18 and 24 months (P < 0.02). These results, which are the first qualitative studies of insulin secretion in type 1 diabetes, indicate that the physiologic metabolic response is greater at diagnosis than has previously been appreciated, and that the qualitative insulin secretory response is an important determinant of the rate of metabolic decompensation from autoimmune destruction.

Intestinal absorption in health and disease: micronutrients

The main theme of this chapter concerns the precise biochemical mechanisms involved in stages up to, and including, gastrointestinal absorption of vitamins and certain selected minerals. Essential data regarding sequential events, immediately following absorption of these micronutrients, are also included. There is reference to water-soluble vitamins that are, in general, either coenzymes in various metabolic reactions or carriers of certain biochemical groupings. In contrast, fat-soluble vitamins frequently function as integral components of cell membranes; they, too, receive ample attention. It is appropriate, nevertheless, to recognize that some minerals required in very small amounts are closely allied biochemically with particular vitamins; these specific associations are apportioned emphasis at relevant places in the text. Although predominant discussion centres on the physiological state, clinical reference is necessarily made to gastrointestinal disorders in which imbalance of vitamins and minerals consequently results in an additional detrimental impact on health.

Randomized clinical trial of adjuvant radiotherapy and 5-fluorouracil infusion in colorectal cancer (AXIS)

Background

Postoperative portal vein infusion (PVI) of 5-fluorouracil (5-FU) is a well tolerated and widely applicable treatment for colorectal cancer that might have an enormous public health impact, even if it produced survival benefits of just a few per cent. Very large trials are required to detect such differences, and the Adjuvant X-ray and 5-FU Infusion Study (AXIS) is the largest such trial yet reported.

Methods

Consenting patients with presumed colorectal cancer were randomized to surgery with or without 7 days of PVI (1 g 5-FU plus 5000 units heparin in 1 litre 5 per cent dextrose infused over each 24-h period). In addition, patients with rectal cancer could be randomized to radiotherapy or no radiotherapy to be given either before or after surgery.

Results

Between November 1989 and December 1997, 3583 patients were randomized with respect to PVI. The survival hazard ratios (95 per cent confidence interval (c.i.)) in all patients randomized and in the curatively resected subgroup (71·2 per cent of patients) were 1·00 (0·92 to 1·11) and 0·94 (0·83 to 1·06) respectively. Tests for heterogeneity suggested a greater treatment benefit for patients with colonic cancer than for patients with rectal cancer with respect to disease-free survival (hazard ratio 0·79 versus 1·03; P = 0·07), and there was a non-significant trend with respect to overall survival (hazard ratio 0·87 versus 1·03; P = 0·17). No survival benefit was seen in the 761 patients randomized with respect to radiotherapy; although not statistically significant, the impact on local recurrence rates was similar to that reported in the literature.

Conclusion

No overall benefit of PVI was established in AXIS when colonic and rectal cancers were considered together, but the evidence suggesting a differential treatment effect according to site of cancer in AXIS was strongly supported by a meta-analysis incorporating the previous trials. Combining the data gave hazard ratios of 0·82 and 1·00 for colonic and rectal tumours respectively (test for interaction, P = 0·024), equating to an absolute survival benefit for patients with colonic cancer of 5·8 (95 per cent c.i. 2·8 to 8·5) per cent, a level close to that seen for prolonged systemic therapy.

Prolongation of satiety after low versus moderately high glycemic index meals in obese adolescents

BACKGROUND

One in 5 American children is overweight, despite a decrease in total fat consumption. This has sparked an interest in the carbohydrate composition of diets, including the glycemic index (GI).

OBJECTIVE

To investigate whether a low-GI meal replacement (LMR) produced similar metabolic, hormonal, and satiety responses in overweight adolescents as a low-GI whole-food meal (LWM) when compared with a moderately high-GI meal replacement (HMR).

METHODS

Randomized, crossover study comparing LMR, HMR, and LWM in 16 (8 male/8 female) adolescents during 3 separate 24-hour admissions. The meal replacements consisted of a shake and a nutrition bar. Identical test meals were provided at breakfast and lunch. Metabolic and hormonal indices were assessed between meals. Measures of participants' perceived satiety included hunger scales and ad libitum food intake.

RESULTS

The incremental areas under the curve for glucose were 46% and 43% lower after the LMR and LWM, respectively, compared with the HMR. Insulin's incremental area under the curve was also significantly lower after both low GI test meals (LMR = 36%; LWM = 51%) compared with the HMR. Additional food was requested earlier after the HMR than the LMR (3.1 vs 3.9 hours, respectively), although voluntary energy intake did not differ.

CONCLUSIONS

Differences in insulin response between the meal replacements occurred, and prolongation of satiety after the LMR, based on time to request additional food, was observed. We speculate that the prolonged satiety associated with low GI foods may prove an effective method for reducing caloric intake and achieving long-term weight control.

A placebo-controlled multi-centred evaluation of an anaesthetic gel (Oraqix) for periodontal therapy

AIMS

Six Canadian dental schools investigated the ability of a thermosetting gel containing 25 mg/g prilocaine and 25 mg/g lidocaine as active agents to produce analgesia in periodontal pockets utilizing a randomized, double-blind, placebo-controlled study.

MATERIALS AND METHODS

The study consisted of 130 patients, each of whom received the active or placebo gel in periodontal pockets in one quadrant of the mouth for 30 s prior to periodontal debridement (scaling and root planing). Pain was measured using both a 100-mm Visual Analogue Scale (VAS) and a Verbal Rating Scale (VRS).

RESULTS

The median VAS pain score for the patients treated with the anaesthetic gel was 5 mm (range 0-85 mm) as opposed to 13 mm (range 0-79 mm) in the placebo-treated patients (P=0.015). There was no significant difference in the percentage of patients reporting no or mild pain (78% and 76% for the anaesthetic gel and placebo, respectively). No significant differences were seen in patient demographics, or mandible versus maxilla.

CONCLUSIONS

The VAS pain scores showed that the anaesthetic gel 5% was statistically more effective than the placebo in reducing pain during periodontal debridement.