Are biomechanics during gait associated with the structural disease onset and progression of lower limb osteoarthritis? A systematic review and meta-analysis

OBJECTIVE

To evaluate if gait biomechanics are associated with increased risk of structurally diagnosed disease onset or progression of lower limb osteoarthritis (OA).

METHOD

A systematic review of Medline and Embase was conducted from inception to July 2021. Two reviewers independently screened records, extracted data and assessed risk of bias. Included studies reported gait biomechanics at baseline, and either structural imaging or joint replacement occurrence in the lower limb at follow-up. The primary outcome was the Odds Ratio (OR) (95% confidence interval (CI)) of the association between biomechanics and structural OA outcomes with data pooled for meta-analysis.

RESULTS

Twenty-three studies reporting 25 different biomechanical metrics and 11 OA imaging outcomes were included (quality scores ranged 12-20/21). Twenty studies investigated knee OA progression; three studies investigated knee OA onset. Two studies investigated hip OA progression. 91% of studies reported a significant association between at least one biomechanical variable and OA onset or progression. There was an association between frontal plane biomechanics with medial tibiofemoral and hip OA progression and sagittal plane biomechanics with patellofemoral OA progression. Meta-analyses demonstrated increased odds of medial tibiofemoral OA progression with greater baseline peak knee adduction moment (KAM) (OR: 1.88 [95%CI: 1.08, 3.29]) and varus thrust presence (OR: 1.97 [95%CI: 1.32, 2.96]).

CONCLUSION

Evidence suggests that certain gait biomechanics are associated with an increased odds of OA onset and progression in the knee, and progression in the hip.

REGISTRATION NUMBER

PROSPERO CRD42019133920.

Business as unusual: medical oncology services adapt and deliver during COVID-19

BACKGROUND

The COVID-19 pandemic has challenged cancer care globally, introducing resource limitations and competing risks into clinical practice.

AIMS

To describe the COVID-19 impact on medical oncology care provision in an Australian setting.

METHODS

Calvary Mater Newcastle and Newcastle Private Hospital medical oncology data from 1 February to 31 April 2019 versus 2020 were retrospectively analysed.

RESULTS

Three hundred and sixty-four inpatient admissions occurred in 2020, 21% less than in 2019. Total inpatient days decreased by 22% (2842 vs 2203). April was most impacted (36% and 44% fewer admissions and inpatient days respectively). Mean length of stay remained unchanged (6.4 vs 6.2 days, P = 0.7). In all, 5072 outpatient consultations were conducted, including 417 new-patient consultations (4% and 6% increase on 2019 respectively). Telephone consultations (0 vs 1380) replaced one-quarter of face-to-face consultations (4859 vs 3623, -25%), with minimal telehealth use (6 vs 69). Day Treatment Centre encounters remained stable (3751 vs 3444, -8%). The proportion of new patients planned for palliative treatment decreased (35% vs 28%, P = 0.04), observation increased (16% vs 23%, P = 0.04) and curative intent treatment was unchanged (both 41%). Recruiting clinical trials decreased by one-third (45 vs 30), two trials were activated (vs 5 in 2019) and 45% fewer patients consented to trial participation (62 vs 34).

CONCLUSION

Our medical oncology teams adapted rapidly to COVID-19 with significant changes to care provision, including fewer hospital admissions, a notable transition to telephone-based outpatient clinics and reduced clinical trial activity. The continuum of care was largely defended despite pandemic considerations and growing service volumes.

A phase I, open label, multicenter dose escalation study of AZD2811 nanoparticle in patients with advanced solid tumors

3098

Background: Aurora kinase B (AURKB) represents a potential target for therapy in solid and hematological malignancies. AURKB inhibitor AZD1152 (barasertib) was previously investigated in solid tumor pts in a phase I setting. AZD2811-nanoparticle (np) is a novel, encapsulated slow release AURKB inhibitor offering several advantages over AZD1152 (Ashton S et al., Sci Transl Med 2016). We report the completed dose-escalation safety, pharmacokinetics (PK), preliminary activity and defined maximum tolerated dose (MTD) of AZD2811-np in pts with advanced solid tumors (NCT02579226). Methods: Adult pts with advanced solid tumors received AZD2811-np IV on Day 1 (D1) and 4 (D4) Q4 week (wk) in six cohorts 15-200 mg/infusion without the use of g-csf in cycle 1. D1 Q4wk and Q3wk schedules were investigated up to 600 mg/infusion (including cohorts with mandatory g-csf prophylaxis on day 8). A standard 3+3 design was used. PK was assessed in cycle 1. Results: 50 pts were recruited into 12 cohorts. D1, D4 Q4wk schedule: 24 pts (15, 25,38, 50, 100 mg/infusion (n=3/cohort), 200 mg/infusion (n=9)). All cohorts were tolerated. Transient grade 4 neutropenia was observed in 7/9 pts at 200 mg/infusion, including 1 DLT (gr4 > 7 days) D1 Q4wk: 200 mg(n=3) was tolerated. D1 Q3wk: 23 pts were evaluated (200/400 mg (n=3,7), and 400/600/500 mg with mandatory g-csf (n=3/5/6)). 400 mg without g-csf was not tolerated (1 gr3 mucosal inflammation & 1 gr4 neutropenia > 7 days). 600 mg with g-csf was not tolerated (gr3 febrile neutropenia & gr3 fatigue). 25/50 pts experienced AE ≥gr 3 (21 considered AZD2811-np-related, 19 neutropenia-related, no deaths within-DLT period). AZD2811-np caused transient gr1/2 fatigue, nausea, diarrhoea and mucosal inflammation. AZD2811 total blood PK appears dose proportional with a t1/2 of 30-50 hours irrespective of schedule. Released AZD2811 concentrations ~1% of total. 14 pts (28%) had disease stabilisation. 1 prostate ca. pt had a confirmed partial response (PR) (continued tx to 451 days). Conclusions: The MTD for AZD2811-np is 500 mg D1 Q3wk. AZD2811-np is now being investigated in a small cell lung cancer expansion. Clinical trial information: NCT02579226.

Long-term trends in antithrombotic drug prescriptions among adults aged 80 years and over from primary care: a temporal trends analysis using electronic health records

PURPOSE

This study aimed to estimate trends in antithrombotic prescriptions from 2001 to 2015 among people aged 80 years and over within clinical indications.

METHODS

A prospective cohort study with 215,559 participants registered with the UK Clinical Practice Research Datalink from 2001 to 2015 was included in the analyses. The prevalence and incidence of antiplatelet and anticoagulant drugs were estimated for each year and by five clinical indications.

RESULTS

The prevalence rate of antithrombotic prescriptions among patients aged over 80 years and diagnosed with atrial fibrillation increased from 53% in 2001 to 77% in 2015 (P_trend <.001). Anticoagulant prescriptions rates also increased five-fold in older adults with atrial fibrillation from around 10% in 2001 to 46% in 2015 (P_trend <.001). Clopidogrel-prescribing rates in patients aged over 80 years and with venous thrombosis increased from 0.4% in 2001 to 10% in 2015 (P_trend <.001). Warfarin-prescribing rates in older patients with venous thrombosis increased from 13% in 2001 to 21% in 2015 (P_trend <.001).

CONCLUSIONS

The use of antithrombotic drugs increased from 2001 to 2015 in people aged 80 years and over across multiple clinical indications. Assessing the benefits and harms of antithrombotic drugs across different clinical indications in older people is a priority.

A phase I, open-label, first-time-in-patient dose escalation and expansion study to assess the safety, tolerability, and pharmacokinetics of nanoparticle encapsulated Aurora B kinase inhibitor AZD2811 in patients with advanced solid tumours

TPS2608

Background: Aurora kinase B performs key roles in the regulation of the cell cycle and represents a potential target for anticancer therapy. AZD2811, formerly designated AZD1152 hydroxy-quinazoline pyrazole anilide (AZD1152 hQPA), is a potent and selective inhibitor of Aurora B kinase activity and has been incorporated into a polymer nanoparticle carrier for intravenous (IV) administration. The phosphate pro-drug of AZD2811, known as AZD1152 (barasertib), reached Phase II of clinical development as a continuous IV infusion. While promising efficacy was seen with barasertib in elderly acute myeloid leukaemia (AML) patients ( Kantarjian HG et al., Cancer 2013;119:2611-19), continuous intravenous drug delivery precluded subsequent development in this disease setting and there were limited clinical responses in solid tumour patients due to dose-limiting myelotoxicity. AZD2811 nanoparticle has been designed to overcome these issues. Methods: Patients with relapsed advanced solid malignancies with no standard treatments are eligible for the part A dose escalation. Primary endpoint is to determine the maximum tolerated dose of AZD2811 nanoparticle using a 3+3 design. Patients with refractory/relapsed small cell lung cancer (SCLC) will be eligible for the part B expansion, where the safety, PK and anti-tumour activity of AZD2811 nanoparticle will be assessed as monotherapy and in combination with chemotherapy. Study enrolment is ongoing. Clinical trial information: NCT02579226.

Cardiovascular risk assessment and treatment in chronic inflammatory disorders in primary care

Objective

To compare differences in cardiovascular (CV) risk factors assessment and management among patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) with that of matched controls.

Methods

A matched cohort study was conducted using primary care electronic health records for one London borough. All patients diagnosed with RA or IBD, and matched controls registered with local general practices on 12th of January 2014 were identified. The study compared assessment and treatment of CV risk factors (blood pressure, body mass index, cholesterol and smoking) in the year before, the year after, and 5 years after RA and IBD diagnosis.

Results

A total of 1121 patients with RA and 1875 patients with IBD were identified and matched with 4282 and, respectively, 7803 controls. Patients with RA were 25% (incidence rate ratio, 1.25, 95% CI 1.12 to 1.35) more likely to have a CV risk factor measured compared with matched controls. The difference declined to 8% (1.08, 1.04 to 1.14) over 5 years of follow-up. The corresponding figures for IBD were 26% (1.26, 1.16 to 1.38) and 10% (1.10, 1.05 to 1.15). Patients with RA showed higher antihypertensive prescription rates during 5 years of follow-up (OR, 1.37, 95% CI 1.14 to 1.65) and patients with IBD showed higher statin prescription rates in the year preceding diagnosis (2.30, 1.20 to 4.42). Incomplete CV risk assessment meant that QRISK scores could be calculated for less than a fifth (17%) and clinical recording of CV disease (CVD) risk scores among patients with RA and IBD was 11% and 6%, respectively.

Conclusions

The assessment and treatment of vascular risk in patients with RA and IBD in primary care is suboptimal, particularly with reference to CVD risk score calculation.

A Randomized Controlled Trial of a Nurse-Led Supportive Care Package (SurvivorCare) for Survivors of Colorectal Cancer

INTRODUCTION

Colorectal cancer (CRC) and its treatments can cause distressing sequelae. We conducted a multicenter randomized controlled trial aiming to improve psychological distress, supportive care needs (SCNs), and quality of life (QOL) of patients with CRC. The intervention, called SurvivorCare (SC), comprised educational materials, needs assessment, survivorship care plan, end-of-treatment session, and three follow-up telephone calls.

METHODS

At the end of treatment for stage I-III CRC, eligible patients were randomized 1:1 to usual care (UC) or to UC plus SC. Distress (Brief Symptom Inventory 18), SCNs (Cancer Survivors' Unmet Needs measure), and QOL (European Organization for Research and Treatment of Cancer [EORTC] QOL questionnaires C30 and EORTC CRC module CR29) were assessed at baseline and at 2 and 6 months (follow-up 1 [FU1] and FU2, respectively). The primary hypothesis was that SC would have a beneficial effect on distress at FU1. The secondary hypotheses were that SC would have a beneficial effect on (a) SCN and QOL at FU1 and on (b) distress, SCNs, and QOL at FU2. A total of 15 items assessed experience of care.

RESULTS

Of 221 patients randomly assigned, 4 were ineligible for the study and 1 was lost to FU, leaving 110 in the UC group and 106 in the SC group. Patients' characteristics included the following: median age, 64 years; men, 52%; colon cancer, 56%; rectal cancer, 35%; overlapping sites of disease, 10%; stage I disease, 7%; stage II, 22%; stage III, 71%. Baseline distress and QOL scores were similar to population norms. Between-group differences in distress at FU1 (primary outcome) and at FU2, and SCNs and QOL at FU1 and FU2 were small and nonsignificant. Patients in the SC group were more satisfied with survivorship care than those in the UC group (significant differences on 10 of 15 items).

CONCLUSION

The addition of SC to UC did not have a beneficial effect on distress, SCNs, or QOL outcomes, but patients in the SC group were more satisfied with care.

IMPLICATIONS FOR PRACTICE

Some survivors of colorectal cancer report distressing effects after completing treatment. Strategies to identify and respond to survivors' issues are needed. In a randomized controlled trial, the addition of a nurse-led supportive care package (SurvivorCare) to usual post-treatment care did not impact survivors' distress, quality of life, or unmet needs. However, patients receiving the SurvivorCare intervention were more satisfied with survivorship care. Factors for consideration in the design of subsequent studies are discussed.

Are healthcare costs from obesity associated with body mass index, comorbidity or depression? Cohort study using electronic health records

The objective of this study was to evaluate the association between body mass index (BMI) and healthcare costs in relation to obesity-related comorbidity and depression. A population-based cohort study was undertaken in the UK Clinical Practice Research Datalink (CPRD). A stratified random sample was taken of participants registered with general practices in England in 2008 and 2013. Person time was classified by BMI category and morbidity status using first diagnosis of diabetes (T2DM), coronary heart disease (CHD), stroke or malignant neoplasms. Participants were classified annually as depressed or not depressed. Costs of healthcare utilization were calculated from primary care records with linked hospital episode statistics. A two-part model estimated predicted mean annual costs by age, gender and morbidity status. Linear regression was used to estimate the effects of BMI category, comorbidity and depression on healthcare costs. The analysis included 873 809 person-years (62% female) from 250 046 participants. Annual healthcare costs increased with BMI, to a mean of £456 (95% CI 344-568) higher for BMI ≥40 kg m(-2) than for normal weight based on a general linear model. After adjusting for BMI, the additional cost of comorbidity was £1366 (£1269-£1463) and depression £1044 (£973-£1115). There was evidence of interaction so that as the BMI category increased, additional costs of comorbidity (£199, £74-£325) or depression (£116, £16-£216) were greater. High healthcare costs in obesity may be driven by the presence of comorbidity and depression. Prioritizing primary prevention of cardiovascular disease and diabetes in the obese population may contribute to reducing obesity-related healthcare costs.

A randomized controlled trial (RCT) of a supportive care package (SurvivorCare, SC) for survivors of colorectal cancer (CRC)

79

Background: Colorectal cancer (CRC) and its treatments can cause distressing short and long-term side effects as well as significant functional consequences. Current models of follow-up do not adequately address these issues. We conducted a multi-center RCT of an innovative program (SurvivorCare (SC)); designed to have a beneficial effect on psychological distress, supportive care needs (SCN) and quality of life (QOL). Methods: At the end of active treatment for stage I-III CRC, eligible patients ( =18 years, adequate English) were randomized 1:1 to usual care (UC) or to UC+SC. SC comprised educational materials, needs assessment, an individualized survivorship care plan, nurse-led end-of-treatment session and three follow up (FU) phone calls. Distress (BSI-18), SCN (CaSUN) and QOL (EORTC QLQ-C30, CR29) were assessed at baseline, 2 (FU1) and 6 (FU2) months. Primary hypothesis: SC would have a beneficial effect on distress at FU1. Secondary hypotheses: SC would have a beneficial effect on (1) SCN and QOL at FU1; and (2) distress, SCN and QOL at FU2. 15 items assessed satisfaction with survivorship care. Sample size of 180 (90/arm) was based on 80% power, 2-sided alpha of 0.05, to detect a between groups difference of 3.6 on BSI-18 at FU1. Outcome analysis was ITT. Results: Of 221 patients randomized (111 UC, 110 SC), 4 were ineligible and 1 lost to FU, leaving 110 UC, 106 SC. Groups appeared well balanced. Median age was 64, 52% male, 56% colon, 35% rectal cancer, 10% overlap. Stage I 7%, II 22%, III 71%. Intervention fidelity was acceptable. Baseline distress and QOL were similar to population norms. Between groups differences in distress at FU1 (primary outcome), distress at FU2 and SCN and QOL at FU1 and FU2 were small and non-significant. SC patients were more satisfied with survivorship care than UC patients (significant differences on 10 of 15 items). Conclusions: The addition of SC to UC did not have a beneficial effect on distress, SCN or QOL outcomes but SC patients were more satisfied with survivorship care. Clinical trial information: ACTRN12610000207011.

Prevalence of depression and utilization of health care in single and multiple morbidity: a population-based cohort study

BACKGROUND

This study aimed to determine whether depression in patients with long-term conditions is associated with the number of morbidities or the type of co-morbidity. Method A cohort study of 299 912 participants aged 30-100 years. The prevalence of depression, rates of health-care utilization and costs were evaluated in relation to diagnoses of diabetes mellitus (DM), coronary heart disease (CHD), stroke and colorectal cancer.

RESULTS

The age-standardized prevalence of depression was 7% in men and 14% in women with no morbidity. The frequency of depression increased in single morbidities including DM (men 13%, women 22%), CHD (men 15%, women 24%), stroke (men 14%, women 26%) or colorectal cancer (men 10%, women 21%). Participants with concurrent diabetes, CHD and stroke had a very high prevalence of depression (men 23%, women 49%). The relative rate of depression for one morbidity was 1.63 [95% confidence interval (CI) 1.59-1.66], two morbidities 1.96 (95% CI 1.89-2.03) and three morbidities 2.35 (95% CI 2.03-2.59). Compared to those with no morbidity, depression was associated with higher rates of health-care utilization and increased costs at any level of morbidity. In women aged 55 to 64 years without morbidity, the mean annual health-care cost was £513 without depression and £1074 with depression; when three morbidities were present, the cost was £1495 without depression and £2878 with depression.

CONCLUSIONS

Depression prevalence and health-care costs are more strongly associated with the number of morbidities than the nature of the co-morbid diagnosis.

Abstract A164: Cardiac effects in a first-in-human (FIH), pharmacokinetic (PK), pharmacodynamic (PD) phase I trial of JNJ-26481585, a second-generation oral hydroxamate histone deacetylase inhibitor (HDACi), in patients with refractory cancer

Background: HDACi have demonstrated activity as anticancer agents and are licensed for use in cutaneous and peripheral T cell lymphoma. Cardiac effects including arrhythmias and QTc prolongation have previously been associated with HDACi administration in humans. This report summarizes the cardiac adverse event (AE) profile observed during the recently completed FIH Phase I trial of JNJ26481585.

Methods: Continuous oral daily dosing (QD) of JNJ26481585 in 21-day (D) cycles (C) was investigated initially in 20 patients (pts) demonstrating activity (including 1 partial response, 1 minor response, 1 prolonged stable disease in melanoma) but ventricular arrhythmia (2 pt) and fatigue (1 pt) were dose-limiting. To improve tolerability, 3 intermittent schedules (QD Mon/Wed/Fri (MWF); QD Mon/Tue/Wed/Thu (MTWT); QD Mon/Thu (MT)) also in 21-D C were subsequently explored in 38 (including expansion cohort), 19 and 15 pts respectively. All pts had triplicate 12-lead ECG (tECG), 24 hour ECG (Holter) and echocardiography or MUGA scan for assessment of left ventricular ejection fraction (LVEF) at baseline and during treatment. Analysis of mean QTcF, categorical QTcF and preliminary assessment of cardiac rhythm/morphology was performed.

Results: 12mg QD MWF was identified as the recommended Phase II dose (RP2D) based on safety, tolerability, PK predictions and PD activity. Maximum average increase in mean QTcF from baseline ranged from 0 to 8 milliseconds (ms) during cycles 1 and 2 across the 4 schedules. At RP2D, the maximum average increase in mean QTcF observed was 6ms. 1 out of 38 pts (2.6%) treated on the MWF schedule experienced a Grade (G) 3 QTcF prolongation, possibly related to ST-T segment changes identified as a class effect of HDACi. QTcF prolongation G1–2 was rarely observed across schedules and mostly occurred as an isolated reversible observation whilst on study drug. Reversible, non-sustained ventricular tachycardia (NSVT) was observed as a dose limiting toxicity (DLT) in 3 out of 39 pts (7.7%) receiving QD or MTWT dosing but was not observed on the MWF or MT schedules. Other reversible, but dose-limiting, cardiac effects were T-wave inversion (2 pts on MT and MTWT), supraventricular tachycardia (1 pt on MT) and hypertension with raised troponin (1 pt on MWF). Non-specific, reversible, asymptomatic ST-T segment changes were frequently observed. LVEF was unaffected during treatment with JNJ26481585.

Conclusion: The RP2D of JNJ26481585 was determined as 12 mg on the MWF schedule and demonstrated an acceptable cardiac safety profile. One pt had QTcF&gt;500 ms but no clinically significant effect on the QTcF interval was observed across schedules. Reversible NSVT was identified as a DLT in some patients on the QD and MTWT dosing schedules but not on the MWF and MT schedules.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A164.

Age-related changes in consultations and antibiotic prescribing for acute respiratory infections, 1995–2000. Data from the UK General Practice Research Database

BACKGROUND

International studies using data aggregated for all ages have shown decreasing rates of general practice consultations for acute respiratory infections with fewer antibiotic prescriptions issued per consultation. The occurrence of different respiratory infections varies widely at different ages but we do not know whether prescribing has reduced equally in all age groups.

OBJECTIVE

We aimed to determine how reductions in consultation rates and antibiotic prescribing varied with age for different respiratory infections.

METHODS

Data were abstracted from the General Practice Research Database for 108 general practices in the UK (mean registered population 642 685). We estimated age-specific changes between 1995 and 2000 in consultation rates, and the proportion of consultations resulting in an antibiotic prescription for 'all respiratory infections' and for 'sore throat', 'ear infection', 'bronchitis' and 'chest infection'.

RESULTS

Consultation rates for 'all respiratory infections' declined in all age groups with the greatest decreases in children aged 1-4 years (41%), 5-10 year olds (53%) and 11-16 year olds (54%), whereas at 75-84 years the reduction was 28%. The pattern of greater reductions in children held for each separate condition even though the age of peak incidence varied. The relative reduction in antibiotic prescribing was greatest at 1-4 years (18%), 5-10 years (17%) and 11-16 years (17%), compared with 5% at 75-84 years. Antibiotic prescribing decreased most for sore throat and this was observed at all ages particularly in 5-10 year olds (relative reduction, 32%).

CONCLUSIONS

School age children account for the greatest reduction in consultations for acute respiratory infection. School age and preschool children account for the greatest reductions in antibiotic prescribing during the consultation. The rapid changes in consultation rates are unexplained.

Physical and psychological co-morbidity in irritable bowel syndrome: a matched cohort study using the General Practice Research Database

BACKGROUND

Irritable bowel syndrome is a common problem known to have a complex relationship with psychological disorders and other physical symptoms. Little information, however, is available concerning physical and psychological comorbidity in irritable bowel syndrome patients studied over an extended period.

AIM

To evaluate physical and psychological morbidity 2 years before and during 6 years after the time of diagnosis in incident cases of irritable bowel syndrome and control subjects.

METHODS

A matched cohort study was implemented in 123 general practices using the General Practice Research Database. Irritable bowel syndrome cases (n = 1827) and controls (n = 3654) were compared for 2 years before and 6 years after diagnosis.

RESULTS

The age-standardized incidence of irritable bowel syndrome in patients over 15 years of age was 1.9 per 1,000 in men and 5.8 per 1,000 in women. From 2 years before the date of diagnosis, more irritable bowel syndrome cases (13%) than controls (5%) consulted with depression or were prescribed antidepressant drugs. Consultation and prescription rates for anxiety were also higher before diagnosis, and both anxiety and depression remained prevalent up to 6 years after diagnosis. Asthma, symptoms of urinary tract infection, gall-bladder surgery, hysterectomy and diverticular disease were recorded more frequently in irritable bowel syndrome patients, who were also more likely than controls to be referred to hospital.

CONCLUSIONS

People who are diagnosed with irritable bowel syndrome experience more anxiety and depression and a range of physical problems, compared with controls; they are more likely to be referred to hospital.

Trends in antihypertensive and lipid-lowering therapy in subjects with type II diabetes: clinical effectiveness or clinical discretion?

Hypertension and lipid disorders in type II diabetes contribute to increased coronary risk, but optimal drug therapy has not been defined. We investigated primary care physicians choices of antihypertensive and lipid-lowering therapy for subjects with type II diabetes diagnosed with hypertension. Subjects were registered with 105 UK general practices in the General Practice Research Database and prescribed oral hypoglycaemic drugs for the first time between January 1993 and December 2001. We evaluated prescriptions for antihypertensive drugs in subjects with secondary diagnoses of hypertension in the first year following initiation of oral hypoglycaemic therapy. Data were analysed for 4519 diabetic subjects with diagnosed hypertension. Between 1993 and 2001, the proportion prescribed thiazide diuretics increased from 20 to 30%; angiotensin-converting enzyme (ACE) inhibitors from 35 to 45% and angiotensin receptor blockers from 0 to 8%. The proportion of subjects prescribed lipid-lowering therapy increased from 8% in 1993 to 33% in 2001, with the proportion prescribed statins increasing from 1 to 30%. At different general practices, the proportion prescribed thiazide diuretics ranged from 0 to 52%, beta-blockers from 5 to 60%, ACE inhibitors from 15 to 81%, and statins from 0 to 50%. Variation between practices was not explained by adjusting for age, sex, prevalent coronary heart disease or study year. Trends in drug utilisation were consistent with the evolving evidence base but there were wide variations in drug utilisation between practices. A more consistent approach to drug selection might be associated with improved patient outcomes.

IgG subclasses serum concentrations in a population of children with Down syndrome: comparative study with siblings and general population

Serum total IgG and subclasses were determined in three different groups of children: with Down syndrome, their siblings and general pediatric population. Several cases of IgG2 and IgG4 deficiency were identified, predominantly in children with Down syndrome. The differences, considering three age groups, were statistically significant for both groups in relation to the general population group, with an increase of IgG1 and IgG3 and a decrease in serum concentrations of IgG2 and IgG4. Down syndrome children and their siblings tend o have a similar variation of the IgG4 serum concentration levels (P < 0.05). The mechanisms of this concordance are not well understood. The results point out that an adequate strategy to improve the immune status of Down syndrome children could have a positive manifestation in the immune profile of their brothers.

Impact of infections on primary care--greater than expected

Though infection has declined as a cause of death it consumes a major proportion of primary care resources, and because of antibiotic resistance is increasingly important. We examined the burden of illness attributable to infection in primary care by analysing data from the fourth practice-based national morbidity survey which monitored all consultations by diagnosis in 470,000 persons over a 12 month period from September 1991 to August 1992. Rates of persons consulting, new episodes of illness and consultations were calculated according to the list of infections published by Wilson and Bhopal (W&B list), and as amended by the Communicable Disease Surveillance Centre (CDSC list); selected comparisons were made with national data on hospital derived finished consultant episodes and deaths. Forty-one percent of all registered persons consulted on at least one occasion during the year for infection (estimated by either list). Infections accounted for 40% of all new episodes of illness and 29% of all consultations; respiratory infections accounted for approximately half the infection total. New episode rates were highest in children aged less than 1 year and lowest in males 25-54 years and females 55-64 years. Except in infancy, rates were higher in females. There were 734 episodes of infection annually per 1,000 population reported in general practice compared with 20 per 1,000 finished consultant episodes. The average episode of infection prompted 1.2 general practice consultations. Improved management through more precise diagnosis by near patient tests is desirable, but is unlikely to be obtained cost effectively if consultation numbers or the time spent is substantially increased. These results emphasise the importance of adequate training for general practitioners in the natural history, epidemiology, diagnosis and treatment (pharmacology) of infection.

Thefurrygene ofDrosophilais important for maintaining the integrity of cellular extensions during morphogenesis

The Drosophila imaginal cells that produce epidermal hairs, the shafts of sensory bristles and the lateral extensions of the arista are attractive model systems for studying the morphogenesis of polarized cell extensions. We now report the identification and characterization of furry, an essential Drosophila gene that is involved in maintaining the integrity of these cellular extensions during morphogenesis. Mutations in furry result in the formation of branched arista laterals, branched bristles and a strong multiple hair cell phenotype that consists of clusters of epidermal hairs and branched hairs. By following the morphogenesis of arista laterals in pupae, we have determined that the branched laterals are due to the splitting of individual laterals during elongation. In genetic mosaics furry was found to act cell autonomously in the wing. The phenotypes of double mutant cells argue that furry functions independently of the frizzled planar polarity pathway and that it probably functions in the same pathway as the tricornered gene. We used a P-element insertion allele as a tag to clone the furry gene and found it to be a large and complicated gene that encodes a pair of large conserved proteins of unknown biochemical function.

Cell size and the morphogenesis of wing hairs in Drosophila

Almost all epidermal cells on the Drosophila wing produce a single cuticular hair. This is formed in the pupae from a microvillus-like cell projection called the prehair. Previous experiments have shown the existence of two mechanisms that ensure that only a single hair is made. One is the restriction of prehair initiation to a small subregion of the cell by the action of the frizzled tissue polarity pathway. The second is a system that ensures the integrity of the prehair. Mutations and drugs that inhibit the actin cytoskeleton lead to the splitting of a single prehair into multiple smaller hairs. We report that large polyploid cells produce multiple hairs both because they form multiple independent prehair initiation centers and because the larger than normal hairs these cells produce have a tendency to split. We show that reducing cell size by starvation partially suppresses the phenotype seen in polyploid cells and that increasing apical cell surface area by mechanical stretching also results in the formation of multiple prehair initiation centers. We also show that the frizzled tissue polarity pathway is functional in large polyploid cells even if it is unable to restrict prehair initiation to a small region of the cell. We conclude that both of these cellular systems are limited in their ability to scale to accommodate larger cell size.

The domineering non-autonomy of frizzled and van Gogh clones in the Drosophila wing is a consequence of a disruption in local signaling

The frizzled (fz) gene is required for the development of distally pointing hairs on the Drosophila wing. It has been suggested that fz is needed for the propagation of a signal along the proximal distal axis of the wing. The directional domineering non-autonomy of fz clones could be a consequence of a failure in the propagation of this signal. We have tested this hypothesis in two ways. In one set of experiments we used the domineering non-autonomy of fz and Vang Gogh (Vang) clones to assess the direction of planar polarity signaling in the wing. prickle (pk) mutations alter wing hair polarity in a cell autonomous way, so pk cannot be altering a global polarity signal. However, we found that pk mutations altered the direction of the domineering non-autonomy of fz and Vang clones, arguing that this domineering non-autonomy is not due to an alteration in a global signal. In a second series of experiments we ablated cells in the pupal wing. We found that a lack of cells that could be propagating a long-range signal did not alter hair polarity. We suggest that fz and Vang clones result in altered levels of a locally acting signal and the domineering non-autonomy results from wild-type cells responding to this abnormal signal.

Families, groups and clusters of local and health authorities: revised for authorities in 1999

This is the second of two articles describing the revision of The ONS classification of local and health authorities of Great Britain to take account of area changes in the 1990's. It presents local authorities in Great Britain as at April 1999 in terms of Families, Groups and Clusters, based on 37 socio-economic and demographic variables from the 1991 Census. Health authorities are presented in terms of Families and Groups only, based on the same variables. The previous article (in Population Trends 98) presented, for each local and health authority, up to four other authorities to which it is 'most similar'.

Which authorities are alike?

This article describes the first results from the recent revision to The ONS classification of local and health authorities of Great Britain to allow for boundary changes. For each local and health authority of Great Britain as at April 1999 it presents 'most similar' authorities as measured by a selection of 37 socioeconomic and demographic variables from the 1991 Census. These results will assist local and health authorities in identifying other appropriate authorities for comparative studies. A second article, to be published in Population Trends 99, will present the results of the analysis to identify groups of authorities in a hierarchy of new Clusters, Groups and Families for the revised classification.

The Drosophila tissue polarity gene starry night encodes a member of the protocadherin family

The tissue polarity genes control the polarity of hairs, bristles and ommatidia in the adult epidermis of Drosophila. We report here the identification of a new tissue polarity gene named starry night (stan). Mutations in this essential gene alter the polarity of cuticular structures in all regions of the adult body. The detailed polarity phenotype of stan on the wing suggested that it is most likely a component of the frizzled (fz) pathway. Consistent with this hypothesis, stan appears to be downstream of and required for fz function. We molecularly cloned stan and found that it encodes a huge protocadherin containing nine cadherin motifs, four EGF-like motifs, two laminin G motifs, and seven transmembrane domains. This suggests that Stan functions in signal reception, perhaps together with Fz.

Densely methylated sequences that are preferentially localized at telomere-proximal regions of human chromosomes

We have constructed a library of densely methylated DNA sequences from human blood DNA by selecting fragments with a high affinity for a methyl-CpG binding domain (MBD) column. PCR analysis of the library confirmed the presence of known densely methylated CpG island sequences. Analysis of random clones, however, showed that the library was dominated by sequences whose G+C content and CpG frequency were intermediate between those of bulk genomic DNA and bona fide CpG islands. When human chromosomes were probed with the library by fluorescent in situ hybridisation (FISH), the predominant sites of labelling were at terminal regions of many chromosomes, approximately corresponding to T-bands. Analysis of the methylation status of random clones indicated that all were heavily methylated at CpGs in blood DNA, but many were under-methylated in sperm DNA. Lack of methylation in germ cells may reduce CpG depletion at some sub-terminal sequences and result in a high density of methyl-CpG when these regions become methylated in somatic cells.

Parallel pathways, noise masking and glaucoma detection: behavioral and electrophysiological measures

PURPOSE

We tested the hypothesis that because of their reduced neural efficiency, glaucoma patients should have increasingly impaired thresholds as external noise is added to a stimulus.

METHOD

We compared the performance of 20 normals (mean age = 39 years) with that of 15 patients with early glaucoma or at very high risk for glaucoma (mean age 45 years). All patients had normal visual acuity. Contrast thresholds were measured on two sets of tasks: (1) behavioral and (2) sweep visually evoked potentials (VEPs). Two stimuli were used (a) 7.5 Hz reversing gratings of 0.69 cpd, and (b) 5.5 cpd gratings. Noise was binary and contrast varied from 0 to 80%. Psychophysical thresholds were determined using a staircase which employed a spatial four alternative forced choice procedure (4AFC) and converged on 50% correct. Sweep VEP thresholds were determined by extrapolation to zero volts as a function of log contrast.

RESULTS

Differences between normal subjects and patients with early glaucoma were not significant without noise. Both the absolute size of the difference and its significance increased as noise level increased. For the behavioral thresholds these trends were clearer with the 5.5 cpd grating, while for the sweep VEPs they were more clear for the 0.69 cpd grating.

CONCLUSION

The performance deficit of glaucoma patients which may be minimal under normal testing conditions is magnified when external noise is added to the stimulus. VEPs and psychophysical thresholds show interesting differences in their sensitivity to this effect. Implications for the early detection of glaucoma are discussed.

Estimation of SELEX pool size by measurement of DNA renaturation rates

We report a general method of measuring the complexity of SELEX pools. In analogy to measurements of genome size by C0t analysis, the complexity of a SELEX pool is measured by determining the reannealing rate of its double-stranded PCR product. We applied this technique to study the selection dynamics of a recently reported SELEX to neutrophil elastase. We found that the number of sequences decreased from 10(7) in round 6 to approximately 60 by round 15, the final round. The intermediate rounds are a mixture of a high abundance/low complexity pool with a low abundance/high complexity pool. As the SELEX progresses, the former pool expands at the expense of the latter. This technique should be useful for studying and optimizing SELEX dynamics, as well as for monitoring the progress of SELEX experiments.

Nonmethylated transposable elements and methylated genes in a chordate genome

The genome of the invertebrate chordate Ciona intestinalis was found to be a stable mosaic of methylated and nonmethylated domains. Multiple copies of an apparently active long terminal repeat retrotransposon and a long interspersed element are nonmethylated and a large fraction of abundant short interspersed elements are also methylation free. Genes, by contrast, are predominantly methylated. These data are incompatible with the genome defense model, which proposes that DNA methylation in animals is primarily targeted to endogenous transposable elements. Cytosine methylation in this urochordate may be preferentially directed to genes.

Patients consulting with Crohn's disease in primary care in England and Wales

OBJECTIVE

To determine annual incidence and prevalence for patients consulting their GP because of Crohn's disease in England and Wales and compare demographic details with matched controls.

DESIGN

We used the fourth Morbidity Statistics in General Practice study (MSGP-4) which covered 468 042 person-years during a 12-month period in 1991-92.

METHODS

All GPs reporting a patient with Crohn's disease in MSGP-4 were sent a questionnaire to confirm the diagnosis and obtain supportive details (surgical, pathological, radiological and/or endoscopic). Data concerning ethnicity, social class, smoking status, living in an urban or rural environment and employment had been collected previously. Conditional logistic regression models were used to analyse the data for cases and matched controls.

RESULTS

Three hundred and fifteen patients were reported to have Crohn's disease. Replies were obtained to 251 (80%) questionnaires. The diagnosis of Crohn's disease was confirmed in 184 cases (89%) and refuted in 23 cases (11%) -- details were unavailable for 44 patients. The mean age of patients was 44 years, the female:male ratio was 1.46:1, and 108 (59%) patients had required surgery. Thirty-three of 178 (18.5%) patients were diagnosed within the study period. Hence, this study detected a prevalence for consulting Crohn's disease of 54.6-59.8/100,000 and an annual incidence of 10.1-11.1/100,000 in 1991-92. No significant differences were found between cases (n = 291) and controls (n = 1682) with regard to ethnicity, social class, smoking or living in an urban/rural environment. Patients with Crohn's disease had similar employment levels as controls, but were significantly more likely to be registered as permanently sick, odds ratio 4.01 (CI 2.21-7.29).

CONCLUSIONS

This national survey, including 1% of the population, suggests there are approximately 30,600 patients consulting their GP because of Crohn's disease in England and Wales, with 5700 new cases diagnosed per year.

Potential for suicide prevention in primary care? An analysis of factors associated with suicide

BACKGROUND

General practitioners (GPs) need to be aware of the risk factors for suicide. GP records may provide clues to identifying the relative importance of such risk factors.

AIMS

To identify, in suicide cases and matched controls, the patterns of consultation, diagnosis, and treatment of mental illness, and recording of risk factors for suicide. To examine the usefulness of data routinely collected by GPs in computerized databases to investigate treatment of patients in general practice prior to suicide.

METHOD

Case control study using GP records from the General Practice Research Database (GPRD). Three controls selected for each case, matched for age, sex, and duration of registration with practice. Information extracted of the prevalence of major disease; diagnosis of, and treatment, or referral for, mental illness; frequency of recording of recent life events; and consultations with the GP in the 12 months prior to death.

RESULT

Of the 339 suicide cases recorded, 80% were male, which is similar to the national percentage for this age group. Females were more likely than males to have a history of mental illness and to have been diagnosed and treated for mental illness in the 12 months before death (59% versus 35%), and women were more likely to have previously attempted suicide (47% versus 27%). There was no significant difference between males and females in period of time since last contact with GP practice, but females consulted more frequently. Twenty-nine per cent of cases had not consulted their GP in the six months prior to death. In multivariate analysis, the following were identified as independent risk factors: history of attempted suicide; untreated serious mental illness (odds ratio > 20); recent (past 12 months) marital life event; alcohol abuse; frequent consultations with GP; and previous mental illness. Recording of life events by GPs was poor.

CONCLUSIONS

Females at risk of suicide are more likely than males to have been diagnosed and treated for mental illness. It is likely that GPs are under-diagnosed and under-treating males at risk. Data from the GPRD give comparable results to those from other studies. The GPRD is a potentially useful tool for research into relatively uncommon events in general practice.

Van Gogh: a new Drosophila tissue polarity gene

Mutations in the Van Gogh gene result in the altered polarity of adult Drosophila cuticular structures. On the wing, Van Gogh mutations cause an altered polarity pattern that is typical of mutations that inactivate the frizzled signaling/signal transduction pathway. The phenotype however, differs from those seen previously, as the number of wing cells forming more than one hair is intermediate between that seen previously for typical frizzled-like or inturned-like mutations. Consistent with Van Gogh being involved in the function of the frizzled signaling/signal transduction pathway, Van Gogh mutations show strong interactions with mutations in frizzled and prickle. Mitotic clones of Van Gogh display domineering cell nonautonomy. In contrast to frizzled clones, Van Gogh clones alter the polarity of cells proximal (and in part anterior and posterior) but not distal to the clone. In further contrast to frizzled clones, Van Gogh clones cause neighboring wild-type hairs to point away from rather than toward the clone. This anti-frizzled type of domineering nonautonomy and the strong genetic interactions seen between frizzled and Van Gogh suggested the possibility that Van Gogh was required for the noncell autonomous function of frizzled. As a test of this possibility we induced frizzled clones in a Van Gogh mutant background and Van Gogh clones in a frizzled mutant background. In both cases the domineering nonautonomy was suppressed consistent with Van Gogh being essential for frizzled signaling.

Use of the census samples of anonymised records (SARs) and survey data in combination to obtain estimates at local authority level

"The Samples of Anonymised Records (SARs) provide large representative samples of 278 small areas of Britain and are thus of great value to planners. This paper describes an approach which takes advantage of the fact that the SARs comprise individual records. Estimates of the proportions of local authority populations suffering serious illness were produced by use of data from the 4th National General Practitioner Morbidity survey and the 2% anonymised sample of individual 1991 Census records. These estimates were compared with external validation criterion, all-cause mortality. The correlation was high, providing some evidence of the validity of the approach."

Oesophageal, rectal, axillary, tympanic and pulmonary artery temperatures during cardiac surgery

PURPOSE

The gradient between temperatures measured at different body sites is not constant; one factor which will change this gradient is rapid changes in body temperature. Measurement of this gradient was done in patients undergoing rapid changes in body temperature to establish the best site to measure temperature and to compare two brands of commercial tympanic thermometers.

METHOD

A total of 228 sets of temperatures were measured from probes in the oesophagus, rectum, and axilla and from two brands of tympanic thermometer and compared with pulmonary artery (PA) temperature in 18 adults during cardiac surgery.

RESULTS

Measurements from the oesophageal site was closest to PA readings (mean difference 0.0 +/- 0.5 degree C) compared with IVAC tympanic thermometer (mean difference -0.3 +/- 0.5 degree C), Genius tympanic thermometer (mean difference -0.4 +/- 0.5 degree C), axillary (mean difference 0.2 +/- 1.0 degrees C) and rectal (mean difference -0.4 +/- 1.0 degree C) readings. When data during cooling were analysed separately, all sites had similar gradients from PA except for rectal, which was larger. On rewarming, oesophageal readings were closest to PA readings; tympanic readings were closer to PA than were rectal or axillary readings. Readings from the two brands of tympanic thermometer were equivalent.

CONCLUSION

Oesophageal temperature is more accurate and will reflect rapid changes in body temperature better than tympanic, axillary, or rectal temperature. When oesophageal temperature cannot be measured, tympanic temperature done by a trained operator should become the reading of choice.

Mutations in the cadherin superfamily member gene dachsous cause a tissue polarity phenotype by altering frizzled signaling

The adult cuticular wing of Drosophila is covered by an array of distally pointing hairs that reveals the planar polarity of the wing. We report here that mutations in dachsous disrupt this regular pattern, and do so by affecting frizzled signaling. dachsous encodes a large membrane protein that contains many cadherin domains and dachsous mutations cause deformed body parts. We found that mutations in dachsous also result in a tissue polarity phenotype that at the cellular level is similar to frizzled, dishevelled and prickle, as many cells form a single hair of abnormal polarity. Although their cellular phenotype is similar to frizzled, dishevelled and prickle, dachsous mutant wings display a unique and distinctive abnormal hair polarity pattern including regions of reversed polarity. The development of this pattern requires the function of frizzled pathway genes suggesting that in a dachsous mutant the frizzled pathway is functioning - but in an abnormal way. Genetic experiments indicated that dachsous was not required for the intracellular transduction of the frizzled signal. However, we found that dachsous clones disrupted the polarity of neighboring wild-type cells suggesting the possibility that dachsous affected the intercellular signaling function of frizzled. Consistent with this hypothesis we found that frizzled clones in a dachsous mutant background displayed enhanced domineering non-autonomy, and that the anatomical direction of this domineering non-autonomy was altered in regions of dachsous wings that have abnormal hair polarity. The direction of this domineering nonautonomy was coincident with the direction of the abnormal hair polarity. We conclude that dachsous causes a tissue polarity phenotype because it alters the direction of frizzled signaling.