Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK

AIMS

To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age.

METHODS

We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes.

RESULTS

Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness.

CONCLUSIONS

The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Basal insulin peglispro: Overview of a novel long-acting insulin with reduced peripheral effect resulting in a hepato-preferential action

Basal insulin peglispro (BIL) is a novel basal insulin with a flat, prolonged activity profile. BIL has been demonstrated in a dog model, in healthy men and in patients with type 1 diabetes (T1D) to have significant hepato-preferential action resulting from reduced peripheral activity. In the IMAGINE-Phase 3 clinical trial program, more than 6000 patients were included, of whom ~3900 received BIL. Of the 7 pivotal IMAGINE trials, 3 studies were double-blinded and 3 were in T1D patients. BIL consistently demonstrated a greater HbA1c reduction, less glycaemic variability and a clinically relevant reduction in the rates of nocturnal hypoglycaemia across comparator [glargine and isophane insulin (NPH)] studies. Trials using basal/bolus regimens had higher rates of total hypoglycaemia with BIL due to higher rates of daytime hypoglycaemia. Severe hypoglycaemia rates were similar to comparator among both patients with T1D or type 2 diabetes (T2D). T1D patients lost weight compared with glargine (GL). Patients with T2D tended to gain less weight with BIL than with glargine. Compared to glargine, BIL was associated with higher liver fat, triglycerides and alanine aminotransferase (ALT) levels, including a higher frequency of elevation of ALT ≥3 times the upper limit of normal, but without severe, acute drug-induced liver injury. Injection site reactions, primarily lipohypertrophy, were more frequent with BIL. In conclusion, BIL demonstrated better glycaemic control with reduced glucose variability and nocturnal hypoglycaemia but higher triglycerides, ALT and liver fat relative to conventional comparator insulin. The hepato-preferential action of BIL with reduced peripheral activity may account for these findings.

Reduced peripheral activity leading to hepato-preferential action of basal insulin peglispro compared with insulin glargine in patients with type 1 diabetes

AIMS

Basal insulin peglispro (BIL), a novel PEGylated basal insulin with a large hydrodynamic size, has a delayed absorption and reduced clearance that prolongs the duration of action. The current study compared the effects of BIL and insulin glargine (GL) on endogenous glucose production (EGP), glucose disposal rate (GDR) and lipolysis in patients with type 1 diabetes.

MATERIALS AND METHODS

This was a randomized, open-label, four-period, crossover study. Patients received intravenous infusions of BIL and GL, each at two dose levels selected for partial and maximal suppression of EGP, during an 8 to 10 h euglycemic clamp procedure with d-[3-³ H] glucose.

RESULTS

Following correction for equivalent human insulin concentrations (EHIC), low-dose GL infusion resulted in similar EGP at the end of the clamp compared to low-dose BIL infusion (GL/BIL ratio of 1.03) but a higher GDR (GL/BIL ratio of 2.42), indicating similar hepatic activity but attenuated peripheral activity of BIL. Consistent with this, the EHIC-corrected GDR/EGP at the end of the clamp was 1.72-fold greater for GL than BIL following low-dose administration. At the lower dose of BIL and GL (concentrations in the therapeutic range), BIL produced less suppression of lipolysis compared with GL as indicated by free fatty acid and glycerol levels at the end of the clamp.

CONCLUSIONS

Compared with GL, BIL restored the hepato-peripheral insulin action gradient seen in normal physiology via its peripherally restricted action on target tissues related to carbohydrate and lipid metabolism.

Social Support and Burden among Caregivers of Patients with Dementia in Malaysia

This study aims to examine selected factors of dementia patients and their caregivers that were associated with the burden of family caregivers. This cross sectional study involves face-to-face interview with family caregivers of patients with dementia. Participants were recruited through convenient sampling from geriatric and psychiatry outpatient clinics from three government hospitals, one university hospital, one rural health centre and Alzheimer Disease caregivers' support groups. 70 caregivers took part in the study. Measures included patient and caregiver demographic variables and caregiver burden using the Zarit Burden Interview (ZBI). Caregiver burden was found to be significantly associated with both ethnicity and informal support. Chinese caregivers were found to have a higher level of burden compared to Indians and Malays. Informal support, in particular assistance from family members, was significantly associated with a lower burden perceived by the caregivers. However, the study shows that formal support such as assistance from maids and private nurses did not alleviate the burden of caregivers. Results highlighted the importance of improving the coping skills in burdened caregivers particularly among family members with dementia relatives. Interventions should be designed for specific needs of caregivers of different ethnicities. Asia Pac J Public Health 2003; 15(1): 23-29.

Evaluation of immunogenicity of LY2963016 insulin glargine compared with Lantus® insulin glargine in patients with type 1 or type 2 diabetes mellitus

AIMS

To compare the immunogenicity profiles and the potential effects on clinical outcomes of LY2963016 insulin glargine (LY IGlar) and Lantus® insulin glargine (IGlar), products with identical primary amino acid sequences, in patients with type 1 or type 2 diabetes mellitus (T1DM or T2DM).

METHODS

To assess immunogenicity, anti-insulin glargine antibodies (measured as percent binding) were compared between treatments in 52-week (open-label) and 24-week (double-blind) randomized studies in total study populations of patients with T1DM (N = 535) and T2DM (N = 756), respectively, and two subgroups of patients with T2DM: insulin-naïve patients and those reporting prestudy IGlar treatment (prior IGlar). Relationships between insulin antibody levels and clinical outcomes were assessed using analysis of covariance and partial correlations. Insulin antibody levels were assessed using Wilcoxon rank sum. Treatment comparisons for treatment-emergent antibody response (TEAR) and incidence of detectable antibodies were analysed using Fisher's exact test.

RESULTS

No significant treatment differences were observed for insulin antibody levels, incidence of detectable anti-insulin glargine antibodies, or incidence of TEAR [overall and endpoint, by last-observation-carried-forward (LOCF)] in patients with T1DM or patients with T2DM, including the insulin-naïve subgroup. A statistically significant difference was noted in the overall incidence of detectable antibodies but not at endpoint (LOCF) nor in TEAR for the prior IGlar subgroup of patients with T2DM. Insulin antibody levels were low (<5%) in both treatment groups. Insulin antibody levels or developing TEAR was not associated with clinical outcomes.

CONCLUSIONS

LY IGlar and IGlar have similar immunogenicity profiles; anti-insulin glargine antibody levels were low for both treatments, with no observed effect on efficacy and safety outcomes.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study

PURPOSE

People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.

METHODS

E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.

RESULTS

In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).

CONCLUSIONS

There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Similar efficacy and safety of LY2963016 insulin glargine and insulin glargine (Lantus®) in patients with type 2 diabetes who were insulin-naïve or previously treated with insulin glargine: a randomized, double-blind controlled trial (the ELEMENT 2 study)

AIMS

To compare the efficacy and safety of LY2963016 insulin glargine (LY IGlar) and the reference product (Lantus(®)) insulin glargine (IGlar) in combination with oral antihyperglycaemic medications in patients with type 2 diabetes (T2D).

METHODS

This phase III, randomized, double-blind, 24-week study enrolled patients with T2D who were insulin-naïve [glycated haemoglobin (HbA1c) ≥7 and ≤11.0%] or previously on IGlar (HbA1c ≤11%) and treated with ≥2 oral antihyperglycaemic medications. Patients were randomized to receive once-daily LY IGlar (n = 376) or IGlar (n = 380) for 24 weeks. The primary efficacy outcome was to test the non-inferiority (0.4% and then 0.3% margin) of LY IGlar to IGlar, as measured by change in HbA1c from baseline to 24 weeks.

RESULTS

Both treatment groups had similar and significant (p < 0.001) within-group decreases in mean HbA1c values from baseline. LY IGlar met non-inferiority criteria compared with IGlar for change in HbA1c from baseline [-1.29 vs -1.34%; respectively, least-squares mean difference 0.052% (95% confidence interval -0.070 to 0.175); p > 0.05]. There were no treatment differences (p > 0.05) in fasting plasma glucose, proportion of patients reaching HbA1c <7% or insulin dose at 24 weeks. Adverse events, allergic reactions, weight change, hypoglycaemia and insulin antibodies were similar between treatment groups. Similar findings were observed in patients who were insulin-naïve or previously treated with IGlar at baseline.

CONCLUSIONS

Both LY IGlar and IGlar, when used in combination with oral antihyperglycaemic medications, provided effective and similar glucose control with similar safety profiles in patients with T2D.

Efficacy and safety of LY2963016 insulin glargine compared with insulin glargine (Lantus®) in patients with type 1 diabetes in a randomized controlled trial: the ELEMENT 1 study

AIMS

To compare the efficacy and safety of LY2963016 insulin glargine (LY IGlar) and the reference product (Lantus®) insulin glargine (IGlar) in patients with type 1 diabetes (T1D).

METHODS

This phase III, randomized, open-label, 52-week study enrolled patients with T1D [glycated haemoglobin (HbA1c) ≤11%] being treated with basal (once-daily) and bolus insulin. Patients were randomized to receive once-daily LY IGlar (n = 268) or IGlar (n = 267) in combination with mealtime insulin lispro for 52 weeks. The primary efficacy outcome was to test the non-inferiority (0.4% and then 0.3% margin) of LY IGlar to IGlar as measured by change in HbA1c from baseline to 24 weeks.

RESULTS

Both treatment groups had similar and significant (p < 0.001) within-group decreases in mean HbA1c values from baseline. LY IGlar met the non-inferiority criteria compared with IGlar for change in HbA1c from baseline to 24 weeks [-0.35 vs -0.46%, least-squares mean difference 0.108% (95% confidence interval -0.002 to 0.219), p > 0.05]. There were no significant (p > 0.05) treatment differences in other efficacy measures, including proportion of patients reaching HbA1c <7%, daily mean blood glucose, and insulin dose at 24 and 52 weeks. At 52 weeks, similar findings were observed between LY IGlar and IGlar for safety outcomes, including adverse events, allergic reactions, hypoglycaemia, weight change and insulin antibodies.

CONCLUSIONS

Both LY IGlar and IGlar, when used in combination with mealtime insulin lispro, provided effective and similar glucose control and similar safety profiles.

Short-term administration of the glucagon receptor antagonist LY2409021 lowers blood glucose in healthy people and in those with type 2 diabetes

AIM

To describe the clinical effects of single and multiple doses of a potent, selective, orally administered, small-molecule antagonist of the human glucagon receptor, LY2409021, in healthy subjects and in patients with type 2 diabetes.

METHODS

LY2409021 was administered in dose-escalation studies to healthy subjects (n = 23) and patients with type 2 diabetes (n = 9) as single doses (Study 1) and daily to patients with type 2 diabetes (n = 47) for 28 days (Study 2). Safety, tolerability, pharmacokinetic (PK) and pharmacodynamic (PD) assessments were made after single doses and in patients receiving once-daily doses of LY2409021 (5, 30, 60 or 90 mg) for 28 days.

RESULTS

LY2409021 was well tolerated at all dose levels in both studies. Fasting and postprandial glucose were reduced and glucagon levels increased after single and multiple dosing, with reductions in fasting serum glucose of up to ∼1.25 mmol/l on day 28. Serum aminotransferases increased in a dose-dependent manner with multiple dosing and reversed after cessation of dosing. Significant glucose-lowering was observed with LY2409021 at dose levels associated with only minor aminotransferase increases.

CONCLUSION

Blockade of glucagon signalling in patients with type 2 diabetes is well tolerated and results in substantial reduction of fasting and postprandial glucose with minimal hypoglycaemia, but with reversible increases in aminotransferases. Inhibition of glucagon signalling by LY2409021 is a promising potential treatment for patients with type 2 diabetes and should be evaluated in longer clinical trials to better evaluate benefits and risks.

Antipsychotic exposure prior to acute myocardial infarction in patients with serious mental illness

OBJECTIVE

To investigate the association between acute myocardial infarction (AMI) and recent exposure to antipsychotic agents in people with serious mental illness (SMI), and modifying influences.

METHOD

A case-crossover design was applied using the Taiwan National Health Insurance Research Database (NHIRD) to compare the exposure frequency of antipsychotic agents within individuals of schizophrenia or bipolar disorder between 60-day case and control periods prior to their first AMI episode during 1996-2007.

RESULTS

A sample of 834 patients with incident AMI was analysed. AMI was significantly associated with more recent antipsychotic exposure in schizophrenia after adjustment (OR 1.87, 95% confidence interval 1.15-3.03) bipolar disorder (OR 1.06, 0.51-2.21). This association in schizophrenia was significantly stronger in men and in patients without previous diagnoses of cardiovascular risk factors.

CONCLUSION

These findings are consistent with a short-term risk effect of antipsychotic exposure on risk of AMI and identify potentially vulnerable groups. Further research is required to clarify underlying biological mechanisms.

Contrasting weight changes with LY2605541, a novel long-acting insulin, and insulin glargine despite similar improved glycaemic control in T1DM and T2DM

AIMS

The basal insulin analogue LY2605541, a PEGylated insulin lispro with prolonged duration of action, was previously shown to be associated with modest weight loss in Phase 2, randomized, open-label trials in type 2 (N=288) and type 1 (N=137) diabetes mellitus (T2DM and T1DM), compared with modest weight gain with insulin glargine. Exploratory analyses were conducted to further characterize these findings.

METHODS

Pearson correlations between change in body weight and other variables were calculated. Continuous variables were analysed using a mixed linear model with repeated measurements. Proportions of subjects with weight loss were analysed using Fisher's exact test for T2DM and Nagelkerke's method for T1DM.

RESULTS

Weight loss was more common in LY2605541-treated patients than in patients treated with insulin glargine (T2DM: 56.9 vs. 40.2%, p=0.011; T1DM: 66.1 vs. 40.3%, p<0.001). More LY2605541-treated patients experienced ≥5% weight loss compared to patients treated with glargine (T2DM: 4.8 vs. 0%, p=0.033; T1DM: 11.9 vs. 0.8%, p<0.001). In both the T1DM and T2DM studies, weight change did not correlate with baseline body mass index (BMI), or change in HDL-cholesterol in either treatment group. No consistent correlations were found across both studies between weight change and any of the variables assessed; however, weight change was significantly correlated with hypoglycaemia rate in glargine-treated T2DM patients.

CONCLUSION

In two Phase 2 trials, improved glycaemic control with long-acting basal insulin analogue LY2605541 is associated with weight loss in previously insulin-treated patients. This weight change is independent of baseline BMI or hypoglycaemia.

Born into adversity: psychological distress in two birth cohorts of second-generation Irish children growing up in Britain

Background

Worldwide, the Irish diaspora experience health inequalities persisting across generations. The present study sought to establish the prevalence of psychological morbidity in the children of migrant parents from Ireland, and reasons for differences.

Methods

Data from two British birth cohorts were used for analysis. Each surveyed 17 000 babies born in one week in 1958 and 1970 and followed up through childhood. Validated scales assessed psychological health.

Results

Relative to the rest of the cohort, second-generation Irish children grew up in material hardship and showed greater psychological problems at ages 7, 11 (1958 cohort) and 16 (both cohorts). Adjusting for material adversity and maternal psychological distress markedly reduced differences. Relative to non-Irish parents, Irish-born parents were more likely to report chronic health problems (odds ratio [OR]: 1.29; 95% confidence interval [CI]: 1.08–1.54), and Irish-born mothers were more likely to be psychologically distressed (OR: 1.44; 95% CI: 1.13–1.84, when child was 10). Effect sizes diminished once material adversity was taken into account.

Conclusions

Second-generation Irish children experienced high levels of psychological morbidity, but this was accounted for through adverse material circumstances in childhood and psychological distress in parents. Public health initiatives focusing on settlement experiences may reduce health inequalities in migrant children.

Migration, social mobility and common mental disorders: critical review of the literature and meta-analysis

OBJECTIVE

Changes in socio-economic position in people who migrate may have adverse associations with mental health. The main objective of this review was to assess the association of social mobility with common mental disorders in migrant and second-generation groups, to inform future research.

DESIGN

Systematic review and meta-analysis of English-language studies assessing the association of social mobility in migrant or second-generation groups with common mental disorders. Approaches to operationalise 'social mobility' were reviewed.

RESULTS

Twelve studies (n=18,548) met criteria for retrieval. Very few included second-generation groups, and most studies were cross-sectional in design. Approaches to operationalise 'social mobility' varied between studies. Downward intragenerational social mobility was associated with migration in the majority of studies. Random effects meta-analysis (n=5179) suggested that migrants to higher income countries who experienced downward mobility or underemployment were more likely to screen positive for common mental disorders, relative to migrants who were upwardly mobile or experienced no changes to socio-economic position. Conclusions on second-generation groups were limited by the lack of research highlighted for these groups. Downward intragenerational mobility associated with migration may be associated with vulnerability to common mental disorders in some migrant groups.

CONCLUSION

Given the increasing scale of global migration, further research is needed to clarify how changes to socio-economic position associated with international migration may impact on the mental health of migrants, and in their children.

The prevalence, correlates and impact of dementia in Cuba. A 10/66 group population-based survey

BACKGROUND

We aimed to estimate the prevalence, correlates and impact of dementia in Havana and Matanzas, Cuba.

METHODS

A 1-phase catchment area survey of all over 65-year-old residents of 7 catchment areas in Havana and 1 in Matanzas was conducted. Dementia diagnosis was established according to DSM-IV and our own, pre-validated 10/66 criteria. The impact of dementia was assessed through associations with needs for care, cutting back on work to care and caregiver psychological morbidity.

RESULTS

We interviewed 2,944 older people, a response proportion of 96.4%. The prevalence of DSM-IV dementia was 6.4% and that of 10/66 dementia 10.8%. Both dementia outcomes were associated with older age, less education, a family history of dementia, shorter leg length and smaller skull circumference. Dementia, rather than physical health problems or depression, was the main contributor to needs for care (population-attributable prevalence fraction = 64.6%) and caregiver cutting back on work (population-attributable prevalence fraction = 57.3%).

CONCLUSION

The prevalence of dementia in Cuba is similar to Europe. Among health conditions, dementia is the major contributor to dependency and caregiver economic and psychological strain. More attention needs to be given to it and other chronic diseases associated more with disability than premature mortality.

Can health workers diagnose dementia in the community?

OBJECTIVE

This study attempted to evaluate sensitivity, specificity and predictive values of the diagnosis of dementia made by trained community health workers.

METHOD

A total of 1,000 subjects over the age of 65 years were recruited for the study. The community health workers identified nine subjects as having dementia. This was compared against an education adjusted diagnosis of dementia made in accordance with the 10/66 dementia research group protocol.

RESULTS

The sensitivity and specificity of the community health worker diagnosis was 3.8% and 99.4% respectively. The false positive rate and positive predictive values were 55.6% and 44.4%, respectively. The false negative rate and negative predictive value were 10.3% and 89.7% respectively. Similar values were obtained against a DSM IV diagnosis. Subjects with dementia who were correctly diagnosed by the community health workers and those whose condition was missed did not differ significantly on socio-demographic and clinical variables.

CONCLUSION

Informal screening by community health workers resulted in low sensitivity and positive predictive values. Screening strategies in situations of low prevalence are not effective.

The diagnosis of dementia in the community

BACKGROUND

Different interview schedules and diagnostic criteria for dementia have contributed to differing incidence and prevalence rates.

AIM

This study aimed to examine the effect of different diagnostic criteria on the prevalence of dementia in the community.

METHODS

Some 1000 subjects (>65 years) were recruited in Kaniyambadi Block, Vellore, India, using a one-stage assessment procedure.

RESULTS

The prevalence of dementia by Diagnostic and Statistical Manual IV standard, the Community Screening instrument for Dementia DF Score, the education adjusted 10/66 Dementia Research Group criteria, and the Geriatric Mental State was 0.8%, 6.2%, 10.6%, 63.2% respectively.

CONCLUSION

Differences in information, interview schedules, diagnostic criteria and settings contribute to variation in identification of people with dementia. Minor variations in criteria have a significant impact on diagnosis. The assessment of the clinical state is influenced by education, level of baseline function, impairment in current functioning, life style and demands on the person, tolerance of impairment and expectation by relatives and by differences between patients attending hospitals and those living in the community. The variation in rates demands a debate on the criteria for dementia in the community in general and for less literate populations in particular.

Physical health and depressive symptoms in older Europeans. Results from EURODEP

BACKGROUND

Associations between physical health and depression are consistent across cultures among adults up to 65 years of age. In later life, the impact of physical health on depression is much more substantial and may depend on sociocultural factors.

AIMS

To examine cross-national differences in the association between physical health and depressive symptoms in elderly people across western Europe.

METHOD

Fourteen community-based studies on depression in later life in nine western European countries contributed to a total study sample of 22 570 respondents aged 65 years and older. Measures were harmonized for depressive symptoms (EURO-D scale), functional limitations and chronic physical conditions.

RESULTS

In the majority of the participating samples, the association of depressive symptoms with functional disability was stronger than with chronic physical conditions. Associations were slightly more pronounced in the UK and Ireland.

CONCLUSIONS

The association between physical health and depressive symptoms in later life is consistent across western Europe.

The effects of oral anti-hyperglycaemic medications on serum lipid profiles in patients with type 2 diabetes

AIM

Patients with type 2 diabetes often have dyslipidaemia, putting them at risk of cardiovascular disease, and are frequently treated with oral anti-hyperglycaemic medications (OAMs). This review compares the effects of OAMs on serum lipids [total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TGs) and free fatty acids (FFAs)] in patients with type 2 diabetes.

METHODS

medline was searched for entries indexed from January 1966 to November 2002; search terms included the names of OAMs and serum lipids, limited to English language and human subjects. We selected clinical studies in type 2 diabetes of OAM monotherapy that included serum lipid data, treated all patients in a treatment group with the same drug, used therapeutic OAM doses not higher than the maximum recommended in the USA, compared therapy with baseline or placebo and specified statistical tests used. One unblinded investigator selected studies for inclusion. Data reported include number of patients, study length, OAM dose, serum lipid data at baseline and endpoint, p-values and statistical tests.

RESULTS

Data on the serum lipid effects of sulphonylureas, repaglinide, nateglinide and miglitol were inconclusive. Acarbose increased HDL-C and decreased LDL-C and voglibose reduced TC. Metformin at higher doses reduced TC; data on its effects on other lipids were inconclusive. Rosiglitazone increased LDL-C, HDL-C and TC and reduced FFAs but had no effect on TGs. Pioglitazone increased HDL-C and reduced TGs and FFAs but did not affect LDL-C or TC.

CONCLUSIONS

Lipid changes as a result of improved glycaemic control are not uniform findings associated with anti-diabetic therapy. Only metformin, acarbose, voglibose, rosiglitazone and pioglitazone had significant effects on the lipid profile. These effects should be considered when selecting OAMs for patients with type 2 diabetes.

Bovine spongiform encephalopathy

Early epidemiological studies identified bovine spongiform encephalopathy as a feed-borne infection associated with infected meat-and-bone meal in animal feed. The infection may have derived from scrapie in sheep, a spontaneous genetic mutation in cattle, or a transmissible spongiform encephalopathy in another mammalian species. Experimental work on the risk of transmission has necessarily tried to identify risk materials and their infectivity levels, the nature and size of species barriers, the infectious dose, the route of infection, the strain of the agent and the genotype of the animals at risk. The identification of levels of infection in cattle tissues has aided the removal of risk materials from the human and animal food chains. Maternally associated transmission is unlikely to maintain an outbreak, but the offspring of clinical cases appear to be at greater risk when the rate of food-borne exposure is high. Studies of embryo transfer have not shown infection to be transmitted by this means. While the control measures appeared to be straightforward, compliance has at times proved difficult to enforce and quantify. This has necessitated more extensive prohibitions, aggressive enforcement and thorough auditing of compliance levels.

Caregivers of people with Alzheimer's disease: a qualitative study from the Indian 10/66 Dementia Research Network

BACKGROUND

Dementia is a rapidly growing problem in all parts of the developing world. Such societies are characterised by low levels of awareness regarding dementia as a chronic degenerative brain syndrome, and by an absence of supportive health and welfare services. There is reliance upon families as the cornerstone of support and care. However, surprisingly little is known of the care arrangements for people with dementia and the strain experienced by their family caregivers.

METHOD

In a qualitative study of 17 caregivers of people with Alzheimer's disease identified through an innovative case-finding program in Thrissur, South India, we obtained information on the range of care arrangements, attitudes towards care giving roles and sources of strain.

RESULTS

The majority of caregivers were young women, often daughters-in-law of women with dementia. The principal sources of caregiver strain were behavioural problems associated with the dementia syndrome, and incontinence. Strain was exacerbated by the lack of supportive response by local health services, and by lack of support and, sometimes, criticism from other family members. Family conflict was commonly encountered. The majority of caregivers experienced significant deterioration in their mental health. One caregiver unfortunately committed suicide after the death of her husband.

CONCLUSIONS

There is a clear need for more education, advice and support for families affected by dementia. Community services in developing countries should consider training existing domiciliary outreach services, the community-based multi-purpose health workers, to identify and support family caregivers.

The impact of pioglitazone on glycemic control and atherogenic dyslipidemia in patients with type 2 diabetes mellitus

BACKGROUND

To evaluate the glycemic control, lipid effects, and safety of pioglitazone in patients with type 2 diabetes mellitus.

DESIGN AND METHODS

Patients (n = 197) with type 2 diabetes mellitus, a hemoglobin A1c (HbA1c) > or = 8.0%, fasting plasma glucose (FPG) > 7.7 mmol/l (140 mg/dl), and C-peptide > 0.331 nmol/l (1 ng/ml) were enrolled in this 23-week multi-center (27 sites), double-blind clinical trial and randomized to receive either a placebo or pioglitazone HCl 30 mg (pioglitazone), administered once daily, as monotherapy. Patients were required to discontinue all anti-diabetic medications 6 weeks before receiving study treatment. Efficacy parameters included HbA1c fasting plasma glucose (FPG), serum C-peptide, insulin, triglycerides (Tg), and cholesterol (total cholesterol [TC], high-density lipoprotein-cholesterol [HDL-C], low-density lipoprotein-cholesterol [LDL-C]). Adverse event rates, serum chemistry, and physical examinations were recorded.

RESULTS

Compared with placebo, pioglitazone significantly (P= 0.0001) reduced HbA1c (-1.37% points), FPG (-3.19 mmol/l; -57.5 mg/dl), fasting C-peptide (-0.076+/-0.022 nmol/l), and fasting insulin (-11.88+/-4.70 pmol/l). Pioglitazone significantly (P < 0.001) decreased insulin resistance (HOMA-IR; -12.4+/-7.46%) and improved beta-cell function (Homeostasis Model Assessment (HOMA-BCF); +47.7+/-11.58%). Compared with placebo, fasting serum Tg concentrations decreased (-16.6%; P = 0.0178) and HDL-C concentrations increased (+12.6%; P= 0.0065) with pioglitazone as monotherapy. Total cholesterol and LDL-C changes were not different from placebo. The overall adverse event profile of pioglitazone was similar to that of placebo, with no evidence of drug-induced elevations of serum alanine transaminase (ALT) concentrations or hepatotoxicity.

CONCLUSIONS

Pioglitazone improved insulin resistance and glycemic control, as well as Tg and HDL-C - which suggests that pioglitazone may reduce cardiovascular risk for patients with type 2 diabetes.

Religion as a cross-cultural determinant of depression in elderly Europeans: results from the EURODEP collaboration

BACKGROUND

The protective effects of religion against late life depression may depend on the broader sociocultural environment. This paper examines whether the prevailing religious climate is related to cross-cultural differences of depression in elderly Europeans.

METHODS

Two approaches were employed, using data from the EURODEP collaboration. First, associations were studied between church-attendance, religious denomination and depression at the syndrome level for six EURODEP study centres (five countries, N = 8398). Secondly, ecological associations were computed by multi-level analysis between national estimates of religious climate, derived from the European Value Survey and depressive symptoms, for the pooled dataset of 13 EURODEP study centres (11 countries, N = 17,739).

RESULTS

In the first study, depression rates were lower among regular church-attenders, most prominently among Roman Catholics. In the second study, fewer depressive symptoms were found among the female elderly in countries, generally Roman Catholic, with high rates of regular church-attendance. Higher levels of depressive symptoms were found among the male elderly in Protestant countries.

CONCLUSIONS

Religious practice is associated with less depression in elderly Europeans, both on the individual and the national level. Religious practice, especially when it is embedded within a traditional value-orientation, may facilitate coping with adversity in later life.

Simple bi- and tricyclic inhibitors of human steroid 5alpha-reductase

A number of tricyclic thiolactams, bicyclic lactams, and bicyclic thiolactams have been prepared and evaluated in vitro as inhibitors of types 1 and 2 steroid 5alpha-reductase. The tricycles with an 8-chloro substituent in the C-ring are nM (IC50) inhibitors of type 1 steroid 5alpha-reductase (SR). In all the cases studied, lactams are more potent than the corresponding thiolactams. Activity against type 2 SR is greatly enhanced by a styryl (or azo) substituent on the aryl ring of the tri- and bicycles and also a related tricyclic aryl acid.

Kinetic characterisation of ene-diol-based inhibitors of alpha-amylase

A kinetic analysis of the inhibition of malt alpha-amylase by compounds based on ascorbic acid has shown the mode of inhibition to be competitive for the parent compound, but more complex for its derivatives. We have further simplified the ascorbic acid ene-diol pharmacophore by demonstrating that dihydroxyfumaric acid is also a good inhibitor of malt alpha-amylase.

Cross-cultural comparison of depressive symptoms in Europe does not support stereotypes of ageing

BACKGROUND

Stereotypes of older people suggest that they are depressed.

AIMS

To examine depression symptoms among people aged > or = 65 in the general population and to ask the following questions. Are there high proportions of depressive symptoms among otherwise well people? Do these levels reflect the prevalence of depression? Do key symptoms vary with age and do they confirm stereotypes?

METHOD

Nine centres contributed data from community-based random samples, using standardised methods (GMS-AGECAT package).

RESULTS

Proportions of depressive symptoms varied between centres. Some often associated with ageing were rare. Many were more common in women. Low-prevalence centres tended to have fewer symptoms among 'well' people, but there were inconsistencies. Low levels of symptoms among the well population of a centre did not necessarily predict lower levels in the depressed.

CONCLUSIONS

Variations in the prevalence of depressive symptoms occurred between centres, not always related to levels of illness. There was no consistent relationship between proportions of symptoms in well persons and cases for all centres. Few symptoms were present in > 60% of the older population--stereotypes of old age were not upheld.

Development of the EURO-D scale--a European, Union initiative to compare symptoms of depression in 14 European centres

BACKGROUND

In an 11-country European collaboration, 14 population-based surveys included 21,724 subjects aged > or = 65 years. Most participating centres used the Geriatric Mental State (GMS), but other measures were also used.

AIMS

To derive from these instruments a common depression symptoms scale, the EURO-D, to allow comparison of risk factor profiles between centres.

METHOD

Common items were identified from the instruments. Algorithms for fitting items to GMS were derived by observation of item correspondence or expert opinion. The resulting 12-item scale was checked for internal consistency, criterion validity and uniformity of factor-analytic profile.

RESULTS

The EURO-D is internally consistent, capturing the essence of its parent instrument. A two-factor solution seemed appropriate: depression, tearfulness and wishing to die loaded on the first factor (affective suffering), and loss of interest, poor concentration and lack of enjoyment on the second (motivation).

CONCLUSIONS

The EURO-D scale should permit valid comparison of risk-factor associations between centres, even if between-centre variation remains difficult to attribute.

Depression in Europe. Geographical distribution among older people

BACKGROUND

This is the first report of results from the EURODEP Programme.

AIMS

To assess the prevalence of depression judged suitable for intervention in randomised samples of those aged > or = 65 in nine European centres.

METHOD

The GMS-AGECAT package.

RESULTS

Differences in prevalence are apparent, 8.8% (Iceland) to 236% (Munich). When sub-cases and cases are added together, five high- and four low-scoring centres emerge. Women predominated over men. Proportions of sub-cases to cases revealed striking differences but did not explain prevalence. There was no constant association between prevalence and age. A meta-analysis (n = 13,808) gave an overall prevalence of 12.3%, 14.1% for women and 8.6% for men.

CONCLUSIONS

Considerable variation occurs in the levels of depression across Europe, the cause for which is not immediately obvious. Case and sub-case levels taken together show greater variability, suggesting that it is not a matter of case/sub-case selection criteria, which were standardised by computer. Substantial levels of depression are shown but 62-82% of persons had no depressive level. Opportunities for treatment exist.

Review of community prevalence of depression in later life

BACKGROUND

Despite considerable interest, there is no consensus regarding the prevalence of depression in later life.

AIMS

To assess the prevalence of late-life depression in the community.

METHOD

A systematic review of community-based studies of the prevalence of depression in later life (55+). Literature was analysed by level of caseness at which depression was defined and measured.

RESULTS

Thirty-four studies eligible for inclusion were found. The reported prevalence rates vary enormously (0.4-35%). Arranged according to level of caseness, major depression is relatively rare among the elderly (weighted average prevalence 1.8%), minor depression is more common (weighted average prevalence 9.8%), while all depressive syndromes deemed clinically relevant yield an average prevalence of 13.5%. There is consistent evidence for higher prevalence rates for women and among older people living under adverse socio-economic circumstances.

CONCLUSIONS

Depression is common in later life. Methodological differences between studies preclude firm conclusions about cross-cultural and geographical variation. Improving the comparability of epidemiological research constitutes an important step forward.

Depression symptoms in late life assessed using the EURO-D scale. Effect of age, gender and marital status in 14 European centres

BACKGROUND

Data from surveys involving 21,724 subjects aged > or = 65 years were analysed using a harmonised depression symptom scale, the EURO-D.

AIMS

To describe and compare the effects of age, gender and mental status on depressive symptoms across Europe.

METHOD

We tested for the effects of centre, age, gender and marital status on EURO-D score. Between-centre variance was partitioned according to centre characteristics: region, religion and survey instrument used.

RESULTS

EURO-D scores tended to increase with age, women scored higher than men, and widowed and separated subjects scored higher than others. The EURO-D scale could be reduced into two factors: affective suffering, responsible for the gender difference, and motivation, accounting for the positive association with age.

CONCLUSIONS

Large between-centre differences in depression symptoms were not explained by demography or by the depression measure used in the survey. Consistent, small effects of age, gender and marital status were observed across Europe. Depression may be overdiagnosed in older persons because of an increase in lack of motivation that may be affectively neutral, and is possibly related to cognitive decline.

The prevalence of diagnoses, impairments, disabilities and handicaps in a population of elderly people living in a defined geographical area: the Gospel Oak project

OBJECTIVE

to measure the prevalence of impairments, disabilities and handicaps in a geographically-defined elderly population.

DESIGN

cross-sectional analysis of an interview survey.

SETTING

a single North London electoral ward (district).

PARTICIPANTS

654 residents (74%) over the age of 65 years were interviewed from a register of 889. A random sample of 225 had additional data collected which are reported in this analysis.

MAIN OUTCOME MEASURES

point prevalence and distribution of the total number of reported diagnoses, impairments and disabilities, and distributions of the Office of Population Censuses and Surveys (OPCS) disability scale and the London Handicap Scale scores.

RESULTS

participants had a median of three reported diagnoses and two impairments. Forty-three percent were in the least disabled OPCS disability category (i.e. below the disability threshold) and 41% were able to undertake all of 12 basic activities of daily living without difficulty. Overall handicap scores were heavily skewed towards no health-related disadvantage, with a median score of 83 out of 100, and 37% having a score of 90 or more. All indicators showed deteriorating health with increasing age, but age-adjusted gender differences were small.

CONCLUSIONS

an elderly population's health problems were classified using a comprehensive framework, revealing high prevalences of diagnoses, impairments, disabilities and handicaps. The schema is appropriate for health care needs assessment and is a suitable basis for describing the population's health.

A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII

BACKGROUND

Population-based studies suggest substantial co-morbidity between physical illness and depression in late-life. However, a causal relationship has not been established. If a relationship exists, it is important to establish which aspects of poor health determine risk for depression, and which factors confer vulnerability or resilience in the face of poor health. We investigate the role of disablement, measured as impairment, disability and handicap.

METHODS

A prospective population-based cohort study, comprising an index assessment and 1 year follow-up, of all residents aged 65 years or over, of an electoral ward in London, UK (N = 889).

RESULTS

The prevalence of SHORT-CARE pervasive depression was 17.7% at index assessment. The 1 year onset rate for pervasive depression was 12.0%, and the 1 year maintenance rate 63.2%. There was a high mortality rate among the depressed. Disablement, particularly handicap was the most important predictor of the onset of depression (population attributable fraction, 0.69). Lack of contact with friends was a direct risk factor but also modified the association between handicap and depression. Marriage was protective for men, but a risk factor for women. Maintenance of depression was predicted by low levels of social support and social participation, rather than by disablement.

CONCLUSIONS

It seems likely that disablement, specifically handicap, is the chief cause of onsets of depression in late-life. Genetic predisposition, early adversity and serious life events may play a less prominent role than in earlier life. Effective prevention of late-life depression requires attention at the structural level to the sources of handicap within communities.

The SOCRATES curriculum: an innovative integration of technology and theory in medical education

This article describes the pilot study of an innovative medical school curriculum module that utilizes a modified problem-based learning (PBL) approach to teach medical students about management of diabetes mellitus. The PBL-based curriculum incorporated computer simulations and analysis of videotaped patient encounters in addition to independent study and group discussion. At the conclusion of the study, student knowledge and clinical decision-making skills were evaluated via questionnaires and examinations. Twenty-three students completed the workshop and all evaluation assessments. Students performed well on the case-study examinations (mean score of 3.39 out of 4) but not on the short answer essay examination, which assessed basic knowledge. Students rated the quality and appeal of the activities using Likert-type scales. In general, students perceived the activities as very worthwhile, with reasonable complexity and adequate time devoted to each activity. Students were very positive about the workshop and preceptor; 15 of the 16 items used to rate workshop appeal yielded mean scores greater than 4 (on a scale of 1 to 5, with 5 being the highest). The results of the pilot study suggest future enhancements that would further improve the outcomes of the training.

Cognitive impairment and social distress as different pathways to depression in the elderly: a cross-sectional study

BACKGROUND

This study investigates the recent suggestion that some putative aetiological factors for depression, such as cerebral deterioration and social distress, may act differentially in the aetiology of depression in old age.

METHOD

In a cross-sectional study, a community sample of 654 elderly subjects were interviewed with Short-CARE to assess the prevalence of depression and cognitive impairment. Information was collected for a variety of potential risk factors for depression such as exposure to social support deficit, threatening life events, impairment, disability and handicap.

RESULTS

The prevalence of depression was 17% and that of a broad concept of cognitive impairment 23.9%. This analysis found associations between depression and exposure to social support deficits and threatening life events in the year prior to interview. These associations were considerably stronger for those subjects with no cognitive impairment than for those with cognitive impairment. We also found a progressive lowering in the strength of these associations the higher the chance of cognitive impairment measured as a longitudinal variable using both the Dementia Diagnostic Scale (DDS) and the Organic Brain Syndrome Scale (OBS) included in Short-CARE.

CONCLUSIONS

The results of this theory-driven analysis lend some support to the notion of at least two differential pathways to depression in the elderly, one via social distress factors and another mediated by cerebral deterioration clinically expressed as cognitive impairment.

Impairment, disability and handicap as risk factors for depression in old age. The Gospel Oak Project V

BACKGROUND

An association between disablement and late-life depression is often reported in cross-sectional studies. However, many lack effect sizes, and do not control for confounding. Therefore, it is difficult both to quantify the overall impact of poor health on depression and to understand which aspects are most salient.

METHODS

A catchment area survey of all over 65-year-old residents of an electoral district in London, UK, using a population register derived from a door-to-door census was undertaken. Depression was measured using SHORT-CARE, and the consequences of disease classified according to the WHO International Classification of Impairments, Disabilities and Handicaps.

RESULTS

Six hundred and fifty-four subjects were interviewed out of an older population of 889. The prevalence of SHORT-CARE pervasive depression was 17%. Impairment, disability and, particularly, handicap were strongly associated with depression. The adjusted odds ratio for depression in the most handicapped quartile compared with the least was 24.2 (8.8-66.6). The population attributable fraction (PAF) for depression attributable to handicap was 0.78. The PAFs for recent life events and female gender were much lower. Handicap explained most of the depression associated with individual impairments and disabilities. Adjusting for handicap abolished or weakened the associations between depression and social support, income, older age, female gender and living alone.

CONCLUSIONS

Even given some uncertainty in distinguishing handicap and depression as constructs, and the impossibility of deciding direction of causality, it seems likely that handicap is of central significance to late-life depression. Handicap may be more amenable to intervention than either impairment or disability.

Social support deficits, loneliness and life events as risk factors for depression in old age. The Gospel Oak Project VI

BACKGROUND

A companion paper reported a very strong cross-sectional association between handicap and late-life depression. Adjusting for handicap weakened associations between sociodemographic variables and depression. It was unclear whether handicap was a confounder, or a useful summary variable, mediating the effect of a range of sociodemographic disadvantages. This paper focuses on the cross-sectional relationship between depression and demographic variables, social support, and life events.

METHOD

A community survey of all residents over the age of 65 years of an electoral district in London, UK.

RESULTS

There was a moderate association between SHORT-CARE pervasive depression and the number of life events experienced over the previous year. Personal illness, bereavement and theft were the most salient events. There was a stronger, graded, relationship between the number of social support deficits (SSDs) and depression. Number of SSDs also related to age, handicap, loneliness and use of homecare services. Loneliness was itself strongly associated with depression; odds ratio 12.4 (7.6-20.0).

CONCLUSIONS

Problems of collinearity, and the cross-sectional design of the study limited interpretation of the exact nature of the relationship between social support, loneliness, handicap and depression. However, the clustering of these four factors can be used to define a large part of the elderly population with a poor quality of life. An important avenue for future research will be the development and implementation of population intervention strategies designed to address some or all of these problems among older people in general.

Do n-3 fatty acids improve glucose tolerance and lipemia in diabetics?

A protective effect of habitual fish consumption on the development of impaired glucose tolerance and diabetes is once again suggested in a recent trial. In nondiabetic individuals with essential hypertension, a group known to be insulin resistant, fish oil was not associated with a negative impact on glycemic control, insulin secretion or peripheral insulin sensitivity, even in a subgroup who had impaired glucose tolerance. Furthermore, more recent, long term, placebo-controlled trials in type II patients have failed to demonstrate a significant impact of fish oil supplementation on glycemic control. Additional information is available regarding qualitative changes in VLDL- and LDL-lipoproteins in type II diabetes patients in response to dietary fish oil supplementation. The impact of fish oil on LDL oxidation is the focus of two recent trials. Vitamin E supplementation may mitigate much of the enhanced oxidation of LDL that is potentially seen with dietary fish oil supplementation.

[Depression and cognitive deterioration: a transversal study of comorbidity]

This cross-sectional study investigates the relation between a broad category of cognitive impairment and depression in a sample of 654 subjects aged 65 or over. This sample represents 74% of all subjects of that age living in a defined electoral district in North London, UK. The presence of depression and cognitive impairment was ascertained by interviewing all subjects with Short-CARE. Information was collected also for a variety of socto-demographic factors, level of social support and variables of functional limitation (i.e., impairment, disability and handicap). We found a cross-sectional association between depression and cognitive impairment (OR = 3.3; 95% CI: 2.1-3.1). However, when the analysis was adjusted for potential confounders using stratified analysis and logistic regression, we found that variables of functional limitation (especially disability and handicap) acted as confounders of the above association. This confounding effect did not differ significantly across sexes in our study.

The treatment of hypertension in older people and its effect on cognitive function

The benefits of antihypertensive drug therapy for older people have been clearly established. Meta-analysis suggests a 12% reduction in all-cause mortality, a 20% reduction in coronary heart disease and a 36% reduction in stroke. The absolute benefits of treatment are great due to the high incidence of vascular disease among older people. Clinicians may nevertheless have been deterred from initiating treatment because of concerns regarding adverse effects on cognition, mood, functional ability and quality of life. Recent evidence from randomised controlled trials suggests that these concerns are groundless. In the light of this evidence it is therefore disturbing that up to 50% of all older people with hypertension may remain untreated; and in over 50% of those who are treated, blood pressure may be inadequately controlled.

Is the cognitive function of older patients affected by antihypertensive treatment? Results from 54 months of the Medical Research Council's trial of hypertension in older adults

OBJECTIVE

To establish whether initiation of treatment with diuretic or beta blocker is associated over 54 months with change in cognitive function.

DESIGN

A cognitive substudy, nested within a randomised, placebo controlled, single blind trial.

SETTING

226 general practices from the Medical Research Council's general practice research framework.

SUBJECTS

A subset of 2584 subjects sequentially recruited from among the 4396 participants aged 65-74 in the trial of treatment of hypertension in older adults. The 4396 subjects were randomised to receive diuretic, beta blocker, or placebo. Subjects had mean systolic pressures of 160-209 mm Hg and mean diastolic pressures <115 mm Hg during an eight week run in.

OUTCOME MEASURES

The rate of change in paired associate learning test (PALT) and trail making test part A (TMT) scores (administered at entry and at 1, 9, 21, and 54 months) over time.

RESULTS

There was no difference in the mean learning test coefficients (rate of change of score over time) between the three treatments: diuretic -0.31 (95% confidence interval -0.23 to -0.39), beta blocker -0.33 (-0.25 to -0.41), placebo -0.30, (-0.24 to -0.36). There was also no difference in the mean trail making coefficients (rate of change in time taken to complete over time) between the three groups: diuretic -2.73 (95% confidence interval -3.57 to -1.88), beta blocker -2.08 (-3.29 to -0.87), placebo -3.01, (-3.69 to -2.32). A less conservative protocol analysis confirmed this negative finding.

CONCLUSION

Treating moderate hypertension in older people is unlikely to influence, for better or for worse, subsequent cognitive function.

Predicting the onset of Alzheimer's disease using Bayes' theorem

Bayes' theorem describes the effect of new information (e.g., a test result) on the probability of an outcome (e.g., a disease). Likelihood ratios for separate tests can be combined to assess the joint effect of their results on disease probability. This approach has been used to develop a test package for Alzheimer's disease that consists of some simple cognitive tests (Paired Associate Learning Test, Trailmaking Test, and Raven's Progressive Matrices) combined with age and family history of dementia. A total of 1,454 subjects who had been recruited into the Medical Research Council Elderly Hypertension Trial between 1983 and 1985 completed cognitive tests at entry to the trial (when they were without signs of dementia) and 1 month later. Their dementia status was ascertained in 1990-1991. The test package identified 52% of Alzheimer's disease cases with a 9% false-positive rate or 90% of Alzheimer's disease cases with a 29% false-positive rate. The author proposes the use of a similar test package in conjunction with a test for apolipoprotein E e4 status, which is a powerful risk factor for late-onset Alzheimer's disease, as a likelihood ratio approach to the prospective identification of Alzheimer's disease cases. This approach could be followed by ethically sound trials of new therapeutic agents for subjects who have a high probability of developing Alzheimer's disease.

Laser lithotripsy: a preliminary study on its application for sialolithiasis

The present study has established that a flashlamp pumped coumarin dye laser is capable of fragmenting salivary calculi. The refinement of spectroscopic feed-back techniques will allow laser lithotripsy to complement ultrasonic lithotripsy in the non surgical management of salivary calculi.

The hypotriglyceridemic effect of fish oil in adult-onset diabetes without adverse glucose control

Diabetic control as judged by five criteria did not deteriorate after 6 months of fish oil compared to 6 months of olive oil supplementation in 16 patients with NIDDM who were eating a low fat, high complex carbohydrate diet. Plasma total and VLDL triglyceride and cholesterol decreased significantly after fish oil supplementation; plasma total and HDL cholesterol concentrations did not change. The LDL cholesterol level was significantly increased with fish oil supplementation, suggesting that patients with NIDDM who are given a fish oil supplement to decrease the plasma total and VLDL triglyceride levels may also need further dietary and/or pharmaceutical therapy to maintain an LDL cholesterol level compatible with a low risk of coronary disease. The study emphasizes the safe use of fish oil over a 6-month period in diabetic patients.

Environmental scanning for Social Services

This article describes the development of a process of systematic regional environmental scanning as part of strategic planning in the Ministry of Social Services (MSS) in British Columbia, over the 1987-1990 period. Social Services, a large regionalized social service organization, adopted a formal strategic planning process in early 1988. Ministry services are delivered in ten regions with widely varying characteristics. To ensure that this diversity is reflected in the planning process, it is essential that regional environmental information receive consideration. A simple format was developed and regional directors asked to consult with their staff and to scan their regions for issues that may impact the ministry over the medium term. The information obtained was presented by regional directors at a Senior Management Committee meeting and included in the ministry's annual Business Plan, a document which informs staff, contractors, stakeholders, and the community at large of the ministry's values, objectives, and operational goals. The inclusion of regional analyses adds useful information to the Plan. A second output of the planning process is the ministry budget. The systematic regional scans were found to be extremely useful to regional staff, other directors, and to the ministry executives while setting priorities.