The Value of Screening for Diabetes in Patients with Skin Sepsis

Four hundred and eighty-two patients with spontaneous skin and superficial sepsis and 291 controls of similar age and sex underwent random capillary blood glucose measurements in order to assess whether screening for diabetes in patients presenting with skin sepsis to an Accident & Emergency Department detects a greater number of cases than that present in the background population. All subjects with a concentration >7.8 mmol/l were subsequently followed up with a 75 g oral glucose tolerance test. Forty-two (8.7%) of the 482 skin sepsis patients had a capillary blood glucose >7.8 mmol/l compared to eight (2.7%) of the 291 without sepsis (χ2=9.71, P<0.002). Of these, 26 of the skin sepsis group and 7 of the control group attended for follow up. Of those who attended, 13 of the skin sepsis group had an abnormal glucose tolerance test (seven diabetes, six impaired glucose tolerance — IGT) compared to two (one diabetes, one IGT) of the control group (χ2=2.87, P<0.1). The difference in cases of frank diabetes between the two groups was not statistically significant. Of the total eight diabetic cases identified, five (on direct questioning) had symptoms of hyperglycaemia (thirst, polyuria and/or weight loss) and two of the others were obese, one of whom had documented ischaemic heart disease. Thus, while most cases of diabetes in patients with skin sepsis could be detected by specifically asking about hyperglycaemic symptoms and performing a blood glucose estimation when these are present, we suggest that the screening of patients with skin sepsis over 40 years of age provides an opportunistic method of screening. This strategy should yield clinically significant numbers of abnormal cases.

Methodology of the National Survey of Sexual Attitudes and Lifestyles

"The preparation and fieldwork for the National Survey of Sexual Attitudes and Lifestyles was carried out between 1987-1991. The survey was a combination of a face-to-face interview and self-completion questionnaire and comprised 18,876 individuals aged 16-59 years in Great Britain. The response rate was similar to other sample surveys on less sensitive topics. Women were overrepresented but the distributions of other demographic characteristics were similar to other data sets. The external validity and internal consistency of the data were found to be adequate. The likely sources and effects of bias are discussed."

Sexual lifestyles and HIV risk

Britain's first large, national survey of sexual attitudes and lifestyles will allow improved estimates of the magnitude of the HIV epidemic in Britain and should lead to better strategies for prevention.

High prevalence of gestational diabetes in women from ethnic minority groups

The influence of ethnic origin, body mass index, and parity on the frequency of gestational diabetes was assessed in 11,205 consecutive women attending a multiracial antenatal clinic in London, where all women were screened for gestational diabetes. Logistic regression was used to model the relationship between gestational diabetes and ethnic origin, age, body mass index (BMI), and parity. Results were presented as adjusted odds ratios, where the reference categories are White women, age < 25 years, BMI < 27, and parity < 3. Ethnic origin was the dominant influence on the prevalence of gestational diabetes. Women from ethnic groups other than White had a higher frequency of gestational diabetes than White women (2.9% vs 0.4%, p < 0.001). Compared to White women the relative risk of gestational diabetes in the other ethnic groups was: Black 3.1 (95% confidence limits 1.8-5.5), South East Asian 7.6 (4.1-14.1), Indian 11.3 (6.8-18.8), and miscellaneous 5.9 (3.5-9.9). Increasing age was an independent risk factor. The relative risk was higher in women > or = 35 years in all ethnic groups other than in South East Asian women. Obesity (BMI > or = 27) was a further independent risk factor in all ethnic groups except in the Indian and South East Asian women. Parity > or = 3 increased the relative risk of gestational diabetes in the White, Black, and South East Asian women only.(ABSTRACT TRUNCATED AT 250 WORDS)

The characteristics of the second stage of labour in 25,069 singleton deliveries in the North West Thames Health Region, 1988

OBJECTIVE

To define the contemporary characteristics of the second stage of labour in one Health Region.

DESIGN

Retrospective analysis of a regional obstetric database.

SETTING

Seventeen maternity units in the North West Thames Health Region.

SUBJECTS

Selected from 36,727 consecutive singleton deliveries in 1988. The analysis was confined to the 25,069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour.

MAIN OUTCOME MEASURES

Second stage duration, obstetric intervention and maternal and fetal morbidity.

RESULTS

The duration of the second stage and the use of operative intervention were strongly negatively associated with parity and positively associated with the use of epidural analgesia. Maternal age, fetal birthweight and maternal height were also independently associated with the duration of the second stage. There were small but significant differences in the characteristics of women using epidural analgesia and those using alternative methods of pain relief. Parous women using epidural analgesia behaved in a similar manner to nulliparae without epidurals. Despite the longer second stages observed in women using epidural analgesia there appeared to be no significant increase in fetal morbidity. Within the region the epidural rate in individual units positively correlated with the overall forceps rate, the rate of caesarean section in the second stage of labour and the duration of the second stage.

CONCLUSIONS

In our study the duration of the second stage in women not using epidural analgesia was similar to previous findings, but in those using epidural analgesia, the duration of the second stage was longer than has been reported previously, possibly reflecting a more conservative approach to operative intervention. Survival analysis indicates that in multiparae not using epidural analgesia the likelihood of spontaneous vaginal delivery after 1 h in the second stage was low, but in those multiparae using epidural analgesia and in all nulliparae there was no clear cut-off point for expectation of spontaneous delivery in the near future; they continue to give birth at a steady rate over several hours. While maternal and fetal conditions are satisfactory, intervention should be based on the rate of progress rather than the elapsed time since full cervical dilatation.

Neonatal and maternal morbidity in relation to the length of the second stage of labour

OBJECTIVE

To investigate the relation between the duration of the second stage of labour and subsequent early neonatal and maternal morbidity.

DESIGN

Retrospective analysis of a regional obstetric database.

SETTING

17 maternity units in the North West Thames Health Region.

SUBJECTS

Selected from 36,727 consecutive singleton deliveries in 1988. The analysis was confined to the 25,069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour.

MAIN OUTCOME MEASURES

The relative risk of early maternal morbidity, postpartum haemorrhage (PPH) and postpartum infection, and neonatal morbidity, as judged by low Apgar scores or admission to the special care baby unit (SCBU), in relation to anthropomorphic characteristics (parity and birthweight), interventions (epidural analgesia, episiotomy and operative delivery), signs of fetal compromise (meconium staining of the amniotic fluid or abnormal cardiotocography (CTG)), maternal morbidity in labour (pyrexia) and the duration of the second stage of labour.

RESULTS

The duration of the second stage of labour had a significant independent association with the risk of both PPH and maternal infection after adjustment for other factors. However, there was a similar or greater risk of PPH in association with operative delivery or a birthweight greater than 4000 g. Both maternal pyrexia in labour and primiparity were associated with a greater risk of post partum maternal infection than was the duration of the second stage, although all these factors were statistically significant. In contrast, the duration of the second stage was not significantly associated with the risk of a low Apgar score or admission to SCBU after adjustment for other factors.

CONCLUSIONS

The duration of the second stage of labour has a positive independent association with early maternal morbidity. We could show no such relation between time spent in the second stage of labour and the frequency of low Apgar scores or the rate of admission to SCBU. With current management approaches, in the absence of factors suggesting fetal compromise, second stage labours of up to 3 h duration do not seem to carry undue risk to the fetus.

Simplified single sample 13Carbon urea breath test for Helicobacter pylori: comparison with histology, culture, and ELISA serology

There is no ideal method for detecting Helicobacter pylori. The 'standard' 13Carbon urea breath test (13C-UBT), which involves collecting eight to 15 breath samples and subsequent costly analysis, was modified by pooling 21 samples of expired breath taken at five minute intervals for 40 minutes into a collecting bag, from which a single 20 ml aliquot was taken and analysed by mass spectrometry. This test was evaluated on 50 patients after routine upper gastrointestinal endoscopy, and results were compared with those from the standard 13C-UBT, bacteriology, ELISA serology, and histology--the latter being taken as the gold standard. H pylori were seen in 34 of 50 (68%) patients (in three it was detected in biopsy specimens from the corpus alone). The modified 13C-UBT was positive (pooled excretion delta 13CO2 greater than 5 per mil) in 31 patients and negative in 19 (three false negative results), specificity was 100% (standard 13C-UBT 94%) and sensitivity 92% (standard 13C-UBT 93%). The modified 13C-UBT had a coefficient of variation within subjects of 3.7%. For the ELISA serology and culture the specificities were both 100%, but the sensitivities were 82% and 68% respectively. The 13C-UBT results correlated with the grade of histological gastritis. The modified 13C-UBT is simpler, cheaper, more reproducible, and provides an easy non-invasive method for the detection of H pylori.

A novel conformationally restricted protein kinase C inhibitor, Ro 31-8425, inhibits human neutrophil superoxide generation by soluble, particulate and post-receptor stimuli

A novel, bis-indolylmaleimide, Ro 31-8425, bearing a conformationally restricted side chain, inhibits protein kinase C isolated from rat brain and human neutrophils with a high degree of selectivity over cAMP-dependent kinase and Ca2+/calmodulin-dependent kinase. It also inhibits phorbol ester-induced intracellular events known to be mediated by protein kinase C (p47 phosphorylation in intact platelets, CD3 and CD4 down-regulation in T-cells). Ro 31-8425 inhibited superoxide generation in human neutrophils activated by both receptor stimuli (formyl-methionyl-leucylphenylalanine, opsonized zymosan, IgG and heat aggregated IgG) and post-receptor stimuli (1,2-dioctanoylglycerol and fluoride). The compound also blocked antigen driven, but not IL-2 induced, T-cell proliferation. These results support a central role for protein kinase C in the activation of the respiratory burst and antigen-driven T-cell proliferation.

Children with atopic eczema. II: Immunological findings associated with dietary manipulations

A group of 91 children with atopic eczema entered a study where clinical and immunological features were compared before and after a food elimination diet, and after double blind randomized food challenges in which a food was given for several days at a time. Eczema improved significantly during the diet and became worse on food challenges. The clinical outcome of food elimination could not be predicted by the initial skin prick test results, serum immunoglobulins, total or food-specific IgE, or complexed IgG or IgE. There was a tendency for patients whose eczema did not improve after food elimination to have higher initial serum IgG levels, without a corresponding increase in skin infections. The radioallergosorbent test to soy gave a higher result in those who improved on diet. No significant changes in serum or complexed immunoglobulins occurred over the period of food elimination or subsequent food challenge. Results of food challenges could not be predicted by initial serum immunoglobulin levels. A history of spring/summer exacerbations of eczema correlated with positive skin prick tests to silver birch pollen, but not to grass pollen. Serological tests did not help in planning food diets in atopic eczema, and the immunological studies did not delineate any particular mechanism by which foods might exacerbate eczema.

Modulation of cellular processes by H7, a non-selective inhibitor of protein kinases

H7 has been described as a potent inhibitor of protein kinase C (PKC) and has been widely used to investigate the regulatory role of this enzyme in intact cell systems. In this comparative study between H7 and the microbial alkaloid, staurosporine, we found that the former inhibited rat brain PKC and cAMP dependent protein kinase with IC50 values of 18 and 16 microM respectively whereas the latter was a much more potent inhibitor of both kinases with IC50 values of 9.5 nM and 42 nM respectively. H7, at concentrations up to 100 microM, failed to block cellular events induced by phorbol esters, agents which specifically stimulate PKC, yet was a potent inhibitor of IL-2 induced T cell proliferation with an IC50 value of 19 microM. In contrast, staurosporine was a potent inhibitor of both phorbol ester induced p47 phosphorylation in platelet (I50 value = 540 nM) and also CD3 and CD4 down-regulation in T cells (I50 values 200 nM and 50 nM respectively). Staurosporine was also a potent inhibitor of IL-2 induced T cell proliferation I50 value = 9 nM). These results provide a strong argument against the use of H7 to probe for PKC involvement in cellular processes.

Association of high density lipoprotein cholesterol with plasma lipolytic activity and C-peptide concentration in type 2 diabetes

In order to assess whether insulin concentration or plasma lipolytic activity has any role in the regulation of HDL cholesterol concentrations in type 2 diabetes, fasting plasma C-peptide and HDL2-cholesterol concentrations and the post-heparin plasma activities of lipoprotein lipase and hepatic endothelial lipase were measured in 148 patients with type 2 diabetes (76 male, 72 female). HDL2-cholesterol was related negatively to hepatic lipase activity in men (r = -0.49, p less than 0.001) and women (r = -0.43, p less than 0.001) and positively to lipoprotein lipase activity in men (r = -0.33, p less than 0.01) and women (r = 0.36, p less than 0.01). A significant inverse relationship was confirmed between C-peptide and the HDL2-cholesterol subfraction in both sexes (men, r = -0.40, p less than 0.001, women r = -0.51, p less than 0.001). This persisted after adjustment for the effects of alcohol intake, mode of hypoglycaemic treatment, plasma glucose and body mass index. The relationship was lost in men and greatly diminished in women when hepatic lipase activity was included in multiple linear regression analysis, whereas the inclusion of lipoprotein lipase activity in the analysis had little effect on the relationship between C-peptide and HDL2-cholesterol. We suggest that hepatic lipase may be partly responsible for the commonly observed inverse relationship between measures of insulin secretion and HDL-cholesterol concentrations. We speculate that this may occur through a direct stimulatory effect of insulin on the enzyme's activity.

Relation between humoral responses to HIV gag and env proteins at seroconversion and clinical outcome of HIV infection

OBJECTIVE

To study the contribution of the humoral response to HIV-I at seroconversion to disease outcome after 84 months.

DESIGN

A retrospective longitudinal study.

SETTING

Two haemophilia centres in the United Kingdom.

PATIENTS

88 Haemophiliac patients infected with HIV-I for whom sera were available from before seroconversion and in whom clinical follow up data were available.

RESULTS

Kaplan-Meier survival analysis showed a significant difference between a high titre (greater than 1600) p24 antibody response at seroconversion and prolonged time before the development of HIV related disease (p = 0.0008). In contrast, higher titres of antibody to gp120 at seroconversion (greater than 25,600) correlated with more rapid clinical deterioration (p = 0.025).

CONCLUSIONS

The first humoral response to HIV proteins at seroconversion is associated with clinical outcome; patients with an initial low titre antibody response to the gagp24 protein have a significantly faster rate of progression to CDC stage IV disease. Patients with a high titre p24 antibody response progress to AIDS more slowly, and these data provide an explanation why p24 antigenaemia is not universally detected in patients with AIDS. It is unclear whether the association between a strong initial p24 antibody response and slower progression of HIV disease is causal and if so whether it is due to viral or host factors.

Alpha-blocker therapy; a possible advance in the treatment of diabetic hypertension--results of a cross-over study of doxazosin and atenolol monotherapy in hypertensive non-insulin dependent diabetic subjects

Hyperglycaemia, a raised fibrinogen, an increased serum triglyceride and a reduced HDL-cholesterol are common metabolic features of non-insulin dependent diabetes mellitus (NIDDM). Hypertension is frequently associated with NIDDM, however the influence of antihypertensive therapy on these combined factors in the diabetic is at present unclear. In a double-blind placebo-controlled crossover study in 20 stable NIDDM subjects with hypertension, the metabolic effects of 6 weeks' treatment with the alpha-blocker, doxazosin, was compared with treatment with the beta-blocker, atenolol. Similar and significant reductions in BP were produced by both drugs. Significant increases in weight, HbA1, apoprotein B, serum triglyceride and cholesterol/HDL ratio were observed with atenolol therapy. Doxazosin therapy was associated with opposite patterns of changes in fasting glucose, lipids and lipoproteins but only for serum triglyceride was difference between treatments significant. Fibrinogen was not altered by either treatment. Conclusions from this study indicate; 1) adrenergic mechanisms may be an important influence on glucose homeostasis and lipid metabolism in NIDDM and 2) the beta-blocker, atenolol, has a small adverse effect on weight, glycaemic control and the atherogenic lipid profile, whereas the alpha-blocker, doxazosin, has no such effect and may, in part, correct the disturbances of lipoprotein metabolism characteristic of NIDDM.

Accuracy of ultrasound measurements of female pelvic organs

Uterine size, endometrial thickness and ovarian volume were measured ultrasonically and the results compared with caliper measurements made shortly afterwards at the time of total hysterectomy and bilateral salpingo-oophorectomy. The results establish the validity of ultrasound measurements. Histological studies also confirmed the diagnosis made with ultrasound of polycystic ovaries in women complaining of pain due to pelvic congestion.

Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion

In a group of 55 women with chronic pain due to pelvic congestion measurement by ultrasound revealed they had a larger uterus and thicker endometrium as compared with a group of normal women matched for age, parity and the presence of polycystic ovaries found on ultrasound scanning. Many women with pelvic congestion (56%) were found on ultrasound to have cystic changes in their ovaries which ranged from a classic polycystic pattern to the appearance of clusters of 4-6 cysts in bilaterally enlarged ovaries. It is suggested that uterine enlargement and thickening of the endometrium are caused by oestrogen, either from the effects on the target organs of an increased concentration or of hypersensitivity to oestrogen.

Time-course and relationship of the early changes in renal sodium excretion and aldosterone secretion during dietary sodium restriction in normal man

1. The fall in renal sodium excretion after dietary sodium restriction is prompt and reproducible. The importance of increased aldosterone secretion during the early phase (within 48 h) of this response is unclear. Using two indirect measures of aldosterone secretion (in urine and saliva), we have tried to relate changes in excretion and concentration of this hormone to renal sodium excretion during the abrupt transition from a normal (approximately 150 mmol/day) or high (260 mmol/day) to a low (5-25 mmol/day) sodium intake in 11 and seven male volunteers, respectively. 2. All subjects showed reduced renal sodium excretion within 36 h of dietary restriction, but the times at which increases in renal aldosterone excretion, saliva aldosterone concentration and plasma renin activity became statistically significant varied widely (8-72 h, 2.5- greater than 62.5 h and less than 4- greater than 38 h for renal aldosterone secretion, saliva aldosterone concentration and plasma renin activity, respectively). Circadian fluctuations in saliva aldosterone concentration were apparent and increased in amplitude during sodium restriction. 3. Urine flow rate tended to increase on the first day of sodium restriction and this reached statistical significance in the group initially on a high sodium intake (64.0 +/- 8.8 to 84.3 +/- 11.2 ml/h, P less than 0.01); although the pattern of urine flow did correlate with plasma arginine vasopressin concentration (r = -0.49, P less than 0.01), there was no significant decrease in mean plasma arginine vasopressin concentration [1.15 (0.92-1.44) to 0.90 (0.72-1.12) pmol/l, P = 0.08; geometric mean and 95% confidence limits].(ABSTRACT TRUNCATED AT 250 WORDS)

Liaison psychiatry in general practice: the comprehensive collaborative model

A model of liaison psychiatry in general practice is described and its impact assessed using data from the Nottingham psychiatric case register. The model incorporates a comprehensive network of general practice psychiatric clinics for both psychiatrists and other mental health professionals, associated with mainly informal liaison with general practitioners and others in the primary care team, and a reduction in psychiatric outpatient clinics. Following the introduction of this model, the proportion of new and referred patients seen in primary care settings rose from 1% to 18% in Nottingham over an 8-year period. Over this period admission rates significantly fell in Nottingham compared with the rest of England and evidence is given that the growth of primary care psychiatry contributed significantly to this reduction.

Potent selective inhibitors of protein kinase C

A series of potent, selective inhibitors of protein kinase C has been derived from the structural lead provided by the microbial broth products, staurosporine and K252a. Our inhibitors block PCK in intact cells (platelets and T cells), and prevent the proliferation of mononuclear cells in response to interleukin 2 (IL2).

The cardiovascular and oncotic effects of albumin infusion in premature infants

We determined the oncotic and cardiovascular effects of a standardised infusion of human albumin (1.2 g/kg over 2 h as a 20% solution) in 12 premature infants on 18 occasions when hypovolaemia was suspected on clinical grounds. Blood volume increased by a median value of 15.5%, and fell to preinfusion values by 3 h post infusion in all but four cases. Albumin concentration and colloid osmotic pressure rose during infusion and remained raised even when blood volume had fallen to preinfusion levels. Blood pressure rose in 3 cases only and heart rate fell by greater than 5 beats/min in 6 cases. Indices of long- and short-term heart rate variability were unchanged, but blood pressure variability fell in the second hour of infusion (P = 0.03), an effect which was independent of changes in lung inflation. No changes in blood gases or oxygenation occurred during infusion and no evidence of pulmonary oedema was found. There were wide variations in oncotic and cardiovascular responses to the standardised infusion both between and within subjects. When human albumin is infused in this manner some protection against respiration-induced variability in blood pressure can result, but the circulatory response may prove difficult to predict in the individual.

Does the warming of local anaesthetic reduce the pain of its injection?

One hundred and fifty-seven patients who warranted the injection of local anaesthetic were divided into two groups. One group received local anaesthetic at room temperature (21 degrees C) and the other at body temperature (37 degrees C). The pain resulting from the injection was assessed using a visual analogue scale. There was no significant difference in the level of pain experienced by the two patient groups. It is concluded that no advantage is gained by the warming of local anaesthetic before its administration.

A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion

The value of medroxyprogesterone acetate (MPA) and of psychotherapy in the treatment of lower abdominal pain due to pelvic congestion was assessed in a randomized controlled trial. Eighty-four women with abnormal pelvic venography were assigned to one of four treatment groups: MPA alone, MPA plus psychotherapy, placebo alone, and placebo plus psychotherapy. Women were treated for 4 months and thereafter followed up regularly for 9 months with pain assessments, pelvic ultrasound scanning, and hormone measurements. During treatment, MPA showed a significant benefit in terms of a reduction in visual analogue scale pain score, with 73% of women reporting at least 50% improvement compared with 33% of those treated with placebo. At 9 months after the end of therapy there was no overall significant effect of MPA or psychotherapy, but there was an interaction between MPA and psychotherapy, with 71% of the women in this group showing a greater than or equal to 50% reduction in pain score. Therapy with MPA is a useful first-line therapy for women with pain associated with demonstrable pelvic congestion.

Medroxyprogesterone acetate in the treatment of pelvic pain due to venous congestion

Ovarian function was suppressed with 30 mg of medroxyprogesterone acetate, daily for 6 months, in 22 women with lower abdominal pain due to pelvic congestion. There was reduction in pelvic congestion demonstrated by venography in 17 of the 22 women, and in 16 this was associated with induction of amenorrhoea which suggests that effective ovarian suppression is an important component of successful treatment. In the 17 women who showed a reduction in venogram score, the median change in pain score was 75% compared with only 29% in the five women with no change in venogram score (P less than 0.01). This significant association between reduction in pelvic congestion and pain indicates that pelvic congestion is likely to be the cause of pain in these women and that treatment with medroxyprogesterone acetate could be of value.

Factors predisposing to and outcome of gestational diabetes

Two hundred thirteen women with abnormal glucose tolerance tests (GTTs) were diagnosed over 9 years by a screening program involving the total antenatal population. Each subject was matched for age, parity, and ethnic group with a control. The gestational diabetics were subdivided into classes A1 or A2 based on the fasting plasma glucose value of their GTT: A1 when below 6.0 mmol/L (108 mg/dL) and A2 when 6.0 mmol/L (108 mg/dL) or higher. All received treatment with dietary advice and some with insulin. Birth weight was not related to maternal age or severity of diabetes, but was related to maternal obesity. However, neonatal morbidity indices such as admission to the special care baby unit for longer than 48 hours and polycythemia (hematocrit above 65%) were related significantly to the severity of the diabetes and not to maternal age or obesity.

Clinical diagnosis from digital displays: preliminary findings of the St Mary's Evaluation Project

Image quality is a fundamental issue in the introduction of picture archiving and communications systems (PACS), and one that has hitherto been eclipsed by other aspects of the considerable technological challenge facing scientists and manufacturers involved in its development. We conducted a formal evaluation of clinical radiological diagnosis from a commercially available PACS viewing station, using subperiosteal resorbtion in renal osteodystrophy as the test pathological diagnosis, with receiver operating characteristic (ROC) analysis of the results. We conclude that the displayed, digitised images were inferior to film using the apparatus tested and believe that careful, objective clinical evaluation of such systems is of paramount important.

A pilot study of sexual lifestyle in a random sample of the population of Great Britain

Rates of sexual-partner change and patterns of high-risk behaviour are important determinants of the spread of HIV. We carried out a survey to assess the feasibility of studying sexual lifestyle in a random sample of the British population, aged 16-64 years, in November 1987. Two thousand and seventy-seven households were selected using a multi-stage probability sampling procedure. Seven hundred and eight-five adults participated in a structured interview. The schedule included demographic details, attitudes to AIDS, numbers of sexual partners in different time periods, history of homosexuality and contact with prostitutes. An interview was obtained in 61% of households where contact was made, but the overall response rate was low (48%). There was marked variability between individuals in numbers of sexual partners in given time intervals. Men and women in younger cohorts had experienced first sexual intercourse earlier and had higher numbers of sexual partners than people in older cohorts. Surprisingly few reported high-risk behaviour such as homosexuality and use of prostitution. The methodological problems in trying to obtain unbiased and valid data on sexual behaviour are discussed. Further work is necessary to improve the response rate and questionnaire design.

Expression of results of histamine challenge

Different aspects of standardization of histamine challenges have been extensively investigated. However, several methods have been used for the actual derivation of the provocation concentration causing a 20% fall in lung function (PC20) from the results of the serial lung function tests (e.g. forced expiratory volume in 1 second [FEV1] ). We have compared these methods on a series of 21 histamine challenges to see if any were systematically inconsistent with the others. The simplest method, with least potential for further error, is interpolation of two points, on either side of the line for 20% fall in lung function, calculated by computer. We conclude that, as this method was consistent with the majority of others, it is the method of choice for deriving the PC20.

Beta-blockers, lipoproteins and non-insulin dependent diabetes

In a study on 138 hypertensive non-insulin dependent diabetic subjects, factors influencing lipoproteins were assessed. Multiple regression analyses were carried out in order to assess the influence of beta-blocker antihypertensive therapy while making allowances for other confounding variables. In males, but not in females, on a beta-blocker for hypertension, total high density lipoprotein- (HDL-) and HDL-subfraction cholesterol were significantly lower while the serum triglyceride was increased, though not significantly. In male non-insulin dependent diabetics, regimens containing a beta-blocker may worsen an already abnormal lipoprotein profile and antihypertensive agents other than beta-blocking agents should be used if possible.

Acute lipoprotein changes associated with atenolol therapy for hypertension in non-insulin dependent diabetes

In a study on 11 stable hypertensive non-insulin dependent diabetic subjects the influence of beta-blocker (atenolol 100mg) withdrawal and reintroduction was assessed. After a three week placebo phase significant increases in pulse rate, high density lipoprotein- and high density lipoprotein2-cholesterol and a significant decrease in triglyceride were observed. Three weeks after recommencement of atenolol therapy the pulse, lipid and lipoprotein changes were reversed and significantly so. Weight and blood pressure remained constant throughout. Results from this study indicate that in non-insulin dependent diabetes, atenolol-induced lipid and lipoprotein changes are reversible in the short term and occur in the absence of significant changes in blood pressure control. The lipoprotein changes observed involved an alteration in high density lipoprotein composition. As a reduced high density lipoprotein cholesterol is associated with macrovascular disease, future studies on the association of lipoproteins and diabetic complications should take into account these changes in lipoproteins with beta-blocker hypotensive therapy.

Treating hypertension in black compared with white non-insulin dependent diabetics: a double blind trial of verapamil and metoprolol

STUDY OBJECTIVE

To compare responses of blood pressure to the calcium antagonist verapamil and the beta blocker metoprolol in black compared with white diabetics with hypertension and to monitor urinary albumin excretion in relation to fall in blood pressure.

DESIGN

Double blind, placebo controlled, random order crossover trial with four week placebo run in period and two six week active phases separated by a two week placebo washout period.

SETTING

Outpatient department of a general hospital in a multiethnic health department. Patients--Diabetic patients with hypertension. Four dropped out before randomisation; 25 black and 14 white patients completed the trial.

INTERVENTIONS

Patients given slow release verapamil 120 mg or 240 mg twice daily with placebo or metoprolol 50 mg or 100 mg twice daily with placebo. Treatment for diabetes (diet alone or with oral hypoglycaemic drugs) remained unchanged.

END POINT

Comparison of changes in blood pressure in the two groups taking both drugs.

MEASUREMENTS AND MAIN RESULTS

Metoprolol had little effect on blood pressure in black patients (mean fall 4.0 mm Hg systolic (95% confidence interval -2.5 to 10.4 mm Hg), 4.3 mm Hg diastolic (-0.8 to 9.5)) but more effect in white patients (mean falls 13.4 mm Hg (0.1 to 26.7) and 10.6 mm Hg (4.5 to 16.7) respectively). Verapamil was more effective in both groups, with mean falls of 8.8 mm Hg (2.4 to 15.0) and 8.1 mm Hg (5.0 to 11.2) in black patients and 19.1 mm Hg (5.4 to 32.9) and 11.4 mm Hg (0.9 to 22.0) in white patients. Heart fate fell significantly in black patients taking metoprolol, which suggested compliance with treatment. Metabolic variables were unaltered by either treatment. Plasma renin activity was low in both groups after metoprolol treatment, but change in blood pressure could not be predicted from baseline plasma renin activity. Urinary albumin:creatinine ratio was independently related to baseline blood pressure but not significantly changed by treatment.

CONCLUSIONS

beta Blockers alone are not effective in treating hypertension in black diabetics. Verapamil is effective but less so than in white patients. As yet no ideal monotherapy exists for hypertension in black patients.

Family recovery after death of a child

Children from a national birth cohort living in families in which a sibling had died or been stillborn were compared with children living in similarly structured families where no such tragedy had occurred by a number of health, developmental, and behavioural outcomes. Surprisingly little ill effect from a sibling death (occurring either before or after the birth of study children) was apparent at the age of 5 years. Families experiencing a stillbirth or death of a child were socially disadvantaged. Even allowing for this and other likely intervening factors, however, a child whose adjacent sibling had died was significantly more liable to bronchitis or wheezing during the first 5 years. Mothers who had experienced the death of a child since the study child's birth had high scores on a psychological screening test, and were more likely to be single parents. Mothers who had lost a child were more likely to smoke during the next pregnancy. No significant differences between cases and control subjects were detected on other health, behavioural, or developmental outcomes. Stillbirth or death of a child appears to have little measurable effect on siblings assessed at 5 years of age. This study does not exclude important longer term psychological effects from sibling death.

Prevalence, concentration, and prognostic importance of proteinuria in patients with malignancies

Protein was found significantly more frequently in single urine samples from 504 patients with malignancy (290; 58%) than in 529 controls (119; 22%) (p less than 0.01). Median protein concentration was greater (p less than 0.001) in patients with neoplasia (0.14 g/l) than in controls (0.07 g/l). Actuarial analysis showed a median survival of 4.5 months in patients with proteinuria compared with 10 months in those without (p less than 0.001). The association between proteinuria and shorter survival was statistically significant for patients with gut tumours, lung tumours, and tumours at other sites analysed as a group. Patients with myeloma or urinary tract tumours were not studied. In many patients with malignancy the presence of proteinuria may be associated with a substantially reduced survival time.