Hyperglycaemia monitoring and management in stroke care: policy vs. practice

AIM

To evaluate the extent to which hyperglycaemia was monitored and managed among patients admitted to hospital with acute stroke and transient ischaemic attack.

METHODS

We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions, clinical outcome and discharge planning between patients who experienced glucose ≥ 7.8 mmol/l in the first 5 days, and patients with lower glucose results.

RESULTS

The daily prevalence rate of hyperglycaemia > 7.8 mmol/l across the first 5 days ranged from 24 to 34%. A total of 41 (37%) patients experienced hyperglycaemia on at least one occasion during the first 5 days. A history of diabetes mellitus prompted near patient glucose testing, but, among patients without diagnosed diabetes, glycaemia was under-monitored. Hyperglycaemia was a persisting trend, was under-treated and under-reported to general practitioners. Elevated glucose results failed to influence higher rates of fasting plasma glucose tests and BMI assessment.

CONCLUSIONS

There is a need for greater vigilance in the detection of hyperglycaemia and undiagnosed diabetes mellitus among patients admitted to hospital with stroke or transient ischaemic attack.

Cytokines and their inhibitors in orf virus infection

The epitheliotropic parapoxvirus, orf virus, can repeatedly infect sheep skin. A specific immune response is generated as reinfections induce smaller lesions with quicker resolution times than primary lesions. Cyclosporin-A treatment abrogates this partial immunity. Cytokine mRNAs detected in lesion biopsies include the transcripts for IL-1 beta, IL-3 GM-CSF, TNF-alpha and, less reproducibly, IFN-gamma. CD4+ T-cells predominate in afferent lymph draining the site of infection, and are the major source of GM-CSF and IFN-gamma. IL-1 beta and IL-8 are also detected. The orf virus genome contains a homologue of mammalian vascular endothelial growth factor that may enhance virulence and a vaccinia virus E3L-like gene which may inhibit the anti-viral effect of the interferons. A GM-CSF inhibitory activity has also been discovered and has been 'chased' into a 10 kb DNA segment of the orf virus genome. These studies indicate that orf virus may temporarily avoid host immunity by a combination of acute, rapid infection and replication in the epidermis and by producing virulence factors that inhibit protective proteins of the host immune and inflammatory response.

Rapidly destructive hip disease: clinical and imaging abnormalities

The clinical and radiographic records of 23 patients (15 women, eight men) with rapidly destructive hip disease (RDHD) were retrospectively reviewed. Criteria for RDHD included a history of hip pain of 1-6 months duration and the radiographic appearance of a rapidly progressive atrophic form of bone destruction involving both the femoral head and the acetabulum. Radiographs of the remainder of the appendicular skeleton were assessed in 14 patients. The mean patient age was 72 years. The average time from clinical presentation to the appearance of severe hip destruction was 14 months. Five patients demonstrated similar atrophic bone destruction around other articulations. No patients had clinical or laboratory evidence of sepsis or neurologic disease. Although previous reports have suggested that RDHD is degenerative in nature, similar involvement of other articulations suggests that it may represent a focal finding of a more generalized process.

Lymphocyte-synovial cell interactions: a role for beta 1 and beta 3 integrin-mediated adhesion to cellular fibronectin

The interactions of lymphocytes with cultured synovial cells derived from rheumatoid arthritis patients were examined. A number of lymphoid cell lines bound to these cells. The adherence of several of these lines was inhibited by antibodies to fibronectin. The adherence of the T cell leukemia Jurkat was sensitive to inhibition by antibodies to the fibronectin receptors alpha 4 beta 1 and alpha 5 beta 1. The adherence of the beta 1 integrin negative B cell line RPMI 8866 was inhibited by antibodies to the vitronectin receptor, alpha v beta 3. The interactions of several other cell lines with synovial cells appeared to be independent of this fibronectin-dependent pathway. These results indicate that multiple potential adhesion pathways for cellular interactions in the tissues may exist. The adherence to cell-associated fibronectin may play a contributory role in such processes for certain lymphocyte subsets.

Surgical interruption of patellar blood supply by total knee arthroplasty

Arterial blood supply of the patella was demonstrated in 21 cadaver knees by intraarterial injection of radiopaque contrast. When the standard medial parapatellar approach or lateral retinacular release was carried out at a distance of at least 1 cm from the margin of the patella, some steps in total knee arthroplasty caused no impairment and others jeopardized the filling of intraosseous vessels. The radial intraosseous vessels are jeopardized by osteotomy of a deformed patella or excision of fat pad. The prepatellar vessels greatly contribute to intraosseous vascularization and should be carefully preserved.

Continuous passive motion device for hand rehabilitation

Prototypes have been designed and manufactured for a lightweight portable device which continually moves all the joints of the hand passively through a range of motion. Inflatable bag modules in the palm of the hand are ganged together to create the required range of motion. A battery-operated air pump cycles compressed air to the modules. Initial clinical experience with patients who have flexion contractures caused by burns, trauma, and Dupuytren's contractures has shown the device to be well tolerated and effective.

Hip arthroplasty surgery in Manitoba: 1973-1978

A review of all (1279) total hip arthroplasties in the Province of Manitoba, Canada, from 1973 to 1978 demonstrates an increase in the number of operations except in the very elderly. Six-week operative mortality was decreased from 2.4% to .6%, and time spent in the hospital has decreased from 54 to 40 days. Utilization of medical services by patients before and after surgery, as recorded by the Manitoba Health Services Commission, enables identification of all serious postoperative complications. Two years after surgery, 95.2% of patients were alive, and 16% had a contralateral hip arthroplasty. Fourteen patients (2.7%) required revision surgery within two years; 20 patients (4%) were readmitted to the hospital with other surgical complications, including trochanteric bursitis, osteomyelitis, pulmonary embolism, and so forth. Visits to physicians for arthritis-related problems and to chiropractors decreased in the two years after surgery compared with the two years before.

The centralization of operations and access to treatment: total hip replacement in Manitoba

The impact of centralized facilities on access to care was tested by studying total hip arthroplasty in the Province of Manitoba, Canada. Data from the Manitoba Health Services Commission, which insures costs of all medical services in the Province, show that the availability of this surgical procedure has increased steadily over the 1973-78 period at a rate similar to that elsewhere in North America. Although Manitoba's population is geographically dispersed, specialized orthopedic services are concentrated in two urban centers. No important difference in access to care for this condition was found between urban center residents and residents distant from the surgical facilities.

Pathogenesis of Charcot-Marie-Tooth disease. Gait analysis and electrophysiologic, genetic, histopathologic, and enzyme studies in a kinship

Little has been written about the pathogenesis of pes cavus in Charcot-Marie-Tooth disease (CMT). In 12 of 22 patients in a family with known autosomal dominant CMT, a predictable pattern of progression was related to a centrifugal pattern of innervation of the extremity. The gait pattern had greater complexity than the steppage gait. Pelvic shift and elevation on the swing side were used to clear the "drop foot" from the floor. Lateral flexion of the trunk to the opposite direction was used for balance. Previous descriptions of the etiology of pes cavus did not apply to this family. The mode of development of pes cavus in CMT is not known and requires further investigation.

Pathogenesis of pes cavus in Charcot-Marie-Tooth disease

Of 22 persons from a single kinship of known Charcot-Marie-Tooth (CMT) disease, 12 were found to be affected. All 12 had a pes cavus deformity. The insidious atrophy of the intrinsic musculature of the foot progressed to a fixed soft tissue and bony cavus deformity.

Development of a diagnostic checklist for low back pain patients

The study of psychosomatic disorders implies that environmental variables, as well as attitudes and personality, can influence an individual's physical health. The present study developed a checklist composed of demographic and psychological variables to help to make diagnostic decisions related to chronic low-back pain. The need for the checklist stems from the situation that medical clinical evidence is often inconclusive to identify the etiology of patient complaints of low back pain. Cut-off scores on the checklist were able to discriminate with greater than 80% accuracy patients who received a specific medical diagnosis from patients who received a non-specific medical diagnosis. The findings provide additional support for procedures used to make difficult diagnoses of low back pain.