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Branched fatty chain fatty acids (BCFAs) are associated with the "mutton flavor" found with the aroma resulting from cooked older sheep meat with three BCFAs, 4-methyloctanoic (MOA), 4-ethyloctanoic (EOA) and 4-methylnonanoic (MNA) acids as the main compounds responsible for "mutton flavor". Usually, BCFA analysis is done by gas chromatography (GC) with the use of quadrupole mass spectrometry (qMS) becoming predominant. 2-Butyloctanoic acid (2BO) has been used in this facility using as an internal standard to determine BCFA content in sheep fat. In this present work, GC-qMS, along with GC-quadrupole-time of flight MS (GC-QTOF-MS), have been deployed to characterize alkyl esters (as methyl, ethyl, propyl, and butyl) for MOA, EOA, MNA, and 2BO. This work presents, for the first time, the mass spectral characterization of 2BO for these alkyl esters using GC-qMS and GC-QTOF-MS.

Nonlinear regression was applied to three empirical equations to model the response of a solid-state lead ion-selective electrode (ISE). One particular equation, previously reported to describe the response of a fluoride ISE, was found to also describe the response of a solid-state lead ISE. Nonlinear regression was applied to the early portion of the response curve for the lead ISE and used to estimate the equilibrium potential for a range of test solutions.

Aims Diabetic retinopathy can deteriorate during pregnancy. This usually manifests itself as an increase in the number of background retinopathy lesions, notably the appearance of new cotton wool spots, predominantly during the first trimester. The changes are usually attributed to the rapid attainment of tight glycaemic control during pregnancy. We present a case report of catastrophic deterioration in retinopathy during a period of stable glycaemic control. Results J.P. had normal fundoscopic appearance at booking and during the early part of pregnancy. She experienced rapid deterioration in visual acuity secondary to cystoid macular oedema and vitreous haemorrhage during the third trimester of pregnancy. Her glycaemic control was stable at that stage and had not changed when compared with earlier stages of pregnancy. She required three sessions of intrapartum laser therapy and postpartum vitrectomy. Conclusions The case highlights the importance of regular retinal surveillance in a diabetic pregnancy, even in the absence of sudden improvements in glycaemic control. Diabet. Med. 18, 675–678 (2001)

There is strong evidence for clustering of renal disease in type 1 diabetes, but few data exist with respect to type 2 diabetes. The objective of this case-control study is to determine whether there is a familial predisposition to the development of proteinuria in patients with type 2 diabetes. Fifty patients with type 2 diabetes with macroproteinuria (proteinor = 500 mg/24 h) with no evidence of causes other than diabetic nephropathy on investigation were identified through routine screening. These patients had 25 living sibs with diabetes, of whom 24 sibs agreed to participate on the study. For each of these sibs, two controls with non-insulin-dependent diabetes were randomly selected, individually matched for age, sex, and duration of diabetes. Twelve of 24 sibs (50%) and 9 of 48 controls (18.8%) had proteinuria (P0.01). Systolic and diastolic blood pressure and the proportion on antihypertensive treatment were similar in the two groups. Our data suggest there is increased prevalence of macroproteinuria in diabetic sibs of macroproteinuric patients with type 2 diabetes in a population of white, Caucasian, European descent.

The effect of ionic activity on the quenching of the quinine dication fluorescence by chloride and bromide ions is examined in solutions of sufficiently low ionic strength to enable ionic activities to be taken into account by means of the Debye-Huckel equation. An equation for the dependence of the Stern-Volmer constant on the ionic strength is derived in a novel way and an iterative, linear least-squares computer program is described from which the optimized values of the ionic size parameter for chloride (a = 4.56 ± 0.07 A) and bromide (a = 4.98 ± 0.23 A) quenching were obtained. The ratio of these parameters (a/a = 1.09 ± 0.07) is found to be similar to the ratio of the ionic radii of the two species, r/r = 1.08. The experimental results suggest that the quenching of quinine fluorescence by bromide ions is about 28% faster than that observed for chloride ions. The results are consistent with the notion that the quenching process is a dynamic one involving the formation of an activated complex whose rate of deactivation is dependent on the ionic strength of the medium. © 2000 John Wiley & Sons, Inc. Int J Chem Kinet 32: 473–477, 2000

The presence of autoantibodies to autonomic nervous tissue structures is a feature of patients with symptomatic diabetic autonomic neuropathy. It has not been established whether these autoantibodies cause, contribute to or simply reflect nervous tissue damage. Serum samples were tested for the presence of complement-fixing autoantibodies to adrenal medulla, vagus nerve, and sympathetic ganglion cells, to demonstrate: (a) reproducibility of the technique, (b) persistence of the antibodies, and (c) whether or not they occur in patients with non-insulin-dependent (Type 2) diabetes (NIDDM) with neuropathy. Examination of 37 samples, by different observers 2 years apart, revealed a high degree of concordance of both positive and negative results, demonstrating the method of testing to be highly reproducible. Re-testing of 37 patients (by analysing a second blood sample) betwen 0.5 and 2.7 years (mean 1.7 years) after their first test also demonstrated that antibodies, once present, normally persist; and that most patients initially negative remained so. Of 17 neuropathic NIDDM patients, 16 were negative for all three antibodies, indicating their rarity in this group of patients. © 1997 by John Wiley & Sons, Ltd.

The characterization of oligomeric compounds separated from waste material produced in the high-pressure, free-radical ethylene polymerization process is reported. A solid wax layer, constituting 11 % ( w w ) of the total waste material, was analysed by Fourier transform infrared (FTIR) spectroscopy and gas chromatography/mass spectrometry (GC-MS) and was found to contain mostly short-branched C18C26 paraffins. An oil fraction constituting 64% ( w w ) of the material was identified by FTIR and NMR analyses as a polyether of complex structure. Both the wax and the oil fractions contain a degree of unsaturation. The molecular weight characteristics of the polyether were determined by gel permeation chromatography and found to be Mn = 1716 Da, Mw = 1926 Da, dispersity Mw/Mn = 1.22, using polystyrene standards to calibrate the Chromatographie column. A liquid fraction constituting about 25% ( w w ) of the waste was separated from the oil layer by distillation. It was identified by FTIR and GC-MS analyses as mainly propan-1-one. This compound is used both as a solvent for the initiator and as a chain transfer agent in the low-density polyethylene (LDPE) polymerization process.

To determine whether cytokines could have a role in the development of insulin-dependent diabetes mellitus (IDDM), we measured serum levels of cytokines derived from T helper 1 (interleukin-2 and interferon-gamma), T helper 2 (interleukin-4 and interleukin-10) lymphocytes and macrophages (tumour necrosis factor-alpha, interleukin-1 alpha and interleukin-1 beta) in patients before and after the onset of IDDM. Recently diagnosed IDDM patients had significantly higher levels of interleukin-2, interferon-gamma, tumour necrosis factor-alpha and interleukin-1 alpha than patients with either long-standing IDDM, non-insulin-dependent diabetes (NIDDM), Graves' disease, or control subjects (p0.05 for all). Compared with control subjects, patients with long-standing IDDM and those with NIDDM had higher interleukin-2 and tumour necrosis factor-alpha levels (p0.01 for all). Interleukin-4 and interleukin-10 were detectable in sera of patients with Graves' disease only, while interleukin-1 beta was not detectable in the serum of any control or test subject. To investigate whether high cytokine levels precede the onset of IDDM, we studied 28 non-diabetic identical co-twins of patients with IDDM, followed-up prospectively for up to 6 years after the diagnosis of the index. Levels of tumour necrosis factor-alpha and interleukin-1 alpha were elevated above the normal range more frequently in the eight twins who developed diabetes than in those 20 who did not (p0.005). Analysis of T helper 1 and T helper 2 profiles of the twin groups did not reveal a clear difference between prediabetic twins and twins remaining non-diabetic. These results support the notion that T helper 1 lymphocytes may play a role in the development of IDDM. This is associated with release of macrophage-derived cytokines, which is also a feature of the prediabetic period. The lack of evidence of a dominant T helper 1 profile of cytokine release before diabetes onset suggests that additional events, activating this arm of the cellular immune response, are required in the immediate prediabetic period.

We present a series of patients with both an eating disorder and diabetes mellitus and compare these to a group of non-diabetic patients from the same clinic. Significantly more of the diabetic patients had previous attempts at treatment for their eating disorder. A high incidence of diabetic complications was noted with clear implications, both clinically and economically, for early intervention. The incidence of childhood trauma was lower in the diabetic than the non-diabetic group. In the majority of patients, diabetes developed before the eating disorder, suggesting that diabetes itself may provide the vulnerability and increase the risk of developing an eating disorder. Early intervention in diabetic clinics may prevent the development of serious eating disorders.

The precision of an analytical method has been evaluated objectively by applying the method of Thompson and Howarth (1976) to the analysis in duplicate of 55 igneous rocks covering a range of silicate matrix types and analyte concentrations. Results were analysed 1.0 characterise the change in precision ( s c ) of the analytical method with concentration ( c ) according to the equation s c = s o + kc , where the k parameter represents the limiting high-level precision and s o , the precision at zero concentration, which is related to the method detection limit (MDL). Test materials were analysed using four analytical methods based on two analytical techniques, inductively coupled plasma-atomic emission spectrometry (ICP-AES) and X-ray fluorescence spectrometry (XRF), as operated under routine working conditions in the two participating laboratories. The two XRF methods were major elements on fused glass discs and trace elements on powder pellets, and the two ICP-AES methods were major elements after a fusion decomposition technique and trace elements together with selected major elements, after an acid attack. Statistical evaluation of the data showed that significant changes in precision as a function of concentration (i.e. the k factor) were determined in 34 cases out of 78 analyte-method combinations. In cases where no significant change in precision could be detected, a grand mean precision, representative of the concentration range analysed was calculated. The s o parameter was found to be significantly different from zero in 36 cases out of 72. To allow evaluation of the detection limit performance of all data, a maximum method detection limit (MMDL) was calculated, which was estimated to be on average 1.62 times greater than the MDL derived from significant values of s o In terms of the four methods studied, median high-level precision of the techniques used to determine major elements were found to be 0.23% relative (XRF/glass discs), 0.43% (ICP-AES/fusion decomposition) and 0.70% (ICP-AES/acid attack). Typical precision values in the determination of trace elements by both techniques was 1.5%, providing elemental concentrations extended over a significant range. MMDL's varied from element to element but for XRF/powder pellet data were found to be approximately equivalent to instrumental detection limits (IDL's) calculated from background count rates. However, for trace elements determined by ICP-AES/acid attack, MMDL were found to be on average three times larger than IDL's measured from repeated analysis of an aqueous blank. As a result of an evaluation of these data, it is proposed that appropriate figures of merit to describe the analytical performance of a technique are: (1) median precision in the determination of major elements; and (2) the number of trace elements that can be determined to MDL's of less than one-tenth the crustal abundance of the element. These factors should then be evaluated in conjunction with logistical factors including the rate at which samples can be analysed and the cost per determination. The influence of these factors on applications of the techniques studied in pure and applied geochemistry are discussed.

OBJECTIVE Distended turgid veins have been noted in the feet of patients with diabetic neuropathy. This study assessed the supine venous pressure and its correlation with diabetic neuropathy and arteriovenous (AV) shunting in the feet of type I and type II diabetic subjects. RESEARCH DESIGN AND METHODS Seventeen patients with chronic Charcot joints, 11 patients with a history of neuropathic foot ulceration, 14 diabetic control subjects, and 11 normal control subjects were studied. Neuropathy was assessed by vibration and thermal thresholds and standard cardiovascular autonomie neuropathy tests. Supine venous pressure was measured by insertion of a 21-gauge needle connected to a strain gauge manometer into the veins on the dorsum of the foot. Venous Po2 was used as a measure of AV shunting. RESULTS Venous pressure was raised in the group with chronic Charcot joints (18.9 ± 4.2mmHg, P < 0.001 vs. the diabetic control group [11.3 ± 2.6mmHg]), the normal control group (12.3 ± 2.3 mmHg, mean ± SD), and the diabetic group with a history of neuropathic foot ulceration (16.0 ± 3.7 mmHg, P = 0.008 vs. diabetic control subjects and P = 0.04 vs. normal control subjects), with a maximum of 28 mmHg. Venous pressure was correlated with heart rate variation to deep breathing, r = −0.61 (P = 0.001), vibration threshold, r = 0.56 (P = 0.001), Valsalva ratio, r = −0.64 (P = 0.001), warm threshold, r = 0.69 (P = 0.001), and venous Po2, r = 0.43 (P = 0.02). There was no correlation with skin temperature, duration of diabetes, age, HbAlc, random blood glucose, ankle/brachial Doppler index, height, or serum creatinine. CONCLUSIONS Venous pressure is much higher in the neuropathic diabetic limb and is correlated with the severity of neuropathy and with AV shunting.

Foot ulceration, sepsis, and amputation are known and feared by almost every person who has diabetes diagnosed. Yet these are potentially the most preventable of all diabetic complications by the simplest techniques of education and care. If lesions do occur, the majority can be cured by immediate and energetic treatment, for which good provision must be made. This article is adapted from the 5th edition of the ABC of Diabetes , which is published by BMJ Books (www.bmjbooks.com/) Neuropathy and ischaemia are the principal disorders underlying foot problems. Whenever a patient presents with an active lesion, it is essential to decide at an early stage whether the foot problem is: #### Precipitating causes of foot ulceration and infection A combination of ulceration and sepsis in an ischaemic foot carries a higher risk of gangrene, and early arterial assessment and management are key to avoiding major amputation. Men of low socioeconomic class are most prone to diabetic foot disorders, and Asian patients least likely to get them. Many causes are avoidable. Patients confined to bed must have their heels elevated to avoid heel blisters and sepsis. Such wounds need weeks or months of treatment and sometimes require …

Blindness is one of the most feared complications of diabetes but also one of the most preventable. Diabetes is the commonest cause of blindness in people aged 30 to 69 years. Twenty years after the onset of diabetes, almost all patients with type 1 diabetes and over 60% of patients with type 2 diabetes will have some degree of retinopathy. Even at the time of diagnosis of type 2 diabetes, about a quarter of patients have established background retinopathy. Treatment can now prevent blindness in the majority of cases, so it is essential to identify patients with retinopathy before their vision is affected.

This report looks at Factors that increase the risk of developing cardiovascular heart disease (CHD) in diabetic patients. Diabetic patients, particularly those with type 2 diabetes or proteinuria, are at considerable risk of excessive morbidity and mortality from cardiovascular, cerebrovascular, and peripheral vascular disease leading to myocardial infarction, strokes, and amputations. Much effort must be given to reducing the risk factors that predispose to major atheromatous arterial disease. The many available measures add to the complexity of treating diabetic patients, especially those with type 2 diabetes.

OBJECTIVE B-cells expressing CD5 are associated with the production of autoantibodies and are present at increased levels in several autoimmune diseases. The aim of this study was to investigate the relationship of these cells to the development of type I diabetes and the presence of organ and non-organ-specific autoantibodies. RESEARCH DESIGN AND METHODS We measured percentage levels of CD5+ B-cells in patients with recent-onset (n = 34) and long-standing (n = 21) type I diabetes and in a cohort of 18 identical twins of patients with type I diabetes studied prospectively, 8 of whom became diabetic (prediabetic twins) during the study; the rest remained nondiabetic after at least 7 years and are now unlikely to develop the disease. Forty-seven healthy individuals were studied as control subjects. RESULTS Percentage levels of total B-cells (CD20+) and the proportion expressing CD5 were increased in patients with recent-onset (P < 0.001 for both) but not long-standing type I diabetes compared with control subjects. Percentage levels of CD20+ B-cells were increased in prediabetic twins throughout the prediabetic period (P < 0.05), and there was an increased proportion of CD5-expressing B-cells that failed to reach statistical significance (P = 0.08). Percentage levels of CD20+ B-cells and the proportion expressing CD5 were normal throughout the study in twins remaining nondiabetic. No relationship between percentage levels of CD5+ B-cells and islet cell antibody, thyroid autoantibodies, or non-organ-specific autoantibodies was found. CONCLUSIONS These results show an increase in B-cell percentage levels at the diagnosis of type I diabetes, which is because of an expansion of the CD5+ subset. These changes are also evident in twins throughout the prediabetic period, which suggests that they are related to the processes that lead to diabetes.

Professor John Malins (1915‐92), distinguished Birmingham physician and my mentor during my training years, used to observe that the consultants’ key role is in outpatients. Why? The Royal College of Physicians (RCP), the King’s Fund and the General Medical Council (GMC) are all commendably emphasising the importance of teaching professional behaviour. 1‐3 But can it be taught? It can certainly be learnt, but not really taught 2 ‐ a view to which many would subscribe. Skills in a profession where a doctor needs to be ‘a shaman, a detective, a priest and a friend’, 4 might only be acquired after extensive studies of humanities, ethics, theology, sociology and anthropology, 5 but can in reality probably only be gained by experiencing and observing the behaviour (good or bad) of more senior teachers and mentors. ‘The only real teacher is experience’, Tony Benn suggested at the Hay-on-Wye Literary Festival. The professional skills needed in a consultation must be acquired by clinical experience, argued

A family of Watkins doctors originating in the Northamptonshire town of Towcester included 13 doctors in seven generations during 250 years. In each generation there were between one and four doctors. Three doctors involved themselves actively in innovative yet controversial practises, described in their own writings and publications. Timothy Watkins' (1755–1834) own handwritten lecture notes describe the problems affecting an 18th-century man-midwife, while his accounts book provides insights into his lifestyle. The concept of the waterborne spread of cholera during the 1854 epidemic in Towcester is described by Robert Webb Watkins (1822–1901) during the same year as the observations made by John Snow (1813–58). John Webb Watkins (1833–1903) in his MD thesis (1856) describes his use of chloroform in labour in Towcester during the early 1850s, followed by self-experimentation with chloroform administered to him between 40 and 50 times by Sir James Young Simpson (1811–70) in Edinburgh. Descriptions of the two 19th-century general practitioners offer insights into the exemplary extent of their civic involvement in all walks of local community life, and of their family ties.

The diabetic neuropathic ulcer is typically slow to heal and recurrent. Macrovascular insufficiency is usually excluded as foot pulses are present and ankle:brachial pressure ratios are not decreased. These assessments cannot however exclude more distal vascular disease. Digital pressure measurements enable a reliable assessment of the distal peripheral vascular status to be made. The aim of this study was therefore to use toe pressures to assess the contribution of distal ischaemia in the pathogenesis of the neuropathic ulcer. Sixteen diabetic patients with recurrent neuropathic foot ulceration had their toe pressures compared to 10 neuropathic patients without a history of foot ulceration, 10 diabetic control subjects, and 11 normal subjects. Four non-diabetic patients with neuropathy and foot ulceration were also assessed. All subjects had ankle:brachial pressure indices ≧ 1. Toe pressure was assessed using laser Doppler flowmetry to record the return of skin blood flow. The toe:brachial pressure index (TBI) was then calculated. The diabetic patients with a history of recurrent neuropathic ulceration, had the lowest mean TBI, 0.63 ± 0.14 (SD), compared to the non-ulcerated diabetic neuropathy patients, the diabetic control subjects, and the normal subjects. 0.84 ± 0.11, 0.82 ± 0.1, and 0.81 ± 0.07, p < 0.01, respectively. Three of the four non-diabetic patients with neuropathic foot ulceration also had an abnormally low TBI. Reduced toe pressure measurements are thus found to be associated with neuropathic foot ulceration. The contribution of distal ischaemia in the pathogenesis of the diabetic neuropathic foot ulcer needs to be evaluated. One hundred and eight non-insulin-dependent diabetic patients who had been tested for autonomic dysfunction in 1984/85 were re-evaluated 5 years later. Autonomic function was assessed by means of four cardiovascular tests (heart rate variation during deep breathing and standing, and blood pressure variation after standing and sustained handgrip). Eighteen subjects were lost to follow-up; in the 90 patients who completed the study, both the deep breathing and the handgrip test significantly worsened (respectively from 13.7 ± 7.8 to 11.6 ± 6.3 beats min−1p < 0.01, and from 16.9 ± 8.2 to 12.7 ± 7.1 mmHg, p < 0.001), whereas both the 30:15 ratio and the variation of blood pressure on standing did not change. The impairment of a comprehensive evaluation score (from 2.5 ± 1.7 to 3.0 ± 1.5; p < 0.05) also confirmed the gradual deterioration of autonomic function over the study period.

Postural hypotension (PH) is a feature of autonomic failure that may result from various causes and can be very difficult to treat. Recently, we and others (1, 2, 3) have shown that some patients with severe symptomatic autonomic neuropathy from type 1 diabetes (type 1 DAN) have a normocytic anemia associated with erythropoietin (EPO) deficiency. The treatment of these patients with EPO rapidly corrects their anemia (1) and improves their overall well-being. Preliminary observations by Hoeldtke et al. (3) of the effect of a maximum of 9 weeks of EPO treatment on blood pressure (BP) demonstrated a positive response in four cases of PH in type 1 DAN patients, but evaluation of BP was limited to only two to three readings before and after EPO treatment. These results stimulated the present study, in which we investigated the effect of EPO treatment for 3 months on supine and standing BP in four anemic EPO-deficient type 1 DAN patients. The patients were treated with recombinant human EPO (25 IU/kg s.c. thrice weekly). All four patients were women (48, 41, 30, and 30 years of age with a duration of diabetes of 13, 24, 19, and 11 years, respectively) and each had normocytic anemia with inappropriately low serum EPO levels. The known causes of anemia were excluded. All of the patients included in the study had pronounced symptomatic PH and at least one other symptom of autonomic neuropathy. …

Diabetes: the biography By Robert Tattersall. Oxford University Press, Oxford 2009. 229pp. £12.99 Diabetes is an ancient disease, yet any understanding of its cause has evolved only since the late 19th century, while its treatment and that of its complications belongs exclusively to the 20th

The determination of low levels of rare-earth elements (REE), Y, Sc and Hf in geological samples has been achieved using minor modifications to established ion-exchange procedures with subsequent analysis by inductively coupled plasma-atomic emission spectrometry (ICP-AES). A lithium metaborate fusion followed by dissolution in dilute hydrochloric acid was used to ensure complete sample decomposition. Sample solutions were loaded onto columns containing AG 50 W-X 8 ® cation-exchange resin, and unwanted elements were removed using elution with 1.75 M HCI followed by 1.75 M HNO 3 . Almost all potentially interfering elements were eliminated using this procedure (only Ba and Zr remaining), and residual inter-element interferences were easily corrected. By adding a small amount of oxalic acid to the 6 M HNO 3 eluant the Hf present in the sample was eluted with the REE, Y and Sc. Analytical data obtained by ICP-AES were judged to be sufficiently accurate and precise (± 5%) for most geochemical applications. Measured detection limits for Y, Sc and Hf were respectively 0.2, 0.1 and 0.2 μg g −1 in samples.

A 35-year-old Type 1 diabetic man with severe disabling postural hypotension was studied for physiological abnormalities, precipitating factors, and effect of current treatment. A 24-h blood pressure profile indicated a diurnal variation in systolic blood pressure with the lowest values recorded between 0100 and 0600 h, during which the patient often lost consciousness on standing (mean standing systolic pressure 78 mmHg at night vs 105 mmHg in the afternoon, p less than 0.001). Food induced a profound fall in systolic pressure, both while supine and while standing erect. The systolic pressure fall during euglycaemia was 49 mmHg vs 3 mmHg during hypoglycaemia. Plasma noradrenaline and adrenaline levels were low during euglycaemia, but increased during hypoglycaemia. Therapeutic manoeuvres aimed at increasing heart rate (by atrial tachypacing) and reducing the peripheral pooling of blood (vasoconstricting drugs and gravity suit), together with the somatostatin analogue octreotide, proved ineffective. These observations demonstrate the phenomenon of post-prandial exacerbation of postural hypotension in a Type 1 diabetic patient, and indicate that despite failure of conventional methods of treatment, hypoglycaemia increased plasma catecholamines and was effective in abolishing the blood pressure fall on standing.

1. The diabetic neuropathic foot exhibits excess arteriovenous anastomotic shunt flow due to a reduced sympathetic vasoconstrictor tone. Local axon reflexes (mediating postural vasoconstriction, for example) are preserved even in severe diabetic neuropathy. This excess shunt flow and its local neurogenic control may be important in the development of complications of the neuropathic limb. 2. The response of arteriovenous anastomoses to local heating was assessed in 13 diabetic patients with neuropathy (12 insulin-dependent), 10 diabetic control patients (seven insulin-dependent) and 10 normal control subjects. The aim was to study the local reflex control of arteriovenous flow when central sympathetic tone had been largely removed. 3. The change in skin blood flow on local heating to 44°C was measured by using a laser Doppler flowmeter in standard environmental conditions with the foot at heart level. Two sites were assessed: (i) the plantar surface of the great toe (a site in which skin blood flow is dominated by arteriovenous shunt flow) and (ii) the dorsum of the foot (a site without anastomotic flow). 4. It was found that when heat was applied to the plantar surface of the great toe in the diabetic patients with neuropathy a paradoxical decrease in flow through arteriovenous anastomoses occurred, flow declining to 65% (P < 0.05) of its resting value. This could be compared with an increase in flow over the same time period of 262% and 228% (P < 0.01) in diabetic control patients and normal subjects, respectively. When the foot dorsum was heated flow increased in a similar fashion in all patient groups, and a decline in flow was not observed. 5. Peak flow at the great toe was significantly lower in the diabetic patients with neuropathy compared with both the diabetic control patients and the normal subjects [23.68 (44.64) flow units versus 57.0 (43.92) flow units and 76.32 (40.88) flow units, respectively, medians and interquartile ranges, P < 0.02]. 6. Thus we have demonstrated that in the presence of neuropathy local heating of the toe pulp may produce (i) a paradoxical fall in skin blood flow and (ii) a greatly reduced peak skin blood flow. The importance of this abnormal vascular control in the pathogenesis of complications of the neuropathic limb has now to be determined.

The ankle/brachial index (abPI) may be falsely raised, notably in diabetes, due to the relative incompressibility of the tibial artery. This paper presents a method of determining tibial artery compressibility by deriving abPIs with the patient supine and with legs raised in increments up to 0.55 m (ankle to heart). The effective negative hydrostatic pressure superimposed on the blood pressure at the ankle was converted to mmHg, normalised with respect to the brachial systolic pressure and then expressed as a hydrostatic pressure index (hPI). abPI was regressed on hPI and the gradient of the regression line calculated. If the arterial wall offers no significant resistance to compression the measured pressure will equal intraluminal pressure. In this case regression of the changing arterial pressure with the applied hydrostatic pressure would be expected to produce a gradient of -1. With resistance to compression the measured pressure is greater than the intraluminal pressure and a steeper gradient would be expected. The method was tested using age and sex matched groups, (A) controls (16 arteries), (B) patients with PVD and no diabetes (17 arteries), and (C) diabetics with PVD (34 arteries). There was no significant difference between the regression line gradients of groups A and B but both differ significantly from group C. The difference between the medians of groups B and C was 0.46, the 95% confidence interval for the difference being 0.66 to 0.02. Twelve of the diabetic arteries had a gradient steeper than -1.8 compared with one from group (B) and none from group (C).(ABSTRACT TRUNCATED AT 250 WORDS)

We highlight 3 recent studies concerning pregnancy and diabetes and ways to potentially reduce health risks of both mother and child.

Meta-analyses show that psychotherapy and complementary and alternative medicine (CAM) are effective primarily or entirely due to contextual factors rather than the specific disease-treating factors suggested by the therapy. Therapists are the most important contextual factor. Psychotherapy research shows that therapist effectiveness varies from zero to about 80%, but has failed to identify what makes a good (ie charismatic) therapist. Therapist effects are unrelated to experience or training or type of therapy. The conclusion that CAM and psychotherapy are effective due to the human effect leads to more questions than it answers. We do not know what charismatic therapists communicate to patients, we do not know the mechanism of communication, and we do not know how this communication influences the patient therapeutically. The therapist matters, but how or why we do not know. We need a better understanding of therapist effects, in psychotherapy, in CAM and also amongst physicians.