Weakness in pregnancy - expect the unexpected

Guillain-Barré syndrome (GBS) is rare in pregnancy with an incidence estimated to be between 1.2 and 1.9 cases per 100,000 people annually, and it is generally accepted that it carries a high maternal risk. Delayed diagnosis is common because the initial non-specific symptoms may mimic changes in pregnancy. GBS should be considered in any pregnant patient complaining of muscle weakness, general malaise, tingling of the fingers and respiratory discomfort. This case aims to highlight the importance of early diagnosis, allowing prompt initiation of the immunomodulatory treatments which have been shown to improve outcome alongside multidisciplinary care.

Effectiveness of rehabilitation intervention in persons with multiple sclerosis: a randomised controlled trial

OBJECTIVE

A stratified, randomised, waitlist controlled study over 12 months assessed the effectiveness of rehabilitation in persons with multiple sclerosis (MS) in an Australian community cohort.

METHODS

Patients with definite MS (n = 101) recruited from a tertiary hospital database, randomised to a treatment group (n = 49) for individualised rehabilitation programme or a control waitlist group (n = 52). Functional Independence Measure (FIM) was used to assess "activity" while the Multiple Sclerosis Impact Scale (MSIS-29) and General Health Questionnaire (GHQ-28) assessed "participation" and quality of life (QoL). Assessments were at baseline and 12 months.

RESULTS

Analysis of data from 98 patients (treatment n = 48, control n = 50) showed reduced disability in the treatment group, with statistically significant differences in post-treatment FIM motor scores for the two groups (p<0.001). There was a clinical and statistically significant improvement in FIM (motor) total scores (p<0.001), and the FIM motor domains of: transfer (p<0.001), locomotion (p<0.001), self-care (p<0.001) and the FIM cognitive subscale (p<0.016). In the treated group, 70.8% improved compared with 13% of controls. Significantly more patients in the control group deteriorated over the study period (58.7% vs 16.7%; p<0.001). There were no differences between the control and treatment group scores on the MSIS-physical (p = 0.18), MSIS-psychological (p = 0.45) or GHQ subscales.

CONCLUSION

An individualised rehabilitation programme reduces disability in persons with MS compared with no intervention. The impact of rehabilitation on QoL needs further evaluation. More information on the effectiveness of the various components of the multidisciplinary rehabilitation programmes are now needed. Australian clinical trials registry: Trials registration number: ACTRNO12605000676617.

Hypoxis hemerocallidea--not merely a cure for benign prostate hyperplasia

The use of Hypoxis hemerocallidea Fisch. and C.A. Mey. (Hypoxidaceae) extracts for ailments other than benign prostate hyperplasia (BPH) is now a reality. The whole extract, the phytosterols, as well as the major constituents it contains (hypoxoside, and its active derivative rooperol) are now finding new applications in the area of anti-oxidants, anti-inflammatories, anti-diabetics, anti-convulsants, inhibitors of drug marker substances and new evidence is presented of activity against cancerous and premalignant cancer cells. In addition, the over-the-counter (OTC) trade has undergone enormous expansion.

Influence of compression pressure from the hand access device on hand microcirculation during hand-assisted laparoscopic surgery

BACKGROUND

Hand access devices in hand-assisted laparoscopic surgery depend on compression pressure to prevent air leakage. Surgeons frequently experience hand ache during surgery. This study aimed to test whether the pressure with such a device affects the microvascular function of the hand.

METHODS

Eight healthy volunteers participated in this experimental study. The hand access device, applied to the forearm, was inflated to 0, 8, 12, and 16 mmHg in a random order, and the microvascular activity of the skin of the hand dorsum was quantified using laser Doppler and iontophoresis of increasing doses of acetylcholine (endothelial-dependent vasodilator) and sodium nitroprusside (endothelial-independent vasodilator). The end point was skin erythrocyte flux ratio as a measure of microvascular skin activity.

RESULTS

No significant differences in microvascular responses to iontophoresis of acetylcholine and sodium nitroprusside were found at the four doses used when the hand access device was inflated at different pressures. The peak values for the hand allocated to acetylcholine were 3.48 +/- 1.33, 3.42 +/- 2.33, 3.38 +/- 2.55, and 2.84 +/- 3.10 arbitrary units, and the peak values for the hand allocated to sodium nitroprusside were 2.79 +/- 1.60, 2.00 +/- 1.60, 2.30 +/- 1.50, and 2.40 +/- 1.62 arbitrary units at cuff pressures of 0, 8, 12, and 16 mmHg, respectively.

CONCLUSION

The pressure in the hand access device up to 16 mmHg does not affect the hand cutaneous microcirculation.

Improvement in systemic endothelial condition following amputation in patients with critical limb ischemia

AIM

Most patients with critical limb ischemia (CLI) have co-existing coronary heart disease, which is the main cause of their increased mortality. Peripheral ischemic tissue produces circulating toxic molecules, which may worsen endothelial function systemically and contribute to the general atherosclerotic process within the body. We looked at whether markers of endothelial function improve after amputation of the ischemic limb, when this potential source of toxins has been removed.

METHODS

We measured blood levels of vascular endothelial growth factor (VEGF), homocysteine, endothelin-1, vascular cell adhesion molecule-1, E-selectin, thrombomodulin and von Willebrand factor (vWF) in 40 patients with CLI. We also assessed peripheral microvascular function in forearm skin by measuring responses to iontophoresis of acetylcholine and sodium nitroprusside. The measurements were repeated 6 months after amputation.

RESULTS

We found abnormally high levels of endothelial products in the patients, and 6 months later VEGF and vWF had both reduced significantly from previous values (by 70% and 40%, respectively; P<0.01 in both cases).

CONCLUSION

Improvements in these two markers after amputation are consistent with the hypothesis that peripheral ischemic tissue has a systemic effect on the vascular endothelium and may contribute to the progression of coronary heart disease in patients with CLI.

Surgical treatment of chondrosarcoma of the sternum

Purpose: We reviewed all tumours of the sternum referred to The London Bone and Soft Tissue Tumour Service between 1956 and 1997 inclusive.

Patients and results: There were eight patients with this pathology, the male to female ratio was 3:1 and their mean age was 53 years. Of these patients, three are alive and disease free, one is alive with recurrence, and four have died, two of the consequences of the disease and two of unrelated causes. Surgery is the principal treatment of these tumours both for excision and subsequent reconstruction.

Discussion: Extended disease-free survival is possible with correct diagnosis, complete excision at the first operation, appropriate skeletal reconstruction, adequate skin cover and appropriate postoperative support and follow-up.

Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury

BACKGROUND

A single serum creatinine measurement cannot distinguish acute kidney injury from chronic kidney disease or prerenal azotemia.

OBJECTIVE

To test the sensitivity and specificity of a single measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL) and other urinary proteins to detect acute kidney injury in a spectrum of patients.

DESIGN

Prospective cohort study.

SETTING

Emergency department of Columbia University Medical Center, New York, New York.

PARTICIPANTS

635 patients admitted to the hospital with acute kidney injury, prerenal azotemia, chronic kidney disease, or normal kidney function.

MEASUREMENTS

Diagnosis of acute kidney injury was based on the RIFLE (risk, injury, failure, loss, and end-stage) criteria and assigned by researchers who were blinded to experimental measurements. Urinary NGAL was measured by immunoblot, N-acetyl-beta-d-glucosaminidase (NAG) by enzyme measurement, alpha1-microglobulin and alpha(1)-acid glycoprotein by immunonephelometry, and serum creatinine by Jaffe kinetic reaction. Experimental measurements were not available to treating physicians.

RESULTS

Patients with acute kidney injury had a significantly elevated mean urinary NGAL level compared with the other kidney function groups (416 microg/g creatinine [SD, 387]; P = 0.001). At a cutoff value of 130 microg/g creatinine, sensitivity and specificity of NGAL for detecting acute injury were 0.900 (95% CI, 0.73 to 0.98) and 0.995 (CI, 0.990 to 1.00), respectively, and positive and negative likelihood ratios were 181.5 (CI, 58.33 to 564.71) and 0.10 (CI, 0.03 to 0.29); these values were superior to those for NAG, alpha1-microglobulin, alpha1-acid glycoprotein, fractional excretion of sodium, and serum creatinine. In multiple logistic regression, urinary NGAL level was highly predictive of clinical outcomes, including nephrology consultation, dialysis, and admission to the intensive care unit (odds ratio, 24.71 [CI, 7.69 to 79.42]).

LIMITATIONS

All patients came from a single center. Few kidney biopsies were performed.

CONCLUSION

A single measurement of urinary NGAL helps to distinguish acute injury from normal function, prerenal azotemia, and chronic kidney disease and predicts poor inpatient outcomes.

Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy

BACKGROUND

Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement.

OBJECTIVES

To assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or knee joint replacement for chronic arthropathy.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL up to September 2006.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared organised multidisciplinary rehabilitation with routine services following hip or knee replacement, and included outcome measures of activity and participation in accordance with the International Classification of Functioning, Health and Disability (ICF).

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed methodological quality of included trials.

MAIN RESULTS

Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only.

AUTHORS' CONCLUSIONS

Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.

Intensive insulin therapy improves endothelial function and microvascular reactivity in young people with type 1 diabetes

AIMS/HYPOTHESIS

Macrovascular disease is an important cause of the increased morbidity and mortality rates associated with type 1 diabetes, and this vascular impairment begins in childhood. The aim of this study was to determine whether introducing intensive diabetes management [intensive insulin therapy (IIT) and 'Sweet Talk' text-messaging support] produces measurable improvements in endothelial function.

METHODS

One hundred and twenty-six patients fulfilled the eligibility criteria (type 1 diabetes for >1 year; on conventional insulin therapy (CIT); aged between 8 and 18 years), of whom 92 enrolled. Patients were randomised to group 1, CIT only (n=28); group 2, CIT and Sweet Talk (n=33); or group 3, IIT and Sweet Talk (n=31). Vascular assessments (including measures of endothelial damage, activation, dysfunction and oxidative stress) and HbA1c were performed at baseline and repeated after 12 months of the study.

RESULTS

Glycaemic control deteriorated in patients on CIT, but improved significantly in patients allocated to IIT (p=0.007). IIT was associated with significantly greater improvements in E-selectin (p<0.0001) than CIT (group 1, p=0.026 and group 2, p=0.053). Vascular responses to acetylcholine improved in patients on IIT (p=0.017), but not in patients receiving CIT. These changes were all independent of HbA1c level.

CONCLUSIONS/INTERPRETATION

IIT appears to be associated with improvements in vascular markers, independently of changes in HbA1c, suggesting that IIT may confer vascular protection in addition to improving glycaemic control.

New steroidal anti-inflammatory antedrugs: 21-thioalkylether derivatives of methyl 16-prednisolone carboxylates

Antedrug approach of the corticosteroids has been described as a fundamentally sound approach for the development of safer anti-inflammatory steroids devoid of systemic side effects. In our continued efforts under the antedrug paradigm, we have recently extended this effort to synthesize the 21-thioalkylether derivatives of methyl 16-prednisolonecarboxylates. The 21-mesylate of the methyl-16-perdnisolonecarboxylates and 9-fluoro-17-dehydro methyl 16-prednisolonecarboxylate were reacted with Na-thioalkoxides to furnish the desired thioalkylethers in 60-75% yields. These newly synthesized thioalkylether steroid series were tested for their in vitro metabolism and corticosteroid receptor binding affinity. They were metabolized in predictable manner to inactive 16-carboxylic acids. All the newly synthesized antedrugs showed lowered glucocorticoid receptor binding affinity than prednisolone indicating that the replacement of the 21-OH function with thioalkylether of the 16-prednisolone carboxylate esters decreases their receptor binding affinity.

Hereditary angioedema and pregnancy

Hereditary Angioedema is a rare but potentially life threatening condition. It is important that Obstetricians are aware of this condition as it affects women in the reproductive years and thus its recognition and proper management in pregnancy is crucial.

Human genetic variation studies and HLA class II loci

Human leucocyte antigen (HLA) loci widely known for their role in generation of immune responses by encoding cell-surface heterodimers are often considered to be effective for the purpose of reconstructing human phylogenies due to high degree of polymorphism and less recombination. In the present study, we have made an attempt to study HLA class II loci (DRB1, DQA1 and DQB1) in inferring phylogenetic relationship based on both phylogenetic and haplotype approach. In the phylogenetic approach, the compiled database of 19 populations got segregated and finely resolved in three basal clusters with very high bootstrap values corresponding to four geo-ethnic groups of Africans, Orientals, Americans and Caucasians. Maximum- likelihood phylogram has placed North Indian Hindus alongside other Caucasian populations. Haplotype analysis revealed high range of haplotype diversity with nearly 144 observed haplotypes. The haplotype distribution suggested that numbers of Caucasian-specific haplotypes are frequently found among north Indian Hindus. Our results indicate that if the property of less recombination is explored to assign extended haplotypes, followed by strong interpretation based on more logistic statistical model, then there is a high possibility that HLA class II loci can infer exact and accurate phylogenetic assessments as revealed by mtDNA and Y-chromosome markers.

Androgen receptor (AR) level in the prostatectomy specimen predicts time to disease progression post androgen suppression therapy

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Background: The androgen receptor (AR) plays an important role in the initiation and growth of prostate cancer and its subsequent response to hormone therapy. Previous analyses, including our own, have determined that elevated AR protein in the prostatectomy specimen is associated with progression of disease. We hypothesized that AR levels may also be predictive of response to androgen deprivation therapy (ADT) by evaluating time to castrate rise in PSA in patients treated with ADT at the time of a biochemical recurrence. By utilizing quantitative immunofluorescence (IF) and spectral imaging we evaluated AR content as an independent predictor of therapeutic outcome. Methods: 63 of 881 patients treated by radical prostatectomy had received ADT for a biochemical rise in PSA and or clinical progression of their disease. 32 of 63 patients had progressed post-ADT with a castrate rise in PSA. Tissue microarrays with triplicate patient cores were stained with a multiplex immunofluorescent assay (IF) which contained the nuclear marker DAPI, along with the following antibodies: Androgen Receptor (AR), Racemase (AMACR), CK18, HMWK and p63. IF images were acquired with spectral un-mixing employed to develop antibody-cell-specific gray scale images. Utilizing image analysis algorithms, quantitative features including intensity and area for selected antigens was generated. Results: Eleven IF antigen features were evaluated after feature selection and filtering using the concordance index with respect to outcome. A total of 5 features were statistically significant for predicting time to progression post therapy of which 2 features (AR intensity within AMACR (+) and (-) epithelial cells; p=0.0003 and p=0.0021, respectively) demonstrated that elevated levels of AR were associated with a shortened time to castrate rise in PSA post ADT. Clinical features alone were not found to be statistically significant with respect to predicting outcome. Conclusions: AR levels in the prostatectomy sample appears to be a useful indicator for determining therapeutic ADT response and potentially guiding future treatment decision and patient monitoring.

No significant financial relationships to disclose.