Real-world adherence to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation measured by an electronic medication event monitoring system

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended as first choice therapy for thrombo-embolic prevention in patients with non-valvular atrial fibrillation (AF) and an elevated CHA2DS2-VASc score. A critical determinant for both safety and effectiveness of NOAC treatment is adherence to the prescribed medication regimen. Real-life adherence is suboptimal for many cardiovascular drugs. Measuring and improving NOAC adherence is primordial for optimising AF care.

Purpose

We measured adherence to any of the four NOACs in a population of AF patients who participate to a clinical trial during which they received targeted education on AF and its treatment.

Methods

This analysis is part of a prospective, multicenter, randomized controlled trial which is currently ongoing at three Belgian hospitals (AF-EduCare study). Ambulatory or hospitalised AF patients of that trial, treated with a NOAC, and who received a short targeted education session about AF and NOAC therapy at initiation, form the study group of this analysis. Monitoring of NOAC intake was performed by an electronic Medication Event Monitoring System (MEMS), starting immediately after initiation of the study and the education session (for 3 months). A special cap fits on a medication bottle and records the exact date and time of bottle openings. An LCD screen on the cap displays the number of openings of the medication bottle over a period of 24 hours, providing feedback about the correct intake. Dabigatran was replaced by a proxy medication as Dabigatran should be stored in the original package in order to protect it from moisture. Regimen adherence was calculated as the number of days on which one bottle opening in case of Rivaroxaban or Edoxaban and two bottle openings in case of Apixaban or Dabigatran is/are registered, divided by the total number of monitored days and multiplied by 100.

Results

A total of 233 patients (mean age 71.0±7.7 years; 71.2% males; CHA2DS2-VASc score 3.4±1.5; mean duration of AF history 5.8±7.5 years) were given a MEMS. Of these patients 32.2%, 31.3%, 26.2% and 10.3% were respectively on Edoxaban, Apixaban, Rivaroxaban and Dabigatran. Regimen adherence for these NOACs was 95.9±9.3%, 91.6±13.7%, 95.6±5.6% and 94.0±7.1% respectively. Overall, 94.4% of the patients had an adherence >80% and 81.1% had an adherence >90%. Adherence for the once and twice daily regimens was 95.8±0.7% and 92.2±1.3%, respectively (p=0.0003; Mann-Whitney U test).

Conclusions

This is a first prospective study investigating adherence for all NOACs using electronic monitoring. In this sample of AF patients who underwent a targeted education session before the 3 month monitoring period, mean adherence to NOAC intake was >90% for all NOACS. This high adherence may be related to both the education and the use of MEMS, which provided direct feedback to the patient.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The AF-EduCare study is a project supported by the Fund for Scientific Research, Flanders (T002917N).

Digital gene expression analysis might aid in the diagnosis of thyroid cancer

Background

Thyroid cancer represents approximately 90% of endocrine cancers. Difficulties in diagnosis and low inter-observer agreement are sometimes encountered, especially in the distinction between the follicular variant of papillary thyroid carcinoma (fvptc) and other follicular-patterned lesions, and can present significant challenges. In the present proof-of-concept study, we report a gene-expression assay using NanoString nCounter technology (NanoString Technologies, Seattle, WA, U.S.A.) that might aid in the differential diagnosis of thyroid neoplasms based on gene-expression signatures.

Methods

Our cohort included 29 patients with classical papillary thyroid carcinoma (ptc), 13 patients with fvptc, 14 patients with follicular thyroid carcinoma (ftc), 14 patients with follicular adenoma (fa), and 14 patients without any abnormality. We developed a 3-step classifier that shows good correlation with the pathologic diagnosis of various thyroid neoplasms. Step 1 differentiates normal from abnormal thyroid tissue; step 2 differentiates benign from malignant lesions; and step 3 differentiates the common malignant entities ptc, ftc, and fvptc.

Results

Using our 3-step classifier approach based on selected genes, we developed an algorithm that attempts to differentiate thyroid lesions with varying levels of sensitivity and specificity. Three genes-namely SDC4, PLCD3, and NECTIN4/PVRL4-were the most informative in distinguishing normal from abnormal tissue with a sensitivity and a specificity of 100%. One gene, SDC4, was important for differentiating benign from malignant lesions with a sensitivity of 89% and a specificity of 92%. Various combinations of genes were required to classify specific thyroid neoplasms.

Conclusions

This preliminary proof-of-concept study suggests a role for nCounter technology, a digital gene expression analysis technique, as an adjunct assay for the molecular diagnosis of thyroid neoplasms.

Towards development of a statistical framework to evaluate myotonic dystrophy type 1 mRNA biomarkers in the context of a clinical trial

Myotonic dystrophy type 1 (DM1) is a rare genetic disorder, characterised by muscular dystrophy, myotonia, and other symptoms. DM1 is caused by the expansion of a CTG repeat in the 3'-untranslated region of DMPK. Longer CTG expansions are associated with greater symptom severity and earlier age at onset. The primary mechanism of pathogenesis is thought to be mediated by a gain of function of the CUG-containing RNA, that leads to trans-dysregulation of RNA metabolism of many other genes. Specifically, the alternative splicing (AS) and alternative polyadenylation (APA) of many genes is known to be disrupted. In the context of clinical trials of emerging DM1 treatments, it is important to be able to objectively quantify treatment efficacy at the level of molecular biomarkers. We show how previously described candidate mRNA biomarkers can be used to model an effective reduction in CTG length, using modern high-dimensional statistics (machine learning), and a blood and muscle mRNA microarray dataset. We show how this model could be used to detect treatment effects in the context of a clinical trial.

De novo repeat interruptions are associated with reduced somatic instability and mild or absent clinical features in myotonic dystrophy type 1

Myotonic dystrophy type 1 (DM1) is a multisystem disorder, caused by expansion of a CTG trinucleotide repeat in the 3'-untranslated region of the DMPK gene. The repeat expansion is somatically unstable and tends to increase in length with time, contributing to disease progression. In some individuals, the repeat array is interrupted by variant repeats such as CCG and CGG, stabilising the expansion and often leading to milder symptoms. We have characterised three families, each including one person with variant repeats that had arisen de novo on paternal transmission of the repeat expansion. Two individuals were identified for screening due to an unusual result in the laboratory diagnostic test, and the third due to exceptionally mild symptoms. The presence of variant repeats in all three expanded alleles was confirmed by restriction digestion of small pool PCR products, and allele structures were determined by PacBio sequencing. Each was different, but all contained CCG repeats close to the 3'-end of the repeat expansion. All other family members had inherited pure CTG repeats. The variant repeat-containing alleles were more stable in the blood than pure alleles of similar length, which may in part account for the mild symptoms observed in all three individuals. This emphasises the importance of somatic instability as a disease mechanism in DM1. Further, since patients with variant repeats may have unusually mild symptoms, identification of these individuals has important implications for genetic counselling and for patient stratification in DM1 clinical trials.

Molecular Assessment of Microcirculation Injury in Formalin-Fixed Human Cardiac Allograft Biopsies With Antibody-Mediated Rejection

Precise diagnosis of antibody-mediated rejection (AMR) in cardiac allograft endomyocardial biopsies (EMBs) remains challenging. This study assessed molecular diagnostics in human EMBs with AMR. A set of 34 endothelial, natural killer cell and inflammatory genes was quantified in 106 formalin-fixed, paraffin-embedded EMBs classified according to 2013 International Society for Heart and Lung Transplantation (ISHLT) criteria. The gene set expression was compared between ISHLT diagnoses and correlated with donor-specific antibody (DSA), endothelial injury by electron microscopy (EM) and prognosis. Findings were validated in an independent set of 57 EMBs. In the training set (n = 106), AMR cases (n = 70) showed higher gene set expression than acute cellular rejection (ACR; n = 21, p < 0.001) and controls (n = 15, p < 0.0001). Anti-HLA DSA positivity was associated with higher gene set expression (p = 0.01). Endothelial injury by electron microscopy strongly correlated with gene set expression, specifically in AMR cases (r = 0.62, p = 0.002). Receiver operating characteristic curve analysis for diagnosing AMR showed greater accuracy with gene set expression (area under the curve [AUC] = 79.88) than with DSA (AUC = 70.47) and C4d (AUC = 70.71). In AMR patients (n = 17) with sequential biopsies, increasing gene set expression was associated with inferior prognosis (p = 0.034). These findings were confirmed in the validation set. In conclusion, biopsy-based molecular assessment of antibody-mediated microcirculation injury has the potential to improve diagnosis of AMR in human cardiac transplants.

Disease-associated CAG·CTG triplet repeats expand rapidly in non-dividing mouse cells, but cell cycle arrest is insufficient to drive expansion

Genetically unstable expanded CAG·CTG trinucleotide repeats are causal in a number of human disorders, including Huntington disease and myotonic dystrophy type 1. It is still widely assumed that DNA polymerase slippage during replication plays an important role in the accumulation of expansions. Nevertheless, somatic mosaicism correlates poorly with the proliferative capacity of the tissue and rates of cell turnover, suggesting that expansions can occur in the absence of replication. We monitored CAG·CTG repeat instability in transgenic mouse cells arrested by chemical or genetic manipulation of the cell cycle and generated unequivocal evidence for the continuous accumulation of repeat expansions in non-dividing cells. Importantly, the rates of expansion in non-dividing cells were at least as high as those of proliferating cells. These data are consistent with a major role for cell division-independent expansion in generating somatic mosaicism in vivo. Although expansions can accrue in non-dividing cells, we also show that cell cycle arrest is not sufficient to drive instability, implicating other factors as the key regulators of tissue-specific instability. Our data reveal that de novo expansion events are not limited to S-phase and further support a cell division-independent mutational pathway.

Banff fibrosis study: multicenter visual assessment and computerized analysis of interstitial fibrosis in kidney biopsies

Increasing interstitial fibrosis (IF) in native and kidney transplant biopsies is associated with functional decline and serves as a clinical trial end point. A Banff 2009 Conference survey revealed a range in IF assessment practices. Observers from multiple centers were asked to assess 30 renal biopsies with a range of IF and quantitate IF using two approaches on trichrome, Periodic acid-Schiff (PAS) and computer-assisted quantification of collagen III immunohistochemistry (C-IHC) slides, as well as assessing percent of cortical tubular atrophy% (TA%) and Banff total cortical inflammation score (ti-score). C-IHC using whole slide scans was performed. C-IHC assessment showed a higher correlation with organ function (r = -0.48) than did visual assessments (r = -0.32--0.42); computerized and visual C-IHC assessment also correlated (r = 0.64-0.66). Visual assessment of trichrome and C-IHC showed better correlations with organ function and C-IHC, than PAS, TA% and ti-score. However, visual assessment of IF, independent of approach, was variable among observers, and differences in correlations with organ function were not statistically significant among C-IHC image analysis and visual assessment methods. C-IHC image analysis correlated among three centers (r > 0.90, p < 0.0001, between all centers). Given the difficulty of visual IF assessment standardization, C-IHC image could potentially accomplish standardized IF assessment in multicenter settings.

The effectiveness of including support people in a cognitive behavioural weight loss maintenance programme for obese adults: study rationale and design

The well-documented finding that obese adults have a high likelihood of weight regain following participation in behavioural weight loss programmes highlights the importance of developing more effective approaches for weight loss maintenance. One promising approach is to improve the quality of social support for effective weight control available to an obese individual by including support people in behavioural weight loss programmes. This paper describes the rationale and design of a randomized controlled trial that evaluates the effectiveness of training support people to assist obese adults in their weight management. The study entails a two-arm randomized controlled trial in which obese participants take part in a 1-year (26-session) cognitive behaviour therapy group weight management programme, including motivational interviewing strategies (CBT-MI). In one arm, participants receive CBT-MI alone, while in the second arm (CBT-MI-SP), participants also have a support person who attends 10 group sessions designed to teach effective skills for supporting an individual in healthy weight control. More specifically, support people will be trained in skills that aim to promote self-motivation for weight management. Assessments of anthropometric, medical, behavioural, motivational, psychological and social functioning take place at pre-treatment, post-treatment and a 1-year follow-up. By helping obese participants to increase and sustain their motivation and skills for weight control both during treatment and in the crucial period after treatment cessation through the ongoing input of support people, the CBT-MI-SP approach of the current study has the potential to effectively help patients to achieve sustained weight loss while minimizing the patient's need for ongoing, intensive weight control treatment with its attendant costs.

Phenoxyl radical complexes of gallium, scandium, iron and manganese

The hexadentate macrocyclic ligands 1,4,7-tris(3,5-dimethyl-2-hydroxybenzyl)-1,4,7-triazacyclononane (L CH 3H3 ), 1,4,7-tris(3,5-di-tert-butyl-2-hydroxybenzyl)-1,4,7-triazacyclononane (L(Bu) H3 ) and 1,4,7-tris(3-tert-butyl-5-methoxy-2-hydroxybenzyl)-1,4,7-triazacyclononane (L OCH 3-H3 ) form very stable octahedral neutral complexes LM(III) with trivalent (or tetravalent) metal ions (Ga(III) , Sc(III) , Fe(III) , Mn(III) , Mn(IV) ). The following complexes have been synthesized: [L(Bu) M], where M = Ga (1), Sc (2), Fe (3); [L(Bu) Mn(IV) ]PF6 (4'); [L OCH 3M], where M = Ga (1 a), Sc (2 a), Fe (3 a); [L OCH 3Mn(IV) ]PF6 (4 a'); [L CH 3M], where M = Sc (2 b), Fe (3 b), Mn(III) (4 b); [L CH 3Mn(IV) ]2 (ClO4 )3 (H3 O)(H2 O)3 (4 b'). An electrochemical study has shown that complexes 1, 2, 3, 1 a, 2 a and 3 a each display three reversible, ligand-centred, one-electron oxidation steps. The salts [L OCH 3Fe(III) ]ClO4 and [L OCH 3Ga(III) ]ClO4 , have been isolated as stable crystalline materials. Electronic and EPR spectra prove that these oxidations produce species containing one, two or three coordinated phenoxyl radicals. The Mössbauer spectra of 3 a and [3 a](+) show conclusively that both compounds contain high-spin iron(III) central ions. Temperature-dependent magnetic susceptibility measurements reveal that 3 a has an S = 5/2 and [3a](+) an S = 2 ground state. The latter is attained through intramolecular antiferromagnetic exchange coupling between a high-spin iron(III) (S1 = 5/2) and a phenoxyl radical (S2 = 1/2) (H = - 2JS1 S2 ; J = - 80 cm(-1) ). The manganese complexes undergo metal- and ligand-centred redox processes, which were elucidated by spectroelectrochemistry; a phenoxyl radical Mn(IV) complex [Mn(IV) L OCH 3](2+) is accessible.

Weight loss and germination failure caused by psocids in different wheat varieties

We investigated weight loss caused by Liposcelis entomophila (Enderlein) feeding in damaged (cracked) and intact kernels of 'Jagger' variety of hard red winter wheat over a 90-d period at 30 +/- 1 degrees C and 75 +/- 5% relative humidity. L. entomophila caused 8.5% weight loss in damaged wheat kernels, which was significantly greater than the weight loss found in intact wheat kernels (0.2%). We also evaluated the suitability of six wheat varieties commonly grown in Oklahoma, namely, Jagger, 'Endurance,' 'Overley,' 'Jagalene,' 'OK Bullet,' and 'Deliver' to support populations of four psocid species, namely, Liposcelis bostrychophila Badonnel, L. decolor (Pearman), L. entomophila, and L. paeta Pearman over a 30-d period. The greatest population increase was observed in L. bostrychophila followed by L. paeta. Subsequently, weight loss of damaged and intact wheat kernels and germination of intact kernels infested by L. paeta over a 45-d period were assessed in OK Bullet variety. L. paeta caused weight loss of 3.3% in damaged kernels, which was significantly greater than the weight loss found in intact kernels (0.4%). Based on our data, 40% of infested intact kernels failed to germinate after 45 d of infestation by L. paeta, but this decreased to 32% when adjusted using germination failure of uninfested kernels. Our data show that psocid infestations do not only cause considerable loss in weight of wheat, but also result in significant germination failure. These data call for the formulation of effective integrated psocid management strategies for stored wheat to mitigate the negative impacts of psocid pests.

Viral infection of Phaeocystis globosa impedes release of chitinous star-like structures: quantification using single cell approaches

Phaeocystis globosa is an ecologically important bloom-forming phytoplankton, which sequesters substantial amounts of inorganic carbon and can form carbon-enriched chitinous star-like structures. Viruses infecting P. globosa (PgVs) play a significant regulatory role in population dynamics of the host species. However, the extent to which viruses alter host physiology and its carbon assimilation on single cell level is still largely unknown. This study demonstrates for the first time the impact of viral infection on carbon assimilation and cell morphology of individual axenic P. globosa cells using two single cell techniques: high resolution nanometre-scale Secondary-Ion Mass Spectrometry (nanoSIMS) approach and atomic force microscopy (AFM). Up until viral lysis (19 h post infection), the bulk carbon assimilation by infected P. globosa cultures was identical to the assimilation by the non-infected cultures (33 µmol C l(-1)). However, single cell analysis showed that viral infection of P. globosa impedes the release of star-like structures. Non-infected cells transfer up to 44.5 µmol C l(-1) (36%) of cellular biomass in the form of star-like structures, suggesting a vital role in the survival of P. globosa cells. We hypothesize that impediment of star-like structures in infected P. globosa cells may inactivate viral infectivity by forming flocculants after cell lysis. Moreover, we show that substantial amounts of newly produced viruses (≈ 68%) were attached to P. globosa cells prior to cell lysis. Further, we speculate that infected cells become more susceptible for grazing which provides potential reasons for the sudden disappearance of PgVs in the environment. The scenarios of enhanced grazing is at odds to the current perspective that viral infections facilitates microbial mediated processes by diverting host material away from the higher trophic levels.

P4-12-02: The Association of Anastrozole Adherence and Cognitive Function in Breast Cancer

Background: Women with breast cancer experience deterioration in cognitive function with adjuvant therapy. Little is known about whether declines in cognitive function are associated with nonadherence to oral hormonal therapy over time. We investigated anastrozole adherence over time and its association with cognitive function over the first 12 months of therapy in women with breast cancer.

Methods: Using a prospective cohort design, 169 women with early stage breast cancer were monitored for 12 months 1) continuously for their adherence to anastrozole using electronic event monitoring and 2) objectively for cognitive function via a neuropsychological battery every 6 months for the first 12 months of hormonal therapy. Adherence data were summarized monthly as to the number of doses taken as the percentage of prescribed doses taken and the timing of doses taken as the percentage of days with correct intake and the percentage of doses with correct timing. Six cognitive factors, derived via exploratory factor analysis applied to the neuropsychological battery, were used for analysis. Data were analyzed using descriptive and longitudinal methods.

Results: Participants were white (n=166, 98.2%), well-educated (Mean=15.1 years; SD=2.9, range=10-26) and on average 61.1 years of age (SD=5.9, range=46-75). Most had stage 1 breast cancer (n=123, 72.8%) and were prescribed anastrozole either alone (n=110, 65.1%) or immediately after chemotherapy (n=59, 34.9%). Initial levels of adherence were fairly high based on number of (Mean=89.1, SD=27.1, range=0-111.1) and timing of doses taken (Days with correct intake: Mean=86.4, SD=26.8, range=0-100; Doses with correct timing: Mean=83.6, SD=29.8, range=0-100); however, adherence decreased over the first 12 months of therapy (p&lt;.05) in terms of the number of and timing of doses taken and regardless of chemotherapy use. Specifically, we found a linear decrease for the percentage of prescribed doses taken (linear: t=-2.97, p=.0035); however, nonlinear declines were observed for both the percentage of days with correct intake (linear: t=-3.33, p=.0011; quadratic: t=2.10, p=.0371) and the percentage of doses taken at the correct time (linear: t=-3.38, p=.0009; quadratic: t=2.28, p=.0242), suggesting a slowing of the rate of decline in adherence related timing of doses for months 9 through 12. We found that a decrease in executive functioning was related to lower percentages of prescribed doses taken (p=.06) and doses taken at the correct time (p=.06) from pretreatment to 6 months post-anastrozole initiation and even greater evidence (p&lt;.05) from pretreatment to 12 months post-anastrozole initiation. From 7 to 12 months post-anastrozole initiation, we found that a decrease in visual learning and memory was related to lower percentages of prescribed doses taken (p=.04), days with correct intake (p=.04), and doses taken at the correct time (p=.03), while a decrease in attention was related to a lower percentage of days with correct intake (p=.04).

Conclusions: These results suggest that breast cancer survivors who experience deterioration in cognitive function tend to have lower adherence. Efforts should be made to develop interventions to compensate for declines in cognitive function and to improve anastrozole adherence.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-02.

Modelling fruit-temperature dynamics within apple tree crowns using virtual plants

BACKGROUND AND AIMS

Fruit temperature results from a complex system involving the climate, the tree architecture, the fruit location within the tree crown and the fruit thermal properties. Despite much theoretical and experimental evidence for large differences (up to 10 °C in sunny conditions) between fruit temperature and air temperature, fruit temperature is never used in horticultural studies. A way of modelling fruit-temperature dynamics from climate data is addressed in this work.

METHODS

The model is based upon three-dimensional virtual representation of apple trees and links three-dimensional virtual trees with a physical-based fruit-temperature dynamical model. The overall model was assessed by comparing model outputs to field measures of fruit-temperature dynamics.

KEY RESULTS

The model was able to simulate both the temperature dynamics at fruit scale, i.e. fruit-temperature gradients and departure from air temperature, and at the tree scale, i.e. the within-tree-crown variability in fruit temperature (average root mean square error value over fruits was 1·43 °C).

CONCLUSIONS

This study shows that linking virtual plants with the modelling of the physical plant environment offers a relevant framework to address the modelling of fruit-temperature dynamics within a tree canopy. The proposed model offers opportunities for modelling effects of the within-crown architecture on fruit thermal responses in horticultural studies.

Modelling fruit-temperature dynamics within apple tree crowns using virtual plants

BACKGROUND AND AIMS

Fruit temperature results from a complex system involving the climate, the tree architecture, the fruit location within the tree crown and the fruit thermal properties. Despite much theoretical and experimental evidence for large differences (up to 10 °C in sunny conditions) between fruit temperature and air temperature, fruit temperature is never used in horticultural studies. A way of modelling fruit-temperature dynamics from climate data is addressed in this work.

METHODS

The model is based upon three-dimensional virtual representation of apple trees and links three-dimensional virtual trees with a physical-based fruit-temperature dynamical model. The overall model was assessed by comparing model outputs to field measures of fruit-temperature dynamics.

KEY RESULTS

The model was able to simulate both the temperature dynamics at fruit scale, i.e. fruit-temperature gradients and departure from air temperature, and at the tree scale, i.e. the within-tree-crown variability in fruit temperature (average root mean square error value over fruits was 1·43 °C).

CONCLUSIONS

This study shows that linking virtual plants with the modelling of the physical plant environment offers a relevant framework to address the modelling of fruit-temperature dynamics within a tree canopy. The proposed model offers opportunities for modelling effects of the within-crown architecture on fruit thermal responses in horticultural studies.

[Pseudo-Conn's syndrome with hypokalemic paralysis due to diuretics and licorice abuse]

Dyskalemic paralyses are characterised by single or periodic episodes with muscle weakness that affect mostly the proximal skeletal muscles. Symptoms may last for a few hours or persist for several days, spontaneous recovery is common. Familial cases can be distinguished from secondary, non-familial forms which are based on other diseases, for example, of the thyroid gland, kidneys or gastrointestinal tract. Familial cases are mostly inherited in an autosomal-dominant pattern and belong to the channelopathies. Both groups are characterised by changed potassium levels in the blood during an episode. A detailed and accurate medical history (plus family history, use of medication and eating habits) often easily leads to the diagnosis. Provoking tests or instrumental and histological investigations can help to solve difficult cases. Treatment focuses on relieving acute symptoms and attacks can be managed by correcting the blood potassium to a normal level. Changing eating and/or exercise habits and also permanent medical treatment helps to prevent further attacks.

Reliability, technical error of measurements and validity of length and weight measurements for children under two years old in Malaysia

The National Health and Morbidity Survey III 2006 wanted to perform anthropometric measurements (length and weight) for children in their survey. However there is limited literature on the reliability, technical error of measurement (TEM) and validity of these two measurements. This study assessed the above properties of length (LT) and weight (WT) measurements in 130 children age below two years, from the Hospital Universiti Kebangsaan Malaysia (HUKM) paediatric outpatient clinics, during the period of December 2005 to January 2006. Two trained nurses measured WT using Tanita digital infant scale model 1583, Japan (0.01kg) and Seca beam scale, Germany (0.01 kg) and LT using Seca measuring mat, Germany (0.1cm) and Sensormedics stadiometer model 2130 (0.1cm). Findings showed high inter and intra-examiner reliability using 'change in the mean' and 'intraclass correlation' (ICC) for WT and LT. However, LT was found to be less reliable using the 'Bland and Altman plot'. This was also true using Relative TEMs, where the TEM value of LT was slightly more than the acceptable limit. The test instruments were highly valid for WT using 'change in the mean' and 'ICC' but was less valid for LT measurement. In spite of this we concluded that, WT and LT measurements in children below two years old using the test instruments were reliable and valid for a community survey such as NHMS III within the limits of their error. We recommend that LT measurements be given special attention to improve its reliability and validity.

The ageing gut: diminished symptom response to a standardized nutrient stimulus

BACKGROUND The prevalence of dyspepsia and the severity of reflux symptoms decreases with advancing age. We postulate that advancing age influences sensory function and this will be associated with a diminished symptom response to a standardized meal stimulus.Our aim was to assess the influence of age on visceral sensory function. METHODS Baseline gastrointestinal symptoms and anxiety and depression were assessed in 53 healthy volunteers using validated questionnaires. After an 8-h fast, subjects received 200 mL of a standardized enteral feeding solution every 5 min up to a cumulative volume of 800 mL. After each 200 mL drink, five key symptoms were assessed (fullness, abdominal pain, retrosternal/abdominal burning, nausea and regurgitation) using a standardized instrument on visual analogue scales (0-100). The cumulative symptom score across all symptoms was calculated. KEY RESULTS Fullness was the most prominent symptom reported (79.8 +/- 9.5) followed by nausea (14.9 +/- 4.9) and pain (9.8 +/- 4.5); these three items accounted for more than 90% of the overall symptom load. The cumulative pain and nausea scores during a standardized nutrient challenge were significantly and inversely correlated with age (r = -0.43, P = 0.002 and r = -0.28, P = 0.045). Subjects >60 years of age reported significantly lower pain and nausea scores (0.9 +/- 0.9, 4.5 +/- 3.9) than did subjects <40 years (22 +/- 11.9, P = 0.002; 29.3 +/- 12, P = 0.043). CONCLUSIONS & INFERENCES Symptom responses to a standardized nutrient challenge, in particular pain and nausea, are inversely correlated with age.

A national database on children and adolescent with diabetes (e-DiCARE): results from April 2006 to June 2007

In Malaysia, Diabetes in Children and Adolescents Registry (DiCARE) was launched nationwide in August 2006 to determine and monitor the number, the time trend of diabetes mellitus (DM) patients, their socio-demographic profiles, outcome of intervention and facilitate research using this registry. This is an on going real time register of diabetic patients < or = 20 years old via the e-DiCARE, an online registration system. To date were 240 patients notified from various states in Malaysia. The mean age was 12.51 years (1.08-19.75) and 46.4% were boys. The mean age at diagnosis was 8.31 +/- 4.13 years old with an estimated duration of diabetes of 4.32 +/- 3.55 years. A total of 166/240 (69.2%) have T1DM, 42/240 (17.5%) have T2DM and 18/240 (7.5%) have other types of DM. Basis of diagnosis was known in 162 patients with T1DM and 41 patients with T2DM. In T1DM patients, 6.0% of the girls and 19.1% boys were overweight or obese. As for T2DM, 64.3% had their BMI reported: 66.7% girls and 91.6% boys were overweight or obese. Most patients (80.4%) practiced home blood glucose monitoring. Patients were seen by dietitian (66.7%), diabetes educator (50.0%), and optometrist or ophthalmologist (45.0%). Only 10.8% attended diabetic camps. In the annual census of 117 patients, the mean HbAlc level was 10.0% + 2.2 (range 5.2 to 17.0%). The early results of DiCARE served as a starting point to improve the standard of care of DM among the young in the country.

Funktionelle Dyspepsie – eine Verlegenheitsdiagnose?

Dyspepsia comprises a broad spectrum of predominantly upper abdominal symptoms, such as pain, indigestion, nausea, early satiety and bloating. While these symptoms are highly prevalent, in less than 50% of patients presenting with dyspepsia, structural lesions or biochemical abnormalities are found that explain the symptoms when routine clinical tests are used. In patients without structural lesions the diagnosis of functional dyspepsia is justified. Exclusion of life-threatening disorders as the cause of symptoms and reassurance of the patient as well as proper explanation of the diagnosis and its underlying disease mechanisms (i.e. symptoms are due to a sensitive gut) is crucial and can be considered as an essential element of treatment. Since there is a remarkable comorbidity of anxiety and depression, psychosomatic interventions might be necessary in selected patients. Based on controlled clinical trials few drugs, such as proton pump inhibitors, prokinetics, tricyclic antidepressants, simethicone and selected herbal preparations have been found to be effective for treatment of functional dyspepsia. Effects of H. pylori eradication, even though strongly advocated, are most likely due to undiagnosed peptic ulcer disease in a very small group of patients. While there is currently no therapy that cures functional dyspepsia, the therapeutic target is to control symptoms.