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Background: We evaluated efficacy and associated adhesion formation of an innovative mesh fixation device versus the helical tack device and analyzed two implantation techniques. Methods: Six purpose-bred female hounds were evaluated in this 90-day survival study. Six 4-cm round patches of 1-mm thick DualMesh were fixed to the abdominal wall with either 10 Pro-Tack or 10 Salute constructs in each patch. Zero to 4 additional patches were implanted with only Salute constructs. Results: Adhesion severity scores were significantly higher for middle left abdominal wall sites versus lower right and upper left sites. The adhesion dissection score was higher for group T (Pro-Tack) versus group S (Salute). Conclusion: No significant effects occurred with adhesion extent scores, but group T developed denser adhesions. The second analysis determined that no significant differences existed relevant to secondary Salute placement, although the total score approached significance (p < 0.09). Salute equipment was easier to handle and allowed repositioning of the patch during operation.

Background: Many prosthetic materials are used in incisional hernia repair, including polypropylene (PP) and expanded polytetrafluoroethylene (ePTFE). However, PP forms severe adhesions and ePTFE has raised concerns about the adequacy of tissue attachment. Methods: The early tissue attachment strength of PP and two new forms of ePTFE (DLM and DLMC) was compared in a rabbit model (n = 12) in which disks of the three meshes (n = 8 of each material) were implanted against the abdominal wall for 3 days. Results: Tensiometer testing found that DLMC mesh had significantly greater attachment strength than PP (p = 0.02). Histologic studies indicated that this was due to cellular ingrowth. Tissue adhesions were observed with all eight PP disks, one DLMC disk, and none of the DLM disks. Conclusion: Modified forms of ePTFE mesh may provide abdominal wall repairs that are as strong or stronger than those obtained with PP, with early tissue attachment and without adhesions.

In order to assess the completeness of clinical clerking, a retrospective study was made of the medical notes of 194 patients admitted with acute stroke over a 1-year period. The noting of clinical features associated with disease severity and prognosis, such as level of consciousness, proprioception, neglect, mental test score and continence was assessed. These features were rarely noted. Factors likely to influence placement following recovery were also poorly reported. In order to allow an accurate guide to stroke severity and prognosis these factors must be noted. An alternative form of clinical clerking is suggested in order to improve patient management.

A highly sensitive flavin adenine dinucleotide-3'-phosphate (FADP)-based enzyme amplification cascade has been developed for determining alkaline phosphatase (ALP; EC 3.1.3.1). The cascade detects ALP via the dephosphorylation of the novel substrate FADP to produce the cofactor FAD, which binds stoichiometrically to inactive apo D-amino acid oxidase (D-AAO). The resulting active holo D-AAO oxidizes D-proline to produce hydrogen peroxide, which is quantified by the horseradish peroxidase-mediated conversion of 3,5-dichloro-2-hydroxybenzenesulfonic acid and 4-aminoantipyrine to a colored product. The FADP-based enzyme amplification cascade has been used in a novel releasable linker immunoassay (RELIA) to quantify thyrotropin (TSH). In the assay, TSH is first captured onto antibody-coated chromium dioxide particles. After formation of an antibody-TSH sandwich with a dethiobiotinylated second antibody, the complex is reacted with a streptavidin-ALP conjugate. Biotin is then used to release the conjugate into solution, and ALP is quantified in an automated version of the FADP-based amplification cascade on the aca discrete clinical analyzer (Du Pont). The sensitivity of the colorimetric RELIA assay for TSH (less than 0.1 milli-int. unit/L) is comparable with that of fluorometric assays. This technology provides a way to adapt to the aca high-sensitivity immunoassays for a wide range of analytes via colorimetric detection.

Transcutaneous blood gas (TCBG) analysis is a noninvasive alternative method of estimation of blood gas tensions. The objective of the study reported here was to validate this method against standard blood gas (STBG) analysis in adult and juvenile Sprague-Dawley rats. We sought to establish the optimal TCBG probe site and temperature, to establish probe temperatures that would not cause thermal burns, to evaluate correlations between blood gas values (PaCO2 and PaO2) determined by use of TCBG and STBG, and to evaluate the sensitivity of the TCBG unit to changes in arterial blood gas partial pressures. Our results indicated that: in general, the xyphoid area was the optimal site for probe placement, with 44.5 degrees C being the optimal probe temperature for the highest correlation, but thermal burns may be a problem; probe temperatures of 42.5 degrees C (adults) and 42.0 degrees C (juveniles) do not cause thermal burns when left in place for three hours; probe temperatures of 44 degrees C (adults) and 42 degrees C (juveniles) resulted in moderate correlation between PaCO2 and PtcCO2; and the TCBG unit adequately responded to changes in arterial blood gas partial pressures. Neither PtcCO2 or PtcO2 reflect actual values of PaCO2 or PaO2, respectively. We concluded that TCBG analysis may be used as an indicator of change in PaCO2 with sufficient animal numbers under tightly controlled conditions, but not as an indicator of change in PaO2 in adult and juvenile rats.

Many prosthetic materials are used in incisional hernia repair, including polypropylene (PP) and expanded polytetrafluoroethylene (ePTFE). However, PP forms severe adhesions and ePTFE has raised concerns about the adequacy of tissue attachment.The early tissue attachment strength of PP and two new forms of ePTFE (DLM and DLMC) was compared in a rabbit model (n = 12) in which disks of the three meshes (n = 8 of each material) were implanted against the abdominal wall for 3 days.Tensiometer testing found that DLMC mesh had significantly greater attachment strength than PP (p = 0.02). Histologic studies indicated that this was due to cellular ingrowth. Tissue adhesions were observed with all eight PP disks, one DLMC disk, and none of the DLM disks.Modified forms of ePTFE mesh may provide abdominal wall repairs that are as strong or stronger than those obtained with PP, with early tissue attachment and without adhesions.

With the increasing number of older people, the cost of providing institutional care has become a major issue. In 1993 the introduction of care management and a needs-led approach aimed to remove the existing 'perverse incentive' to institutional care and to ensure equality in the dependency levels of those who were admitted to care. To test this consistency, we examined the dependency levels of all persons agedor = 65 years admitted to residential and nursing homes in two adjacent Health and Social Services (HSS) Community Trusts in Belfast, Northern Ireland, in the year following the introduction of care management. We measured differences between the Trusts with respect to number of admissions, levels of dependency as determined by several standard scoring systems, financial support, source of admission and demographic information. A total of 389 people were surveyed. Trust A had significantly higher levels of physical dependency and mental impairment in both residential and nursing homes than Trust B. We also identified differences in dependency with respect to funding status, with those who were self-funding in Trust B having lower physical dependency in residential and nursing homes and less mental impairment in nursing homes than supplemented residents. This study reports the existence of variations between adjacent Community Trusts operating under the same policy guidelines with respect to the dependency levels of admissions to residential and nursing care. These differences may relate to number of places available, the economic status of the population, and the assessment procedures of the two Community Trusts. The need for standard assessment and eligibility criteria is highlighted.

Small differences in levels of certain haemostatic components may be clinically significant. It is important therefore to eliminate potential sources of confounding variability. This study investigated the effect of removing tourniquet pressure prior to sample collection on plasma fibrinogen levels, platelet P-selectin and monocyte tissue factor expression. Blood was collected from the right arm under maintained tourniquet pressure and from the left arm following the release of pressure once the vein was sufficiently inflated for insertion of a needle. Whole blood was labelled within one hour of venepuncture to allow analysis of platelet P-selectin and monocyte tissue factor by flow cytometry. Plasma fibrinogen levels were analysed in samples stored at -70 degrees C, for all individuals at the end of the study using a method based on the Clauss technique. Intra-individual variability for each of the components was assessed by collecting samples under tourniquet pressure from four individuals on the same day on three consecutive weeks. Intra-individual variations were greater than assay CVs for all three components. There were no significant differences between the two tourniquet methods of collection for fibrinogen, P-selectin or tissue factor. In conclusion, there is no reason not to use a tourniquet during collection of blood for analysis of plasma fibrinogen, platelet P-selectin or monocyte tissue factor.

To investigate sympathetic function in the peripheries of patients on chronic ambulatory peritoneal dialysis (CAPD) using noninvasive techniques.Comparison of peripheral blood flow responses in sympathetic vasoconstrictor reflexes in CAPD patients and matched control subjects.Tertiary care hospital and research institution.Twenty-three clinically stable CAPD patients and 23 control subjects matched for age, sex, and drug therapy.Sympathetic activity assessed from the reductions in hand and foot blood flow induced by a deep breath and by body surface cooling. Cardiac autonomic activity measured by the changes in heart rate produced by deep breathing, a Valsalva maneuver, and standing from lying.A deep breath induced mean decreases in hand blood flow of 65.1% in the patients and 82.8% in their matched controls. Corresponding reductions in the foot were 46.0% and 70.0%. Body surface cooling reduced mean hand blood flow by 50.3% in the patients and 71.8% in the control subjects. Corresponding values in the foot were 26.7% and 43.6%. The differences in response between the patients and their matched control subjects were all significant (p0.01). Cardiac autonomic function assessed by standard tests of heart rate variability was significantly impaired in the patients compared with the control subjects in two of the three tests used (p0.001).Cardiovascular autonomic impairment can affect the peripheral circulation as well as the heart in patients on dialysis, and this may have implications for cardiovascular homeostasis.

We assessed all patients starting renal replacement therapy during a 1-year period to identify factors influencing 1-year survival in older and younger dialysis patients.Data was collected from 113 patients. Twenty-four possible prognostic factors were introduced into a multivariate, time-based analysis.Hazard ratios, and hence risk of mortality, were increased with increasing alcohol consumption, cardiac dyskinesis, age at onset of dialysis, serum phosphate, number of comorbid illnesses, and Karnofsky score (listed in decreasing order of risk). Risk of death within 1 year was reduced in patients with normal serum albumin and higher Barthel scores at the time of commencing dialysis. No age interactions were found. In the elderly age group the risk of death was also increased if left ventricular dilatation was present. Comorbidity and the age of onset were not independent risk factors in patients aged over 65 years at the time of starting dialysis.All factors listed above increase the 1-year mortality of elderly patients. Factors known to increase medium-term morbidity in dialysis patients including diabetes mellitus, ischaemic heart disease, and hypertension do not appear to be important in the short-term survival of older patient on dialysis.

This paper reports the epidemiology of hospital-diagnosed acute viral hepatitis in U.S. Air Force personnel from 1980-89. First hospitalizations for viral hepatitis generally declined, ranging from 24.6 to 47.2 per 100,000 personnel. Hepatitis rates were higher among men, (RR = 1.3; 95% C.I., 1.1-1.5) and higher among blacks, compared to whites (RR = 1.4; 95% C.I., 1.3-1.6). Analysis of risk associated with various occupations demonstrated an increased risk of viral hepatitis for procedurally oriented medical personnel (physicians, clinical nurses, dentists) when compared to all other occupations (RR = 1.5; 95% C.I., 1.1-1.9). Pilots and navigators demonstrated a decreased risk of acute viral hepatitis. Members hospitalized for hepatitis B had a prior or concurrent diagnosis for sexually transmitted disease in 37% of cases; for drug abuse, 32% of cases. Serum samples from 332 individuals demonstrated that hepatitis A had the highest rate of agreement (84%) between serology and hospital discharge diagnosis. Only 3% of individuals with the diagnosis of NANB hepatitis were positive for hepatitis C.

Alcohol-related morbidity and mortality represent a major public health problem in the United States, particularly among young men. Standardized comparisons of alcohol use have demonstrated that members of the military consume more alcohol than matched civilians. To quantify the impact of alcohol use by active duty members of the Air Force for calendar year 1990, we reviewed 283 death certificates and analyzed the cause of death using the Alcohol-Related Disease Impact (ARDI) computer program. Injuries accounted for 73% of all deaths among active duty Air Force personnel, with motor vehicle accidents (MVAs) accounting for 31% of total mortality. Sixty-six deaths (23%) were attributable to alcohol-related causes and accounted for 2,300 years of potential life lost before 65 years of age. Analysis of blood alcohol levels taken from a subset of active duty deaths resulting from MVAs and suicides yielded alcohol-attributable fractions similar to those obtained by the ARDI method. Periodic assessment and dissemination of alcohol-related mortality statistics in the military using the ARDI methodology represent an important public health education tool.

Hyperglycaemia has been observed after acute stroke, and is associated with a poor prognosis. It is not known whether this is due to the stress response of the acute illness or whether hyperglycaemia is, in itself, harmful to ischaemic nervous tissue. Seventy-one patients admitted to hospital with acute stroke and no history of diabetes or other acute illness were recruited, and fasting blood sampling was carried out within 24 h of symptom onset, for plasma glucose and stress hormones and levels of haemoglobin A1c (HbA1c). Computerized tomography of the brain was carried out on 77% of the subjects. The subjects were followed up for 3 months or until death. Glucose levels were higher in subjects who died during the course of the study (p = 0.025), but this relationship became non-significant after age (p0.001) and cortisol (p = 0.001) levels were taken into account with multivariate analysis. The correlation between serum cortisol and the volume of the lesion on CT scan was also stronger than the relation of glucose with volume. Haemoglobin A1c had no relationship with either mortality or lesion volume. These findings suggest that the hyperglycaemia seen after an acute stroke is secondary to a stress response and they do not support the theory of hyperglycaemia being harmful to ischaemic nervous tissue. These findings have implications for the treatment of acute stroke with hypoglycaemic agents.

We analysed the characteristics of patients aged 75 and over admitted to the geriatric and general medical wards over a three month period in a teaching hospital. Patients admitted to the geriatric wards were slightly older, were more often female, more likely to be admitted during the day and during a week day, more likely to have been seen by their own general practitioner, had more chronic and multiple illness with non-specific presentations, and stayed longer in hospital. Referring doctors seem to discriminate between patients needing geriatric care and those more suitable for general medical care, but there is an overlap in the characteristics of the two groups.

A highly sensitive flavin adenine dinucleotide-3'-phosphate (FADP)-based enzyme amplification cascade has been developed for determining alkaline phosphatase (ALP; EC 3.1.3.1). The cascade detects ALP via the dephosphorylation of the novel substrate FADP to produce the cofactor FAD, which binds stoichiometrically to inactive apo D-amino acid oxidase (D-AAO). The resulting active holo D-AAO oxidizes D-proline to produce hydrogen peroxide, which is quantified by the horseradish peroxidase-mediated conversion of 3,5-dichloro-2-hydroxybenzenesulfonic acid and 4-aminoantipyrine to a colored product. The FADP-based enzyme amplification cascade has been used in a novel releasable linker immunoassay (RELIA) to quantify thyrotropin (TSH). In the assay, TSH is first captured onto antibody-coated chromium dioxide particles. After formation of an antibody-TSH sandwich with a dethiobiotinylated second antibody, the complex is reacted with a streptavidin-ALP conjugate. Biotin is then used to release the conjugate into solution, and ALP is quantified in an automated version of the FADP-based amplification cascade on the aca discrete clinical analyzer (Du Pont). The sensitivity of the colorimetric RELIA assay for TSH (less than 0.1 milli-int. unit/L) is comparable with that of fluorometric assays. This technology provides a way to adapt to the aca high-sensitivity immunoassays for a wide range of analytes via colorimetric detection.

The extent and duration of changes in circulating leukocyte and lymphocyte subpopulations, cortisol, and catecholamines were examined in 12 women who walked 45 min at 60% VO2max in a laboratory setting. A two-factor, 2 x 6 design with repeated measures on both factors was utilized. The first factor was condition (exercise and rest), and the second factor was time (six points of measurement over a 24-h period), with treatment order counterbalanced. The 45-min walk, in comparison with rest in a seated position, was associated with a significant but moderate leukocytosis and lymphocytosis immediately following the walk. The leukocytosis was still evident after 3 h of recovery and was primarily due to a neutrophilia. The change in lymphocyte count, relative to baseline levels and the control condition, lasted less than 1.5 h, with an increase in the natural killer (CD16 and/or CD56) and cytotoxic T cell component (CD3 and CD16 and/or CD56) (NKCT) representing approximately two-thirds of the lymphocytosis and T cells (CD5) the other third. A significant decrease in the CD4:CD8 ratio was seen, with cytotoxic/suppressor (CD8) cells increasing and helper/inducer (CD4) cells demonstrating little change in comparison with baseline. This seems to have been due to a subpopulation of CD8 (low density antigen) cells, probably natural killer cells. The 45-min walk had no effect on plasma cortisol and epinephrine levels relative to the rest condition but was associated with a moderate increase in norepinephrine.(ABSTRACT TRUNCATED AT 250 WORDS)

A survey of dependency levels was carried out in 1985 and 1989 in 41 residents of old peoples homes and 25 patients in geriatric continuing care wards. There was an increase in all levels of dependency for those in both types of care. In the hospital patients surveyed in 1985, mortality was greatest in the most dependent, particularly those with impaired mental function. There was a positive correlation between length of survival and mental function. The results of this study emphasise the important role of dementia in the health and survival of old people.

A number of processes are involved in the pathogenesis of atherosclerosis. These include an "injury" to the endothelial cell barrier of the inner lining of the artery, infiltration of the artery by lipid filled monocyte-macrophages, proliferation of smooth muscle cells, synthesis of connective tissue and thrombus formation. Insulin may be involved in several of these processes. Over 40 years ago it was shown that insulin is necessary for the production of experimental atherosclerosis in cholesterol fed, alloxan diabetic rabbits. Insulin inhibits regression and stimulates formation of lipid containing lesions in a number of species, and can promote lesions in animals fed normal diets. Insulin is also related to lipid metabolism in the artery wall and interacts with blood pressure to stimulate lipid synthesis in arteries. Arterial smooth muscle cells cultured from a number of species including humans proliferate in response to levels of insulin similar to those found in normal human physiology. The proliferative effects of insulin are mediated by the insulin-like growth factor receptor and hence may not be impaired in states of insulin resistance. Insulin also stimulates arterial smooth muscle cell migration. Insulin stimulates cholesterol synthesis in cultured smooth muscle cells and enhances LDL receptor activity in a number of cell types. Insulin stimulates connective tissue synthesis, and promotes clotting.

T relationship of diabetes to cardiovascular disease has been known for over half a century and has been the subject of a number of reviews. The topic was discussed by the author and two colleagues in 1975, and the present paper concentrates on information published since that time. Although it is well known that diabetic patients commonly die from cardiovascular disease and that cardiovascular disease is particularly common in diabetes, a number of questions remain unanswered. It is now clear that diabetes mellitus consists of at least two distinct disorders that differ both genetically and in their metabolic abnormalities. The majority of diabetics have Type II, or noninsulin-dependent, diabetes mellitus (NIDDM), characterized by mild to moderate glucose intolerance, a high frequency of obesity, absence of a tendency to ketoacidosis, and response to treatment with diet or oral antidiabetic drugs. A minority (20%) of diabetics have Type I, or insulin-dependent, diabetes mellitus (IDDM), characterized by marked hyperglycemia, weight loss, and a requirement for insulin therapy to prevent the development of ketoacidosis. The old terms of "juvenile diabetes" for IDDM and "maturity-onset diabetes" for NIDDM are no longer used, as either type of diabetes can occur at any age. The possibility that the two major types of diabetes have different relationships to atherosclerosis remains to be explored. The criteria for the diagnosis of diabetes are clearly arbitrary, although they correlate with clinical and epidemiological data. Assessment of the severity of diabetes is even more arbitrary, while the duration of diabetes can only be measured as the time since diagnosis.

Oral glucose tolerance tests were performed in young and elderly subjects with minimal risk factors for diabetes mellitus. Compared to the normal glucose tolerance in the young there was a 45% rate of impaired tolerance in the elderly. Fasting insulin levels were significantly lower in the elderly but post-glucose insulin responses in the first hour were similar in young and elderly subjects. Peripheral insulin action was assessed in terms of the 125 monoiodoinsulin binding to specific insulin receptor sites on circulating lymphocytes in the young, the elderly and a group of age and sex matched obese maturity-onset diabetics. Specific insulin binding was not significantly different in the elderly than in the young but was significantly lower in the diabetics than the young and the elderly. The results suggest that neither defective insulin binding are major causative factors in the reduced glucose tolerance of the elderly.

A successful feature of the 4th-year curriculum in the Medical Faculty of the Queen's University, Belfast has been the development of interdisciplinary teaching in a three-week joint course to which several clinical departments contribute...Co-ordinated teaching of topics of common interest in small groups included, until the academic year 1987/88, a three-hour session on medical ethics. In the spring of 1987 the authors approached the Department of Philosophy at Queen's; subsequently proposals for a formal multidiscipinary course in medical ethics for 4th-year clinical students in the Medical Faculty, for the academic year 1987/88, were approved by the Education Committee of the Medical Faculty.

Summary In order to provide ‘horizontal’ integration of related clinical subjects, a combined teaching course in community medicine, general practice, geriatric medicine and mental health has been devised. The course lasts 12 weeks and is divided between joint teaching of topics of common interest and clinical clerkships in individual disciplines. A joint assessment takes place at the end of the course. The course was popular with students who all felt that it covered topics not encountered in other parts of the medical curriculum. A course of this type leads to a better integration of clinical subjects and avoids repetition or omission of topics which are not clearly the responsibility of any individual department.

A prospective study of 419 patients aged 70 and over admitted to acute medical wards was carried out by medical staff from a geriatric unit. Data, including presenting problem, housing, social support, mental state, continence, and degree of independence before and after admission, were recorded. Of the 419 patients, 143 remained in hospital after 14 days and 65 after 28 days. The major factors associated with prolonged stay in hospital included advanced age, stroke, confusion and falls as reasons for admission to hospital, incontinence, and loss of independence for everyday activities. Social circumstances did not predict length of stay. Although these factors are interrelated, the most important influence on length of stay was the medical reason for admission. Early contact with the geriatric medical unit in these patients may speed up the recovery or result in more appropriate placement.

Experiments were undertaken to study the role of hyperinsulinism in the pathogenesis of atheroma. Chickens injected with long-acting insulin for 19 weeks developed lipid containing lesions in their aortas. This provides further evidence in favour of the hypothesis that insulin and atheroma are causally related.

Summary The construction of a new teaching course in geriatric medicine is described. Course objectives are established, and teaching arrangements designed to meet these objectives. The course takes place late in the medical curriculum when students have some knowledge of clinical medicine, therapeutics and pathology. Particular features of the course include residential attachments in hospital departments of geriatric medicine and coordinated teaching with the departments of general practice and mental health. The attainments and methods of assessment are then discussed.

Two hundred and six patients with acute stroke admitted consecutively to District General Hospitals, were studied for a period of six months. Significance tests conducted singly detected 21 factors present during the first 48 h of stroke, which were related to outcome six months later in terms of both mortality and functional recovery. Among these significant factors were various measures of perceptual dysfunction, including Albert's Test. Multivariate statistical analysis which included discriminant analysis and linear logistic modelling, revealed six factors (Albert's Test Score, leg function, level of consciousness, arm power, weighted mental score and ECG changes) which were significantly and independently related to outcome. A statistical model based on these factors predicted functional outcome with an overall accuracy of 67 per cent and mortality with an accuracy of 83 per cent. This model provides a useful basis for stratification in future randomized controlled trial in stroke, and may have a role in the management of the individual stroke patient.

Undergraduate teaching at the Queen's University, Belfast, takes place in the fourth year of a five year curriculum. It lasts three weeks and this is divided into two parts. First, held within the university department, is topic-based teaching including seminars, discussions, case histories and visits. The second phase of two weeks consists of attachment of two to four students to geriatric medical units both in and outside Belfast. The whole of this module is situated within a combined course involving community medicine, general practice, geriatric medicine and mental health lasting 12 weeks and involving one-third of the year of 150 students each time. In addition to the three weeks teaching in geriatrics, joint discussion groups are held.

The responses of plasma gastro-entero-pancreatic (GEP) hormones and free fatty acids (FFA) to a standard mixed meal before and after starvation have been measured. Raised insulin, glucose and FFA levels were found following refeeding after starvation and levels of secretin and C-terminal glucagon-like-immunoreactivity (C-GLI), raised by starvation, were rapidly suppressed on refeeding. The responses of gastrin and N-terminal glucagon-like-immunoreactivity (N-GLI) to a standard mixed meal were not altered by starvation. Although this study does not directly support that secretin and glucagon are responsible for the hyperglycaemia or hyperinsulinaemia of starvation diabetes, a role for both hormones in the raised FFA levels is proposed, as well as a role for glucagon in the initial hyperglycaemic response to a meal after starvation.

Two hundred and six patients with acute stroke admitted consecutively to District General Hospitals, were studied for a period of six months. Significance tests conducted singly detected 21 factors present during the first 48 h of stroke, which were related to outcome six months later in terms of both mortality and functional recovery. Among these significant factors were various measures of perceptual dysfunction, including Albert's Test. Multivariate statistical analysis which included discriminant analysis and linear logistic modelling, revealed six factors (Albert's Test Score, leg function, level of consciousness, arm power, weighted mental score and ECG changes) which were significantly and independently related to outcome. A statistical model based on these factors predicted functional outcome with an overall accuracy of 67 per cent and mortality with an accuracy of 83 per cent. This model provides a useful basis for stratification in future randomized controlled trial in stroke, and may have a role in the management of the individual stroke patient.

There is both epidemiological evidence that elevated insulin levels are associated with clinical atherosclerosis and experimental evidence that insulin has actions on the arterial wall which may be relevant to the development of atheromatous lesions. This paper reviews the evidence and puts forward the hypothesis that insulin may have a role in the pathogenesis of atherosclerosis. If this hypothesis is correct, measures to reduce insulin levels, including weigh reduction, exercise and improved methods for treating diabetes, may contribute to the prevention of atherosclerosis.