No abstract

One hundred and eighty-seven diabetic and 105 control subjects collected timed overnight urine samples to measure the inter-individual variation in creatinine excretion rate and its determinants, and to test the relationship between albumin excretion rate (AER) and two 'surrogate measures', the albumin concentration and albumin:creatinine ratio. Creatinine excretion was 55% higher in men than women (geometric mean 8.9 mumol min-1 (95% confidence limits 4.7-17.0) compared with 5.7 (3.0-10.9); p < 0.001). Gender accounted for 31% of the variation in creatinine excretion and body mass index 1.4%; neither age nor the diabetic state had a significant effect. The relationships between AER and the two surrogate measures differed between diabetic subjects and controls such that relationships constructed from non-diabetic data would not hold true for diabetes. Likewise, the relationship between AER and albumin:creatinine ratio differed between men and women such that a ratio of 4.0 mg mmol-1 corresponded to a predicted AER of 35 micrograms min-1 in men and 23 micrograms min-1 in women. The albumin:creatinine ratio outperformed albumin concentration in terms of sensitivity and specificity and its performance was better in women than men. We conclude that the albumin:creatinine ratio is a better surrogate for AER than albumin concentration. If 'action levels' are to be defined for screening programmes, they should be derived from diabetic and not non-diabetic data and should be different in men and women. We propose a direct rather than screening role for the albumin:creatinine ratio in the management of diabetic nephropathy.

Between 1969 and 1976, 317 adults were admitted to hospital in Nottingham with severely uncontrolled diabetes (plasma glucose over 33 mmol/l and/or venous bicarbonate less than 14 mmol/l). A third of episodes were in patients over the age of 50 years, of which 43% were fatal. In contrast, only 3.4% of episodes in patients under 50 years were fatal. In the older group, 65% of deaths occurred within 48 h of admission and in 44% no cause was found other than uncontrolled diabetes. Later deaths were due to underlying disease, infection or thromboembolism. Amongst older patients 38% were not previously known to have diabetes. Presentation to hospital was late and we conclude that many deaths were potentially avoidable by earlier detection in the community.

The University of Manchester Medical School has adopted problem-based learning as its main educational method, with a change of emphasis from a biomedical to a biopsychosocial approach. The training of junior medical students in clinical interviewing is intended to reinforce and develop their interpersonal skills. We measured the impact of this new curriculum by assessing two intakes of students covering the period before and after its introduction; a third intake was later added to examine the effect of further curriculum adjustments. 86 students, randomly selected, were videorecorded conducting diagnostic interviews with standardized patients 10 weeks after they had started to learn clinical interviewing. Two instruments were developed--a 23-item communication skills scale and a 13-item information-gathering scale and both showed acceptable inter-rater and test-retest reliability. Communication skills did not differ between years. The total score for information-gathering fell by 13% (95% confidence interval -20 to -6%, P < 0.001) in the first year after introduction of the new educational approach but returned to baseline the following year after further modification of the course. Although the new approach yielded no measurable improvement in the process of communication, assessment 10 weeks after the start of interview training may be too early to permit definitive conclusions. We conclude that it is possible to change to a more patient-centred emphasis in teaching medical interviewing. Some initial loss of information content was rectified by adjustment of the course. Our unfavourable early experience highlights the need to evaluate educational change.