Biomedical subjects
Publications and source records attributed to R J Stevens.
We conducted a systematic review of the risk of pancreatic cancer in people with type I and young-onset diabetes. In three cohort and six case-control studies, the relative risk for pancreatic cancer in people with (vs without) diabetes was 2.00 (95% confidence interval 1.37-3.01) based on 39 cases with diabetes.
AIMS/HYPOTHESIS: This study estimated the economic efficiency (1) of intensive blood glucose control and tight blood pressure control in patients with type 2 diabetes who also had hypertension, and (2) of metformin therapy in type 2 diabetic patients who were overweight. METHODS: We conducted cost-utility analysis based on patient-level data from a randomised clinical controlled trial involving 4,209 patients with newly diagnosed type 2 diabetes conducted in 23 hospital-based clinics in England, Scotland and Northern Ireland as part of the UK Prospective Diabetes Study (UKPDS). Three different policies were evaluated: intensive blood glucose control with sulphonylurea/insulin; intensive blood glucose control with metformin for overweight patients; and tight blood pressure control of hypertensive patients. Incremental cost : effectiveness ratios were calculated based on the net cost of healthcare resources associated with these policies and on effectiveness in terms of quality-adjusted life years gained, estimated over a lifetime from within-trial effects using the UKPDS Outcomes Model. RESULTS: The incremental cost per quality-adjusted life years gained (in year 2004 UK prices) for intensive blood glucose control was 6,028 UK pounds, and for blood pressure control was 369 UK pounds. Metformin therapy was cost-saving and increased quality-adjusted life expectancy. CONCLUSIONS/INTERPRETATION: Each of the three policies evaluated has a lower cost per quality-adjusted life year gained than that of many other accepted uses of healthcare resources. The results provide an economic rationale for ensuring that care of patients with type 2 diabetes corresponds at least to the levels of these interventions.
There is a growing need to rapidly scan bulk air cargo for contraband such as illicit drugs and explosives. The Commonwealth Science and Industrial Research Organisation (CSIRO) have been working with Australian Customs Service to develop a scanner capable of directly scanning airfreight containers in 1--2 minutes without unpacking. The scanner combines fast neutron and gamma-ray radiography to provide high-resolution images that include information on material composition. A full-scale prototype scanner has been successfully tested in the laboratory and a commercial-scale scanner is due to be installed at Brisbane airport in 2005.
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AIMS/HYPOTHESIS: The aim of this study was to develop a simulation model for type 2 diabetes that can be used to estimate the likely occurrence of major diabetes-related complications over a lifetime, in order to calculate health economic outcomes such as quality-adjusted life expectancy. METHODS: Equations for forecasting the occurrence of seven diabetes-related complications and death were estimated using data on 3642 patients from the United Kingdom Prospective Diabetes Study (UKPDS). After examining the internal validity, the UKPDS Outcomes Model was used to simulate the mean difference in expected quality-adjusted life years between the UKPDS regimens of intensive and conventional blood glucose control. RESULTS: The model's forecasts fell within the 95% confidence interval for the occurrence of observed events during the UKPDS follow-up period. When the model was used to simulate event history over patients' lifetimes, those treated with a regimen of conventional glucose control could expect 16.35 undiscounted quality-adjusted life years, and those receiving treatment with intensive glucose control could expect 16.62 quality-adjusted life years, a difference of 0.27 (95% CI: -0.48 to 1.03). CONCLUSIONS/INTERPRETATIONS: The UKPDS Outcomes Model is able to simulate event histories that closely match observed outcomes in the UKPDS and that can be extrapolated over patients' lifetimes. Its validity in estimating outcomes in other groups of patients, however, remains to be evaluated. The model allows simulation of a range of long-term outcomes, which should assist in informing future economic evaluations of interventions in type 2 diabetes.
BACKGROUND: Excess cardiovascular mortality complicates systemic rheumatic disease, suggesting an accelerated atheromatous process, which it has been proposed relates to the vascular inflammation common in such diseases. Impaired endothelium dependent vasodilatation is an early marker of atheromatous disease. It has previously been shown that such endothelial cell dysfunction (ECD) occurring in the brachial artery can complicate primary systemic necrotising vasculitis (SNV). OBJECTIVE: To determine if ECD occurs in a wider spectrum of primary SNV, if it is restricted to the major arteries, and whether vasculitis subgroup, ANCA status, or renal involvement influenced the endothelial responses. METHODS: Fifty four patients attending the Birmingham vasculitis clinic, including patients with a range of ANCA and non-ANCA associated primary vasculitides, and a group of age matched controls were recruited. The length of patient follow up and disease activity was variable. Disease activity, damage scores, and cardiovascular risk factors were recorded before assessment of flow mediated brachial artery vasodilatation by high resolution ultrasound. Dermal microvascular responses to acetylcholine were also measured in 32 patients and 21 controls by laser Doppler flowmetry. RESULTS: ECD was demonstrated in all primary SNV subgroups of patients with ANCA associated vasculitis and in polyarteritis nodosa, compared with controls. Significant impairment occurred in both vascular beds, regardless of vessel size targeted in the inflammatory vasculitis, ANCA association and titre, or renal involvement. CONCLUSIONS: Diffuse endothelial dysfunction, a predictor of atherosclerotic disease, is found extensively in primary systemic vasculitis. Involvement of different vascular beds is independent of target vessel size or ANCA association, and is unrelated to local disease expression. It is suggested that this results from a systemic response that may be a consequence of primary vasculitis, but is distinct from the local inflammatory vasculitic process.
The observation that systemic inflammatory rheumatic diseases such as rheumatoid arthritis (RA) are associated with a significantly increased rate of cardiovascular disease, which often occurs at a younger age than in the normal population, is particularly important given the increasing interest in the role of inflammation in atherogenesis in the general population. This review examines the accumulating evidence for accelerated atherogenesis of RA and updates the hypothesis that vasculitis plays a major role in this. Endothelial dysfunction (ECD), widely regarded as initial lesion in atherogenesis, has been shown to occur commonly in primary vasculitis. This ECD is a diffuse event, demonstrable in more than one vascular bed. It is not simply due to scarring in the vessel wall, related to the focal inflammation of the underlying vasculitis, since it may be reversed by suppression of the immune inflammation. However, the mechanisms for this ECD differ from that of the primary vasculitis. Preliminary evidence suggests that inflammatory mediators such as CRP, TNF, or sphingolipids may be involved. The diffuse ECD of vasculitis may have important consequences for both the progression of the primary disease and for cardiovascular events. A model for the role of vasculitis-induced ECD in the accelerated atherogenesis of rheumatic diseases is presented. These concepts are discussed together with the messages they suggest for 'idiopathic' atherosclerosis in the general population.
The same emission factor is applied to fertiliser N and manure N when calculating national N2O inventories. Manures and fertilisers are often applied together to meet the N needs of the crop, but little is known about potential interactions leading to an increase in denitrification rate or a change in the composition of the end-products of denitrification. We used the 15N gas-flux method in a laboratory experiment to quantify the effect of liquid manure (LM) application on the fluxes of N2 and N2O when the soil contained fertiliser 15NO3-. LM increased the mole fraction of N2O from 0.5 to 0.85 in the first 12 h after application. More than 94% of the N2O was from the reduction of NO3-, probably due to aerobic nitrate respiration as well as respiratory denitrification.
In a laboratory study, soil amended with and without wheat straw (2.8 g kg(-1) soil) was incubated under 70% water holding capacity (WHC), continuously flooded and flooded/drained cycle conditions at 30 degrees C for 51 days. Dinitrogen and N2O evolution and ammonia volatilisation were measured during the incubation. Extractable NH4+-N and NO3--N were determined at the end of the incubation. Entrapped N2, N2O, and dissolved NH4+-N and NO3--N in drainage water were measured in the flooded/drained cycle treatment when the floodwater was drained. The results indicated that N loss through ammonia volatilisation was undetected in all treatments due to the low soil pH value (pHH2O= 5.87) and no air movement. The recovery of urea-15N as N2 was lowest in the continuously flooded treatments (0.75% and 0.96% with and without straw amendment, respectively), highest in the 70% WHC treatments (5.65% and 4.41%, respectively), and intermediate in the flooded/drained cycle treatments (1.79% and 2.65%, respectively). The recovery of urea-15N as N2O was in the same order as that of N2, negligible in the continuously flooded treatments, 0.01% and 0.07% in the flooded/drained cycle treatments, and 1.29% and 2.23% in the 70% WHC treatments, respectively. Peak N2O evolution rates were observed after the floodwater was drained but no substantial evolution was found after the soil was reflooded following drained periods. However, peak N2 evolution rates were observed after the onset of both drainage and re-flooding. Considerable quantities of N2 but no detectable N2O were entrapped in the flooded soil.
A definitive model for predicting absolute risk of coronary heart disease (CHD) in male and female people with Type II diabetes is not yet available. This paper provides an equation for estimating the risk of new CHD events in people with Type II diabetes, based on data from 4540 U.K. Prospective Diabetes Study male and female patients. Unlike previously published risk equations, the model is diabetes-specific and incorporates glycaemia, systolic blood pressure and lipid levels as risk factors, in addition to age, sex, ethnic group, smoking status and time since diagnosis of diabetes. All variables included in the final model were statistically significant (P<0.001, except smoking for which P=0.0013) in likelihood ratio testing. This model provides the estimates of CHD risk required by current guidelines for the primary prevention of CHD in Type II diabetes.
BACKGROUND & AIMS: The relative movements of longitudinal muscle (LM) and circular muscle (CM) and the role that nerves play in coordinating their activities has been a subject of controversy. We used fluorescent video imaging techniques to study the origin and propagation of excitability simultaneously in LM and CM of the small intestine. METHODS: Opened segments of guinea pig ileum were loaded with the Ca(2+) indicator fluo-3. Mucosal reflexes were elicited by lightly depressing the mucosa with a sponge. RESULTS: Spontaneous Ca(2+) waves occurred frequently in LM (1.2 s(-1)) and less frequently in CM (3.2 min(-1)). They originated from discrete pacing sites and propagated at rates 8-9 times faster parallel (LM, 87 mm/s; CM, 77 mm/s) compared with transverse to the long axis of muscle fibers. The presence of Ca(2+) waves in one muscle layer did not affect the origin, rate of conduction, or range of propagation in the other layer. The extent of propagation was limited by collisions with neighboring waves or recently excited regions. Simultaneous excitation of both muscle layers could be elicited by mucosal stimulation of either ascending or descending reflex pathways. Neural excitation resulted in an increase in the frequency of Ca(2+) waves and induction of new pacing sites without eliciting direct coupling between layers. CONCLUSIONS: Localized, spontaneous Ca(2+) waves occur independently in both muscle layers, promoting mixing (pendular or segmental) movements, whereas activation of neural reflexes stimulates Ca(2+) waves synchronously in both layers, resulting in strong peristaltic or propulsive movements.
OBJECTIVE: intermittent pneumatic compression (IPC) of the foot (IPC(foot)), calf (IPC(calf)) or both (IPC(foot+calf)) augments calf inflow, and improves the walking ability and peripheral haemodynamics of claudicants (IPC(foot), IPC(foot+calf)), largely due to venous outflow enhancement. This cohort study, using direct pressure measurements in healthy limbs, determines the optimal combination of frequency (2-4 impulses/minute), applied pressure (60-140 mmHg), mode (IPC(foot)-IPC(calf)-IPC(foot+calf)) and delay time of calf-to-foot impulse (0 s-0.5 s-1 s) that enables IPC to generate an almost complete and sustained decrease in venous pressure. RESULTS: (a) IPC(foot)at 120 and 80 mmHg generated lower venous pressure than that with 100 and 60 mmHg (p=0.036) respectively, for 2-4 impulses/minute; venous pressure differences between applied pressures of 140 and 120 mmHg or between 80 and 100 mmHg were insignificant. (b) Venous pressure with IPC(calf)at 80 mmHg was lower than that with 60 mmHg (p=0.036) (2-4 cycles/minute); differences in venous pressure between applied pressures of 140 and 100 mmHg or between 120 and 80 mmHg were insignificant. (c) At applied pressures 60-140 mmHg, IPC(foot+calf)with one-second delay generated lower venous pressure than that with half-second delay (p=0.036), the latter being more efficient than zero delay; increasing applied pressures produced lower venous pressure, but differences were small. Venous pressure decreased with increasing IPC frequency (from 2 to 3-4/minute), at applied pressures 60-140 mmHg. CONCLUSIONS: IPC(foot+calf)at applied 120-140 mmHg, a frequency of 3-4 impulses/minute and one-second delay, provided the optimum intermittent pneumatic stimulus.
The motility of the gastrointestinal tract consists of local, non-propulsive mixing (pendular or segmental) and propulsive (peristaltic) movements. It is generally considered that mixing movements are produced by intrinsic pacemakers which generate rhythmic contractions, and peristalsis by intrinsic excitatory and inhibitory neural reflex pathways, but the relationship between mixing and peristalsis is poorly understood. Peristalsis is compromised in mice lacking interstitial cells of Cajal, suggesting that these pacemaker cells may also be involved in neural reflexes. Here we show that mixing movements within longitudinal muscle result from spontaneously generated waves of elevated internal calcium concentration which originate from discrete locations (pacing sites), spread with anisotropic conduction velocities in al directions, and terminate by colliding with each other or with adjacent neurally suppressed regions. Excitatory neural reflexes control the spread of excitability by inducing new pacing sites and enhancing the overall frequency of pacing, whereas inhibitory reflexes suppress the ability of calcium waves to propagate. We provide evidence that the enteric nervous system organizes mixing movements to generate peristalsis, linking the neural regulation of pacemakers to both types of gut motility.
The origin and spread of excitation were visualized with fluo 3 fluorescence in tissues isolated from canine gastric antrum. Sheets of circular muscle (5 x 6 mm) had at least 1 (30%) and up to 3 discrete slow-wave pacing sites located near the longitudinal-circular muscle boundary, whereas similarly sized longitudinal sheets had an average of 5 sites (range 3-12 sites) that initiated Ca2+ waves. Superimposed fluorescent oscillations (circular muscle) and spikes (longitudinal muscle) were seen to initiate and propagate as distinct events, separate from their underlying activities. Average propagation velocities transverse (6-7 mm/s) and parallel (39-45 mm/s) to the long axis of muscle fibers were similar for each type of event in circular and longitudinal tissues; however, distinct regions where velocities of some (but not all) events decreased by up to an order of magnitude were present. The distance propagated by individual events was limited by collisions with concurrent excitable events or recently activated regions. Complex patterns of excitation in gastrointestinal smooth muscle arise as a result of interactions between multiple pacing sites, heterogeneous conduction velocities, and the interplay of adjacent pacemaker domains.
We review the efficacy, tolerability and safety of low-dose thalidomide in the treatment of refractory disfiguring rash in 16 patients with cutaneous manifestations of lupus. Rashes, which included discoid lupus erythematosus (DLE), subacute cutaneous lupus (SCLE), photosensitive malar rash and non-specific chronic erythema, were diagnosed on clinical grounds, supported by skin biopsy in 11/16 patients. Using starting doses of 50-100 mg/day, 7/16 (44%) patients gained complete or near-complete remission of skin disease and 6/16 (37%) partial remission. Three out of 16 patients failed to respond. Maximum benefit was achieved within 16 weeks in all patients. Doses of 25-50 mg/day were effective in maintaining response. Rapid relapse occurred in 6/8 (75%) patients following drug withdrawal, but the response to thalidomide in those requiring repeat courses appeared to be maintained. There was no detectable improvement in systemic disease. One patient developed symptoms of mild peripheral neuropathy which resolved on drug withdrawal. Our experience suggests that thalidomide is effective in the treatment of severe skin manifestations of lupus refractory to other treatment and can be used safely in specialist rheumatological practice.
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