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Introduction Among men with diabetes, little attention has been given to premature ejaculation (PE), reduced libido, and their associations with erectile dysfunction (ED), despite the presence of physical and psychologic factors that could predispose to all three. Aim To estimate the prevalence and inter-associations of ED, PE, and reduced libido among diabetic men and to describe the associated clinical, socioeconomic, and lifestyle parameters. Methods Cross-sectional observational study of 253 men with type 2 diabetes randomly selected from a clinic in Colombo, Sri Lanka. Main Outcome Measures Erectile function was assessed using the five-item version of the International Index of Erectile Function scale. The presence of PE, reduced libido, sociodemographic, and lifestyle data was obtained using an interviewer-administered questionnaire. Clinical data were obtained from relevant physical examination, patient records, and laboratory tests, which included glycosylated hemoglobin, serum cholesterol, serum creatinine, and electrocardiogram. Results One hundred and eighty-five (73.1%) of the individuals had some degree of ED, while 84 (33.2%) had severe to complete ED. After excluding men with complete ED, the prevalence of PE was 68 (40.2%). The overall prevalence of reduced libido was 64 (25%). In the multivariate analysis, the strongest associations with ED were PE (odds ratio [OR] = 4.41, 95% confidence interval [CI] = 2.08–9.39) and reduced libido (OR = 4.38, CI=1.39–13.82) followed by lower income (OR = 2.16, CI=1.32–3.52), advancing age (OR = 2.06, CI=1.44–2.95), and duration of diabetes (OR = 1.48, CI=1.09–2.01). In addition, ED was univariately associated with lower educational level ( P = 0.05), the presence of hypertension ( P = 0.005), and no alcohol intake ( P = 0.001). The only significant association of PE was the severity grade of ED. Associations of reduced libido in the multivariate analysis were ED (OR=1.61, CI=1.23–2.70), advancing age (OR = 1.7, CI=1.4–2.2), and absence of masturbation (OR = 3.3, CI=1.2–8.8). Conclusions ED was strongly associated with PE and reduced libido. Diabetic patients presenting with one of these three conditions should be screened for the other two. Malavige LS, Jayaratne SD, Kathriarachchi ST, Sivayogan S, Fernando DJ, and Levy JC. Erectile dysfunction among men with diabetes is strongly associated with premature ejaculation and reduced libido. J Sex Med 2008;5:2125–2134.

Background: While only 30% of all hip fractures occurred in Asia in 1990, more than 50% will occur by the year 2050. We investigated the relationship between the Stiffness Index (SI), assessed with quantitative ultrasound, and calcium intake in a cross-sectional survey of suburban males of different ages. Methods: From 496 people who were invited, 274 participated (55%). A single operator performed quantitative ultrasound measurements at the right calcaneus using Lunar Achilles. We derived the Sri Lankan T-score values for SI. Calcium intake was measured using semiquantitative food frequency questionnaire to measure the previous 7 days intake. Results: There was gradual decrease in mean SI from the age of 30 years. Eighty percent of the men between 21–40 years had normal T-scores. This percentage value fell to high 60s in men between 41–70 years. After 71 years, 35% had normal T-scores and 30% had T-scores less than –2.5. The mean calcium intake was 197 mg/day (95% CI 187–287 mg). Conclusions: This is the first population-based study done in Sri Lanka regarding calcium intake and SI in males. Although few men had low T-scores according to SI after 40 years, bone health of elderly (after 71 years) is at risk levels. The overall prevalence of low SI was negligible (4%) even with low calcium intake. Age is the only factor that influenced SI.

OBJECTIVE—Strategies for initiating statin use among adult patients with diabetes for primary cardiovascular disease (CVD) prevention include treating all patients (assuming diabetes is a coronary risk equivalent) or treating patients who are at risk of developing CVD. The aim of the study was to combine both strategies to derive an appropriate age cutoff for prescribing statins. By considering different strategies, we also aim to assess the effectiveness and efficiency of different strategies to reduce CVD events. RESEARCH DESIGN AND METHODS—This was a cross-sectional primary care population study using electronic patient files from 304 general practitioner practices in England and Wales. Of 60,258 patients with diabetes, 11,005 men and women aged 30–74 years fullfilled criteria for primary CVD prevention. Model outcomes were extrapolated to an estimated national diabetes prevalence of 3.6%. RESULTS—The age transition from a low-risk to a moderate-risk category for diabetic men and women occurred at ages 40.6 and 44.2 years, respectively, and sensitivity and specificity for fulfilling moderate CVD risk criteria were 97.9 and 61.8% for men and 92.0 and 77.0% for women. When applied to the national population, the age cutoff strategies were an effective and efficient strategy, potentially avoiding 11,094 events with a number needed to treat of 25.1. CONCLUSIONS—A strategy to treat all men and women with diabetes aged >40 and 45 years, respectively, with statins showed good compromise between high effectiveness and high efficiency for reducing CVD events. Strategy to intervene if cholesterol was >5 mmol/l was the least effective and efficient in preventing CVD events.

Dengue fever (DF) is one of the world's emerging infectious diseases. The steady increase in European tourists, as well as soldiers serving on peacekeeping duties, in endemic areas, coupled with the present resurgence of dengue, raises the risk of exposure for a large number of European travellers. Significant numbers of travellers have, in fact, developed DF. There is a risk of dengue haemorrhagic fever (DHF) in travellers who revisit the same place, and they have the potential not only to acquire, but also to spread, the dengue viral infection. Of concern is the potential for a dengue outbreak in a previously dengue-free country through imported cases. Another major concern is the potential area of dengue transmission, due to spread of its vectors through sizeable parts of southern Europe. In addition to the risk of haemorrhagic fever in returning tourists, the introduction of DF by returning travellers, whether they have symptoms or are unaffected by signs and symptoms of the disease, poses a threat to health systems in Europe.

Patient complaints are an important source of information for service improvements. We audited patient complaints made about medical care in a National Health Service District general hospital over a 22 month period. Complaints were about medical care, nursing care, attitudes of staff, poor communication, clinical delay (9%) and hospital environment. The complaints department closed 66% complaints within 20 days. The majority of the complaints were directly related to clinical care, poor communication, attitudes of staff and nursing care. However, 99% of patients were satisfied with an explanation and an apology indicating that almost all have been due to a lack of good communication than due to real deficiencies in the clinical care. The hospital management has investigated the majority of cases within 20 days and has made several policy changes after the investigations.

Many physicians are unaware of the power of the internet. In an era of an empowered public and patients, the internet may be a more powerful determinant of health-seeking behaviour than medical opinion. In the same way, it may provide more information for self-harm than was ever available to the public domain in the past. The internet is effective across cultural and geographical boundaries. In addition to reporting and romanticising suicide, it has a significant impact in assisting and promoting suicide. It provides services and information ranging from general information to online orders of prescription drugs or other poisons that bypass government regulations and custom controls. This bridges the gaps of locality and accessibility, which previously formed a natural divide in selecting the means of suicide. In addition to these negative effects, there is a vast potential to harness these properties to a beneficial effect. The wide acceptance of the internet makes it a powerful tool for recognition of the at-risk individual, for preventing suicide and supporting survivors, with chat rooms taking the place of telephone help lines. In an information age, it is vital for physicians to use all available means of informing and empowering the public and patients. The internet also has a role in training, providing accessible self-help sites for suicidal persons and web-based prevention services, all of which remain sadly under-utilised. The challenge to physicians of the 21st century is to harvest the internet in a beneficial manner.

Purpose: To assess the frequency of retinopathy and vision loss in patients with insulin-dependent diabetes mellitus and their relations to potentially modifiable risk factors. Methods: The authors conducted a multicenter cross-sectional study of diabetic complications and their risk factors using standardized methods of assessment. The sample was comprised of 3250 insulin-dependent diabetic patients (1668 men, 1582 women) aged 15 to 60 years with mean (standard deviation) duration of diabetes of 14.7 (9.3) years from 31 European diabetes centers; 2991 of the patients were eligible for retinal photography. Visual acuity was measured using the Snellen chart. Retinopathy was evaluated by retinal photographs (two fields per eye) graded at a central facility. Glycated hemoglobin (HbA,c), cholesterol, triglyceride, fibrinogen, von Willebrand factor, and urinary albumin excretion rate were assessed at a single location. Results: Corrected visual acuity was greater than or equal to 1.0 in both eyes in 69.7% of patients and less than or equal to 0.1 in the best eye in 2.3%. Factors significantly related to vision loss were age, duration of diabetes, glycated hemoglobin (HbA 1c ), and level of retinopathy. Mild nonproliferative retinopathy was found in 25.8% of the patients, moderate-severe nonproliferative retinopathy in 9.8% of the patients, and proliferative retinopathy in 10.6% of the patients. After adjustment for age, duration of diabetes, HbA 1c , and albumin excretion rate, significant risk factors for moderate-severe nonproliferative retinopathy were blood pressure and triglyceride, and risk factors for proliferative retinopathy were triglyceride and fibrinogen. Conclusion: Vision loss is a common complication of patients with insulin-dependent diabetes, with diabetic retinopathy an important cause. Apart from poor glycemic control, several other potentially modifiable risk factors for retinopathy may be important, including elevated blood pressure, plasma triglyceride, and fibrinogen. In view of the possible barriers to the full implementation of strict glycemic control in this type of diabetes, additional strategies for the prevention and slowing of progression of retinopathy should be investigated, such as blood pressure and lipid lowering therapies.

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34-90) years, diabetes duration 7.4 (0-50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or > or = 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3-44.9%) and the prevalence of PVD, 11% (9.1-13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.

Summary The prevalence of macrovascular disease and hyperlipidaemia was examined in 500 patients with non-insulin-dependent diabetes mellitus attending a diabetic clinic in a Sri Lankan teaching hospital and 250 controls matched for age and gender. Macrovascular disease was assessed using a modified World Health Organisation questionnaire and modified Minnesota coding of electrocardiogram recordings. Twenty-one per cent of diabetic patients and 14.3% of controls had hypercholesterolaemia (P < 0.05). Macrovascular disease was present in 13.4% of diabetic patients and 8.2% of controls. Significant differences were seen in the prevalence of hypertension (15.6% vs 4.8%, P < 0.05), obesity (16.2% vs 9.7%, P < 0.05), peripheral vascular disease (5.6% vs 2%, P < 0.05) and electrocardiographic abnormalities (12% vs 6%, P < 0.05) in diabetic patients when compared to controls. Hyperlipidaemia and macrovascular disease is common in non-insulin-dependent diabetic patients in Sri Lanka and accounts for significant morbidity.

It is now well established that high foot pressures in diabetic patients are associated with foot ulceration. Using the optical pedobarograph, dynamic foot pressures were measured during walking in 135 diabetic patients and 69 healthy, age-matched controls. Diabetic subjects were clinically subdivided to those with neuropathy (83 patients) and without neuropathy (52 patients). Mean peak foot-pressure in the diabetic group was significantly higher than the controls (10.1 kg.cm −2 ±4.2 SD versus 8.3±4.0, p 12.3 kg.cm −2 ), compared to non-neuropathic (15%, p

Both vibration perception threshold (VPT) by biothesiometry and pressure perception using Semmes-Weinstein monofilaments (filaments) have been proposed to identify diabetic patients at risk of foot ulceration. The two methods were compared in 182 subjects attending a national patients conference. Both measures were made over the great toe. Filaments of three calibres were used: 4.17, 5.07 and 6.10 bending with 1, 10 and 75 g force, respectively. Pressure perception was normal (4.17) in 122 patients (group 1) whereas in 45 patients it was grade 5.07 (group 2) and 6.10 or greater in 15 (group 3). The corresponding mean VPT (+/- SD) for the three groups were 10.6 (+/- 6.7), 22.8 (+/- 12.7) and 32 (+/- 14.3), respectively. The mean VPT for the 3 groups were significantly different (P less than 0.001). The filaments were more sensitive (100%) but less specific (77.7%) in identifying patients who had foot ulcers compared to biothesiometry which was less sensitive (78.6%) but more specific (93.4%). The filaments are therefore reliable and may be superior to biothesiometry in screening for patients at risk of foot ulceration since sensitivity is the more important parameter. In addition, they are inexpensive (12 pounds) compared to the biothesiometer (400 pounds) and are simple and easy to use.

Objective To investigate the role of limited joint mobility (LJM) in causing abnormal foot pressures and foot ulceration. Research Design and Methods The subjects were recruited from a general diabetes clinic where patients were screened for neuropathy, retinopathy, and elevated plantar foot pressure. Sixty-four patients in five groups were matched by age and sex in the following groups: group 1, patients with LJM and neuropathy; group 2, nonneuropathic diabetic patients with LJM; group 3, patients with neuropathy and no LJM; group 4, diabetic control subjects; and group 5, nondiabetic control subjects. Joint mobility was assessed in the foot at subtalar and metatarsophalangeal joints; plantar foot pressures were assessed by optical pedobarography and neuropathic status by a Biothesiometer and electrophysiology. Results Joint mobility was reduced at both sites in groups 1 and 2 compared with groups 3, 4, and 5 (P < 0.001). Plantar foot pressures were significantly higher in groups 1 and 2 compared with groups 3, 4, and 5 (P < 0.001). No differences in plantar foot pressures were observed between groups 1 and 2. There were strong correlations between plantar foot pressures and joint mobility in the foot (r = −0.7, P < 0.001). Previous foot ulceration was present in 65% of patients in group 1, none in group 2, and 5% in group 3. Conclusions 1) LJM may be a major factor in causing abnormally high plantar foot pressures, 2) abnormal plantar foot pressures alone do not lead to foot ulceration, and 3) LJM contributes to foot ulceration in the susceptible neuropathic foot.

Objective: To determine an appropriate age threshold at which to prescribe aspirin for primary cardiovascular disease (CVD) prevention among men and women without diabetes. Design: Cross-sectional study. Setting: 304 general practices in England and Wales contributing to The Health Improvement Network (THIN) electronic patient files. Participants: Subjects aged between 30 and 75 years without diabetes, not prescribed any lipid-lowering treatment and with no previous history of CVD. Subjects had to have been registered by their practices for the whole of the preceding 12 months to be included in the analysis. Outcomes measures: Relation between age and coronary heart disease (CHD) risk, and the age threshold at which subjects without diabetes develop an estimated 10-year CHD risk of ⩾10%. Results: The age transition from 10%, 10-year CHD risk for men and women without diabetes occurred at ages 47.8 for men and 57.3 for women. Conclusions: In the absence of significant bleeding risks, aspirin should routinely be considered for all men and women without diabetes above the ages of 48 and 57 years, respectively, for primary CVD prevention. For subjects below these age thresholds or for those above the age of 75 years, the decision to initiate aspirin should be based on a patient’s individual cardiovascular risk profiles. These proposed age thresholds aim to take into account a patient’s gender, bleeding risk and the cardioprotective benefits of low-dose aspirin treatment.

Objective: Non-migrant Asian Indians have a high prevalence of diabetes and coronary heart disease (CHD). Since the relation between age and CHD risk in this population is not known, the appropriateness of existing age threshold for patients with diabetes to be suitable for primary CHD prevention with statins is not known. We aimed to determine an age threshold above which patients develop a higher risk of CHD and would merit routine statin prescription. Design: Cross-sectional analysis of 1087 patients with diabetes from the Chennai Urban Rural Epidemiological Studies (CURES). CHD risk assessment was calculated using the United Kingdom Prospective Study (UKPDS) risk engine, externally validated by using data obtained from the 7-year follow-up cohort of the Chennai Urban Population Study (CUPS). Relation between age and CHD risk was determined and the age threshold for increased CHD risks was calculated using line of best fit. Results: UKPDS risk engine overestimates CHD event rates by 50% in this population. Age is a strong independent predictor of CHD risk. Transition from low to moderate-risk category for men and women with diabetes occurred at ages 37 and 50 years, respectively. Sensitivity for fulfilling this CHD risk criteria are 98.7% for men and 87.1% for women. Conclusions: Statins should be routinely prescribed to all Asian Indian men and women with diabetes above the ages of 37 and 50 years, respectively. For patients below these age thresholds, decision to initiate statins should be based on patient's individual cardiovascular risk factors. This strategy may facilitate public health efforts to reduce CHD events in India.

Yellow oleander (Thevetia peruviana) is a tree that is common in Sri Lanka and that is used as a method of self-harm. Accidental poisonings have been reported in developing countries, but intentional poisonings are very uncommon in Europe. We report on a patient in the UK who used the internet to obtain information and purchase a poison from a tropical plant for suicidal use. Language: en

A system of electronic discharge summaries was developed. It replaced conventional discharge prescriptions and dictated discharge summaries. We conducted a prospective case-control study of 102 consecutive patients admitted to our hospital under the care of one consultant physician. Patients discharged after 1 December 2004 were discharged using the new computerised system (50 patients) while patients admitted under the same medical team, but to another ward were discharged using the conventional paper discharge system (52 patients). Patients in the electronic group and the conventional group were similar in age (mean 67 years versus 58 years, P>0.05) and duration of hospital stay (6 days versus 1 day, P>0.05). The mean time taken to produce an electronic discharge summary was immediate (0 days) which was significantly (P

It seems likely that the development of effective diabetes education for patients, carers and staff would prove highly cost-effective. Diabetes-e is an electronic diabetes encyclopaedia designed to provide comprehensive education to patients, carers (e.g. family, schools, care homes) and health professionals (specialist and non-specialist). In addition, educational media such as information leaflets (that can be printed during a consultation), streaming educational video and slide resource packs are available. Self-assessment questionnaires with feedback guide further education and facilitate targeted continuing professional development (CPD) for health professionals. The prototype has been developed with a particular emphasis on patient input. It is anticipated that Diabetes-e will be implemented across Central Nottinghamshire, including training of key personnel, by the end of 2005. The project has already gone live for insulin commencement.

A 68-year-old female with type 2 diabetes mellitus presented to the diabetic foot clinic with a recurrent superficial ulcer, 4 cm in diameter, involving only skin and subcutaneous tissue over the right metatarsal head. This had been treated as a soft corn in primary care during the 12 months before the referral. The recurrent ulceration had been attributed to debridement of the corn. At referral, there were no risk factors for diabetic foot ulceration, such as neuropathy or vascular disease [1]. We excluded infection microbiologically and osteomyelitis by imaging. Histology of the ulcer was of an invasive malignant melanoma. Though melanoma accounts for only 4% of all skin cancers, it is the leading cause of skin cancer-related deaths worldwide. Early detection reduces mortality. The unacceptable delay in biopsying this non-healing ulcer, by attributing it to her diabetes in the absence of risk factors, delayed treatment of her malignant melanoma. The absence of peripheral neuropathy or limb ischemia makes the search for alternative causes of recurrent ulcer mandatory. There is only one previous case report of a melanoma posing as a ‘diabetic foot ulcer’ and leading to delayed

Dengue viral infections are one of the most important mosquito borne diseases in the world. They may be asymptomatic or may give rise to undifferentiated fever, dengue fever, dengue haemorrhagic fever (DHF), or dengue shock syndrome. Annually, 100 million cases of dengue fever and half a million cases of DHF occur worldwide. Ninety percent of DHF subjects are children less than 15 years of age. At present, dengue is endemic in 112 countries in the world. No vaccine is available for preventing this disease. Early recognition and prompt initiation of appropriate treatment are vital if disease related morbidity and mortality are to be limited. This review outlines aspects of the epidemiology of dengue infections, the dengue virus and its mosquito vector, clinical features and pathogenesis of dengue infections, and the management and control of these infections.

We conducted a randomised single centre double blind cross over clinical trial to investigate the effects of a herbal tea containing Salacia reticulata (Kothala Himbutu tea) in patients with type II diabetes mellitus. Fifty-one patients with type II diabetes mellitus for longer than 6 months and with evidence of stable glycaemic control over the preceding 6 months (as assessed by HbA1C) participated in the study. They were randomised to receive a standard preparation of Kothala Himbutu tea for 3 months followed by placebo in similar tea bags for a further 3 months (n = 28) or in reverse order (n = 23). All patients received detailed advice on diet, exercise and lifestyle modification. HbA1C was measured at recruitment, at 3 months and on completion of the study at 6 months. Liver and renal functions were assessed biochemically at baseline, at 3 and 6 months and adverse events were recorded. There were no significant differences between the two groups in age, body mass index, male/female ratio, glycaemic control and baseline laboratory tests. All patients completed both arms of the trial. The HbA1C at the end of drug treatment was significantly lower than after treatment with placebo (6.29 +/- S.D. 1.02 versus 6.65 +/- S.D. 1.04; P = 0.008). A statistically significant fall in HBA1c was seen with the active drug compared to a rise in HbA1C with the placebo group (0. 54 +/- S.D. 0.93) versus -0.3 +/-S.D. 1.05; P < 0.001. The daily mean dose of Glibenclamide fell by 1.89 (S.D. 6.2) mg in the drug treated group but rose by 2.25 mg in the placebo treated group (P = 0.07). The differences in the metformin dose were not significantly significant in the two groups. We conclude that Kothala Himbutu tea is an effective and safe treatment for type 2 diabetes.

The results of glucose tolerance testing (OGTT) in 1004 consecutive women were examined with respect to risk factors for gestational diabetes mellitus (GDM). GDM was diagnosed in 41 of 1004 (4.08%) women. GDM was present in 7.8% of women aged over 35 years (compared to 3.1% if less than 35 years), in 8.1% women with a body mass index (BMI) >/=30 (compared to 3.6% if BMI

High plantar pressures and painless trauma are associated with the development of foot ulcers in diabetic patients. Padded hosiery has been reported to reduce plantar pressures in patients at risk of ulceration. Using the optical pedobarograph we have studied 10 patients who regularly wore experimental padded hosiery for 6 months. The hosiery continued to provide substantial and significant reduction in peak forefoot pressures at 3 months (mean reduction 15.5%, p less than 0.01) and 6 months (17.6%, p less than 0.01), although the level of reduction was less than that seen at baseline (31.3%, p less than 0.05). In addition, commercially available hosiery designed as sportswear has been tested, and compared with experimental hosiery. Although these socks (with high or medium density padding) provided significant pressure reduction versus barefoot (mean 17.4% and 10.4%, p less than 0.01), this was not as great as that seen with experimental hosiery (27%, p less than 0.05). Thus the use of socks designed to reduce pressure stress on diabetic neuropathic feet is effective, and continues to be so for a considerable period of time. Commercially available sports socks may also have a place in the management of the diabetic insensitive foot.

Summary The prevalence of impaired glucose tolerance and diabetes mellitus was studied in a suburban Sri Lankan community using 1985 WHO criteria. Oral 75 g glucose tolerance tests were performed on 633 subjects aged 30-64 years. The age-standardized prevalence rates for diabetes mellitus were 5.02 (95% CI 3.59-6.43) and impaired glucose tolerance 5.27 (95% CI 3.74-6.78). A total of 21% of diabetic patients were not known to have diabetes and were diagnosed for the first time during the survey. Obesity was more common (P < 0.05) in diabetic patients (21%) when compared to non-diabetic subjects (10.5%). Diabetes mellitus is a common health problem in Sri Lanka, and there is a need for developing national policies for its prevention and control.

This paper presents a prospective study on the validity of clinical diagnostic criteria of acute pelvic inflammatory disease (PID) in Sri Lanka over a period of 15 months. The study assessed 1817 consecutive gynecological admissions and acute PID was diagnosed according to the established clinical criteria. Clinical signs and symptoms of PID among women aged 18-22 years include abdominal pain abnormal vaginal discharge urinary symptoms irregular bleeding vomiting rectal symptoms fever an erythrocyte sedimentation rate of 15 mm/hour or higher abnormal adnexal tenderness and a palpable adnexal mass. The gynecological casualty admissions categorized into one of the following clinical groups are outlined. The study identified 29 visually confirmed acute PID cases with 41 patients with acute PID in the series. This indicates that there is a 2.26% acute PID incidence in the casualty gynecological setting (95% confidence interval 1.91-2.61). When the clinical diagnosis was equivocal the positive value for acute PID diagnosis was 76%. This indicates that if laparoscopy had not been used to confirm acute PID 24 patients with equivocal PID would have been overtreated with expensive broad-spectrum antibiotics. This article emphasizes that in the absence of contraindications and availability of facilities laparoscopy is very useful; and at the same time treatment of clinically equivocal cases must not be delayed as this may lead to serious consequences.

Arid systems are markedly different from non-arid systems. This distinctiveness extends to arid-social networks, by which we mean social networks which are influenced by the suite of factors driving arid and semi-arid regions. Neither the process of how aridity interacts with social structure, nor what happens as a result of this interaction, is adequately understood. This paper postulates three relative characteristics which make arid-social networks distinct: that they are tightly bound, are hierarchical in structure and, hence, prone to power abuses, and contain a relatively higher proportion of weak links, making them reactive to crisis. These ideas were modified from workshop discussions during 2006. Although they are neither tested nor presented as strong beliefs, they are based on the anecdotal observations of arid-system scientists with many years of experience. This paper does not test the ideas, but rather examines them in the context of five arid-social network case studies with the aim of hypotheses building. Our cases are networks related to pastoralism, Aboriginal outstations, the ‘Far West Coast Aboriginal Enterprise Network’ and natural resources in both the Lake-Eyre basin and the Murray–Darling catchment. Our cases highlight that (1) social networks do not have clear boundaries, and that how participants perceive their network boundaries may differ from what network data imply, (2) although network structures are important determinants of system behaviour, the role of participants as individuals is still pivotal, (3) and while in certain arid cases weak links are engaged in crisis, the exact structure of all weak links in terms of how they place participants in relation to other communities is what matters.

Poole and Compston highlight important points on osteoporosis that practising clinicians need to consider.1 However, doctors managing patients from ethnic minorities in developed Western countries (nearly 10-20% in some UK cities, such as Manchester) or developing countries in Asia, Africa, and South America would wish to know if and how recommendations on diagnosis, management, and prognosis apply to their individual patients. …

A 41-year-old woman with type 2 diabetes for 5 years presented with sudden dyspnoea and orthopnoea. She had no past history of ischaemic heart disease, heart failure or microor macrovascular complications. She was on gliclazide 80 mg bd, acarbose 50 mg tds, and a tablet combining rosiglitazone 4 mg and metformin 500 mg. This was started in 2001 as 1 tablet bd and was increased to 1 tablet tds (rosiglitazone 12mg andmetformin 3 g) by her family doctor. She presented 1 week after the dose had been increased. Clinical examination and radiography confirmed pulmonary oedema. Her ECG did not show ischaemic heart disease and cardiac enzymes were normal. Echocardiography showed no systolic or diastolic dysfunction. The patient was given a high dose of diuretics after discontinuing the combined formulation. She improved within 24–48 h. Thiazolidinediones are associated with plasma volume expansion, causing both peripheral and pulmonary oedema. A number of vascular mechanisms can cause pulmonary oedema within 48 h of commencing treatment [1]. The effect of rosiglitazone is dose-dependent. High concentrations of rosiglitazone cause a reversible, fourfold increase in pulmonary endothelial permeability, especially at higher doses

Dengue fever is an acute mosquito-borne viral infection caused by any one of four Flavivirus, Den 1–4 [1]. It is endemic in many popular tourist destinations and reported with increasing frequency in returning tourists [2]. Infections with the dengue virus may be asymptomatic or give rise to an undifferentiated fever, dengue fever (DF) or dengue haemorrhagic fever (DHF), including dengue shock syndrome (DSS). We report a case of DHF in a traveller returning from an endemic area. A 50-year-old housewife of Indian origin, residing in the UK, was admitted with a history of high fever, vomiting, diarrhoea, abdominal pain and severe loss of appetite after returning from holiday in India. She was previously well and travelled mainly in urban India during an epidemic. She had taken vaccines for typhoid and cholera but had not taken malaria prophylaxis. Apart from pyrexia and generalised abdominal tenderness, clinical examinationwas normal. Her haemoglobinwas 14 g%, haematocrit 0.43, platelets 16×10 and leucocyte count 2.7×10 while other routine investigations were normal. Blood films for malarial parasites and tests for malarial anti

Objective: To identify risk factors for long­ term complicatio os in patients with type 2 diabetes in Sri Lanka. Methodology: An unmatched, clinic- based, case control study. Diabetic patients enrolled from randomly selected medical clinics from primary, secondary and tertiary care level hospitals were interviewed to determine possible risk factors and· screened for long­ term complications. 252 diabetic patients having one or more Jong term complications were selected as cases and 288 diabetic patients free from long term complications included as controls. Results: Peripheral diabetic neuropathy (25.2%), micro albuminuria (22.8%), retinopathy (20%), and coronary heart disease (12.4%) were some complications present among cases. 21.9% had only one complication while 16.5% and 6.9% had two and three com plications respectively. Only 1.5% had au fourcomplications. In the univariate analysis, smoking, low family income, body mass index over 25, older age (over 60 years), longer duration of diabetes (11 -15 years), random blood sugar > 11, 0mmoV/, raised diastolic blood pressure > 90mmHg were significantly (p Conclusion: Long-term complications in type 2 diabetes are common among patients. Most of the significant risk factors are preventable.

The Neurometer is a variable constant current sine wave stimulator, and has recently been proposed as a simple non-invasive and quantitative measure of peripheral nerve function. The device is portable and battery operated; assessment of upper and lower extremities takes only a few min, in contrast to conventional assessment techniques. In order to assess its potential in the quantification of diabetic neuropathy, detection thresholds for constant current electric sine wave stimulation were measured at three different frequencies in different sites in 31 healthy control subjects and 90 diabetic patients with and without neuropathy. The device provides good discrimination between neuropathic and non-neuropathic groups (p less than 0.001) and is quick and easy to use. Comparisons with results of conventional tests of nerve function show that high frequency detection thresholds correlate best with tests of large fibre function (r = 0.42-0.69, p less than 0.001), and low frequency detection thresholds correlate with tests of small fibre function (r = 0.34-0.46, p less than 0.005). It is concluded that the device may be a simple and comprehensive way of assessing peripheral nerve function.

High pressures under the feet of diabetic patients with neuropathy are associated with the development of plantar ulceration. The aim of management is the reduction of such stresses with orthoses and insoles. An American hosiery manufacturer has developed socks designed to reduce stress on athletes' feet, and we report a preliminary evaluation of this technique in the reduction of elevated plantar pressure in 27 neuropathic diabetic patients. With a computerized optical pedobarograph, three footsteps on each side were recorded under three conditions: 1) barefoot, 2) wearing the patients' own hosiery, and 3) wearing experimental patented padded hosiery. The patients' own hosiery did not have a significant effect on plantar pressure, but the experimental hosiery reduced both peak forefoot pressure and the area under the timepressure curve (P < .001) by a mean of 26 and 29%, respectively. We conclude that the experimental hosiery is effective in reducing vertical pressures under the diabetic foot and, in conjunction with established orthotic techniques, may be a useful addition to the treatment of the diabetic patient at risk for foot ulceration.

We screened 597 newly-diagnosed diabetic patients (201 women) mean +/- SD age 42.3 +/- 6.2 years to determine the prevalence of diabetic complications; 22% presented because of symptoms of diabetes, 27% were diagnosed when hyperglycaemia was discovered at a health screening, and 36% were diagnosed while being treated for intercurrent illness. Neuropathy was present in 25.1%, nephropathy in 29%, retinopathy in 15%, coronary vascular disease in 21%, stroke in 5.6%, peripheral vascular disease in 4.8%, hypertension in 23%, obesity in 16%, central obesity in 21.3%, hypercholesterolaemia in 11%, hypertriglyceridaemia in 14%, and low high-density lipoprotein cholesterol in 12%. The prevalence of coronary vascular disease, hypertension, stroke, neuropathy and retinopathy at the time of diagnosis were higher in our patients than in Caucasian and Indo-Asian patients in the UK. Both a genetic predisposition to develop complications, and exposure to a longer duration of asymptomatic hyperglycaemia due to poor access to adequate health care, may contribute to the high frequency of complications at diagnosis. Since complications are already present at diagnosis, there is a case for implementing primary prevention programmes combined with screening for diabetes in high-risk groups.