Functional somatic symptoms in youths in general practice: A cross-sectional study on prevalence, clinical management and perceived burden

OBJECTIVE

Functional somatic symptoms (FSS) may progress into a functional disorder if poorly managed, which may have serious implications. This cross-sectional study describes the management of youths compared to adults in general practice and estimates the prevalence of FSS in youths in this setting by comparing consultation-related aspects between youths with FSS and 1) youths with a specific diagnosis and 2) adults with FSS.

METHODS

We used data from a Danish survey (2008-2009), including 3295 face-to-face consultations between GPs and patients aged 15-64 years. Patients were divided into youths (15-24 years) and adults (25-64 years) and then into subgroups according to the GPs' classifications: 1) specific diagnosis, 2) resolving symptom and 3) FSS. Logistic regression analysis was used for all comparisons, and estimates were adjusted for gender, concomitant chronic disorder and GP cluster.

RESULTS

The GPs more frequently ensured continuity of care in adults (AOR:0.75, 95%CI:0.61-0.92, p < 0.01) and perceived youths as less time consuming (AOR:0.58, 95%CI: 0.43-0.77, p < 0.01) and less burdensome (AOR:0.60; 95%CI: 0.45-0.81, p < 0.01) compared to adults. FSS prevalence was 4.4% in youths and 9.0% in adults. However, GPs perceived youths with FSS as more burdensome (AOR:7.77, 95%CI:2.93-20.04, p < 0.01) and more time consuming (AOR:3.98, 95%CI:1.42-11.12, p < 0.01) than youths with a specific diagnosis. No significant differences were found between youths and adults with FSS, respectively, in regards to perceived burden and consultation time.

CONCLUSION

The results indicate age-related variations in the prevalence and clinical management of FSS in general practice. The GPs perceived both youths and adults with FSS time consuming, which underlines a need for supportive management strategies.

A compact filtered x-ray diode array spectrometer for the National Ignition Facility: SENTINEL

Sentinel is a 16-channel, filtered x-ray diode array spectrometer that has been developed to measure ∼1 keV-20 keV x-ray emission generated by the National Ignition Facility (NIF) laser. Unlike the large, fixed-port versions of this diagnostic that currently exist on the NIF (known as Dante), Sentinel is a Diagnostic Instrument Manipulator compatible such that it can be fielded along the polar or equatorial lines-of-sight-an essential new capability for characterizing the often anisotropic x-ray emission from laser-driven sources. We present the diagnostic design along with preliminary diode calibrations and performance results. The novel, small-form-factor x-ray diode design allows for ≳5×-25× increased channel areal density over that of Dante, simultaneously enabling improved diagnostic robustness and fidelity of spectral reconstructions. While the Sentinel diagnostic is anticipated to improve line-of-sight spectral characterization of x-ray sources for a wide variety of programs on the NIF, the compact and portable design is also attractive to small- and mid-scale facilities with limited diagnostic real estate.

Incidence of medically treated depression in Denmark among individuals 15-44 years old: a comprehensive overview based on population registers

OBJECTIVE

Examine the overall incidence of medically treated depression in Denmark among individuals 15-44 years old, and estimate the 5-year cumulative incidence of psychiatric hospital care among individuals treated first in non-hospital-based care.

METHODS

We followed all individuals born in Denmark between 1969 and 1998 from age 15 or 2006 (whichever came first) until first depression treatment; death; emigration; or December 31, 2013. Incidence rates were estimated using Poisson regression. Cumulative incidence of hospital care following treatment in non-hospital care was estimated using Kaplan-Meier curves.

RESULTS

In this sample of 2 014 760 individuals, incidence rates of depression in non-hospital and hospital-based care in 2012-2013 were 6.6 (95% Confidence Interval: 6.5-6.7) per 1000 person-years and 1.5 (95% CI: 1.5-1.6) per 1000 person-years, respectively. Overall, 85-90% of first medical treatment for depression took place outside of psychiatric hospitals, but a quarter (26.3%) of individuals treated for depression received hospital care initially or within 5 years. Incidence of hospital care was higher in women and younger individuals.

CONCLUSIONS

Most medical treatment for depression in Denmark takes place in non-hospital settings. Women and younger individuals are more likely to receive hospital care both initially and within 5 years after first antidepressant treatment.

[A free musculocutaneous flap and an intramedullary nail made the use of a prosthesis possible in a high traumatic femoral amputation]

The length of the stump and the quality of the soft tissue coverage are important for prosthesis fitting and mobility. In a high traumatic femoral amputation soft tissue reconstruction with a free musculocutaneous latissimus dorsi (LD) flap was performed to preserve bone length and provide proper tissue coverage. The extremely short stump was later on lengthened using a motorized intramedullary nail (Fitbone), and the achieved bone-lengthening was 14 cm. With the combined modalities of an LD-flap and Fitbone lengthening of the stump, the patient now has a useful limb function.

[Treatment of reflex dystrophy with continuous peripheral nerve block]

Physiotherapy is an important part of the treatment of reflex dystrophy or Complex Regional Pain Syndrome (CRPS)-type I, but this treatment is very painful. We report two cases of reflex dystrophy: a child with recurrent episodes and an adult. Both patients were treated with continuous peripheral nerve block in addition to physiotherapy. The method allows complete pain relief. At follow up (at 2 and 5 months) the results were excellent. By decreasing pain and thereby improving the ability to tolerate physical therapy, this method may have an advantage compared to other treatment modalities.

Male-to-male transmission in Laurin-Sandrow syndrome and exclusion of RARB and RARG

We report on a father and a son with nasal and limb defects characteristic of Laurin-Sandrow syndrome (LSS) excluding for the first time X-linked inheritance in this rare condition. Based on a search for genes expressed late during nose formation and early in limb formation we identified retinoic acid receptor B (RARB) and retinoic acid receptor G (RARG) as possible candidate genes and sequenced bidirectionally including all exons and intron-exon bounders. We identified a single nucleotide substitution in intron 2 of RARB, which is conserved in human, chimp, dog, mouse, rat, and chicken. However, it was located 83 bp from exon 2, suggesting it is a rare polymorphism which does not account for the phenotype. No other mutations were found. This suggests that another yet unknown gene is responsible for the condition.

Recombinant human vascular endothelial growth factor enhances bone healing in an experimental nonunion model

The re-establishment of vascularity is an early event in fracture healing; upregulation of angiogenesis may therefore promote the formation of bone. We have investigated the capacity of vascular endothelial growth factor (VEGF) to stimulate the formation of bone in an experimental atrophic nonunion model.

Three groups of eight rabbits underwent a standard nonunion operation. This was followed by interfragmentary deposition of 100 μg VEGF, carrier alone or autograft.

After seven weeks, torsional failure tests and callus size confirmed that VEGF-treated osteotomies had united whereas the carrier-treated osteotomies failed to unite. The biomechanical properties of the groups treated with VEGF and autograft were identical. There was no difference in bone blood flow.

We considered that VEGF stimulated the formation of competent bone in an environment deprived of its normal vascularisation and osteoprogenitor cell supply. It could be used to enhance the healing of fractures predisposed to nonunion.

Ilizarov treatment of tibial nonunions results in 16 cases

Treatment with the Ilizarov technique was performed in 16 patients with complex tibial nonunions. Two years post treatment the functional stage and patient satisfaction were recorded. There were 4 hypertrophic, 3 atrophic and 9 infected nonunions. Eleven patients had segmental bone loss. Fifteen nonunions united, and limb length discrepancy was reduced within 1.5 cm of the contralateral leg. Average time in the frame was 182 days. Fifteen of the 16 patients were satisfied with the treatment. One patient demanded an amputation after 3 months of treatment, despite good signs of healing. There were no refractures or recurrent infections. In conclusion the Ilizarov technique for complex nonunions has a high rate of success in achieving union and eradicating infection, bone loss and malalignment. The treatment is demanding both to the surgeon and to the patient, but we strongly recommend the Ilizarov treatment for tibial nonunion, especially in cases with chronic infection and severe bone loss.

[Congenital kyphoscoliosis complicated by paraplegia]

Congenital scoliosis accounts for 10% of all scolioses which require treatment. Correct treatment demands an exact and early detection of the deformity. Early intervention may only require a minor operation. Two cases are presented with paraplegia as the first presenting symptom of congenital kyphoscoliosis. In both cases anterior decompression and spondylodesis was followed by early neurological recovery. After a second operation with posterior spondylodesis and instrumentation ad modum Cotrel-Dubousset the patients were mobilised. Patients with congenital spinal deformity ought to be investigated and treated in a highly specialized department of spinal surgery.

Assessment of intermittent claudication by means of the transcutaneous oxygen tension exercise profile

Transcutaneous oxygen tension was measured simultaneously on both feet during exercise (TcpO2 exercise profile) in patients with claudication. The following groups were studied: 1) 21 control subjects; 2) 25 patients with bilateral claudication of whom eight had unilateral predominance; 3) 40 patients with unilateral claudication. The control group showed no significant decrease in TcpO2 during exercise. Patients with bilateral claudication and unilateral predominance showed a significant decrease in the TcpO2 exercise profile of both feet (P less than 0.05), the decrease in the more affected leg being significantly greater than that of the less affected leg (P less than 0.05). In patients without unilateral predominance of claudication there was a slight, yet significant decrease in TcpO2 of both legs. Patients with unilateral claudication were classified into three groups based on a constant work load of 50 W, which provoked typical leg pain during exercise (group I: 0-2 min; group II: 2-4 min; group III: greater than 4 min). The decrease in the TcpO2 exercise profile was always significant on the symptomatic leg. In the asymptomatic leg TcpO2 did not decrease. The changes in TcpO2 relative to values at rest of the symptomatic leg showed significant differences after 1 min in groups I, II, and III (P less than 0.05). In conclusion, the TcpO2 exercise profile appears to be a suitable objective method by which the peripheral arterial insufficiency during exercise in patients with intermittent claudication can be quantified.

A model for prediction of failure in amputation of the lower limb

A logistic regression analysis of eighteen variables in eighty-three lower limb amputations was performed in order to predict stump failure. Five variables were identified as having a significant effect on the logistic model: Age had an inverse relation to failure rate (p less than 0.005). This effect was mediated through a subgroup of 23 patients who had had a vascular operation (p less than 0.02), as this group had a higher failure rate and were younger than those without previous vascular surgery. Furthermore, the surgical experience (p less than 0.005) was of major importance for stump failure. Experienced surgeons had a failure rate of 2% while less experienced had a rate of 29% (p less than 0.001). In addition, it was confirmed that the higher the skin perfusion pressure (p less than 0.05) and the amputation level, (p less than 0.05) the better the healing. A model including "skin perfusion pressure," "previous vascular surgery," "amputation level" and "surgical experience" had a good predictive capability with a misclassification rate of 0.08-0.11. Therefore it is suggested that a logistic model including these variables could be a helpful tool to predict the risk of stump failure.

Forefoot transcutaneous oxygen tension at different leg positions in patients with peripheral vascular disease

Transcutaneous oxygen tension (TcPo2) was measured on the forefoot of 150 limbs of 128 patients with different stages of peripheral vascular disease (PVD) and on 36 limbs of 18 healthy subjects in the sitting and supine position. The diagnostic value of TcPo2 measurements was tested and compared with indirect toe pressure measurements. TcPo2 measured in the supine position gives the best diagnostic discrimination between healthy controls and patients with PVD and between patients with different degrees of PVD. The median TcPo2 in patients with PVD and rest pain (severe PVD), patients with PVD without rest pain (moderate PVD) and control subjects was 12 mmHg (range 0-61), 50 mmHg (range 0-86), and 60 mmHg (range 35-78), respectively. In the supine position, 95% of the patients with severe PVD had TcPo2 values below 40 mmHg, as opposed to 28% of the patients with moderate PVD and 8% of the control subjects. TcPo2 below 40 mmHg measured on the forefoot in the supine position suggests severe ischaemia. The diagnostic value of TcPo2 measurement is comparable with that of toe systolic pressure measurement. As a diagnostic and quantitative non-invasive method of evaluating patients suspected of PVD, TcPo2 measurement is ideal as it is easy to perform, and does not cause discomfort.

The cerebral arterio-venous oxygen content differences (AVDO2) during halothane and neurolept anaesthesia in patients subjected to craniotomy

In 20 patients subjected to craniotomy for supratentorial cerebral tumours, the haemodynamic changes during halothane and neurolept anaesthesia were evaluated by measuring mean arterial blood pressure (MABP) and cerebral arterio-venous oxygen content differences (AVDO2) repeatedly during the operation. Ten patients were given 0.5% halothane anaesthesia and ten patients neurolept anaesthesia. MABP, AVDO2 and PaCO2 were measured after induction of anaesthesia, before and after incision, after opening and closure of the dura, at the time of extubation and 1 h later. Concerning MABP and PaCO2, no significant difference between the two groups was found. In both groups an increase in MABP was observed after incision (P less than 0.01 in the neurolept group and P less than 0.05 in the halothane group) and in the neurolept group after extubation (P less than 0.01). In both groups a decrease in AVDO2 was observed after incision (P less than 0.01) and after extubation (P less than 0.01 in the neurolept group and P less than 0.05 in the halothane group). During the operation AVDO2 values were significantly higher in the neurolept group (P less than 0.05). The results indicate that even a moderate increase in MABP after incision during neuroanaesthesia affects AVDO2 values, suggesting an increase in cerebral blood flow. The study suggests that autoregulation of cerebral blood flow might be better preserved during neurolept anaesthesia. A state of hyperperfusion of the brain after extubation was unveiled in both groups.

Selection of lower limb amputation level not aided by transcutaneous pO2 measurements

The transcutaneous oxygen pressure measurements were evaluated as supplementary ones for predicting stump healing in 58 below-the-knee and 16 above-the-knee amputations; the lower level was selected if the skin perfusion pressure was greater than 30 mm Hg below the knee. The failure rates in below-the-knee and above-the-knee amputations were 17 and 25 percent, respectively, and unrelated to the transcutaneous oxygen pressure measured at the amputation level. We conclude that no further information is acquired by measuring transcutaneous oxygen pressure.

[Postoperative analgesia with morphine versus morphine and paracetamol. A double-blind clinically controlled study with a placebo]

The effect of paracetamol on the postoperative employment of morphine was investigated in a double-blind clinically controlled investigation with a placebo. The operations concerned were elective gynaecological laparotomies and hip replacements. During the first 60 hours postoperatively, the employment of morphine was reduced significantly in the patients who received paracetamol. Reductions of 16, 22 and 26% were concerned. The differences between the various types of operation were not significant. Patients for joint replacements who had been treated preoperatively with non-steroid anti-inflammatory preparations did not have any significantly greater consumption of morphine postoperatively but the reduction in consumption of morphine in the paracetamol group was significantly greater with a saving of 43%. Patients who had received treatment with morphine preparations preoperatively had significantly greater consumption of morphine postoperatively but the additive analgesic effect of paracetamol remained unchanged at approximately 25%.

Long posterior flap versus equal sagittal flaps in below-knee amputation for ischaemia

We analysed the complication rate in 140 below-knee amputations in relation to surgical technique and the presence of diabetes. In all cases, the skin perfusion pressure was measured below the knee before operation to provide an objective evaluation of the microcirculation. In diabetic patients we found a significantly higher complication rate after using a long posterior flap than after equal sagittal flaps. No such difference could be demonstrated in non-diabetic patients. We suggest that the higher incidence of atherosclerotic lesions in the three major arteries below the knee in diabetic patients may account for the difference. We recommend the use of the sagittal technique for below-knee amputation in diabetic patients.

Results of amputation for gangrene in diabetic and non-diabetic patients. Selection of amputation level using photoelectric measurements of skin-perfusion pressure

Evaluation was done of 235 patients who had had 273 primary amputations for gangrene. Measurements of local skin-perfusion pressure or systolic blood pressure were made in 222 limbs (188 patients). For the other fifty-one limbs, for which no measurements of pressure were available, the surgeon elected to perform an above-the-knee amputation in nine of seventeen diabetic limbs and a below-the-knee amputation in eight. An above-the-knee amputation was selected by the surgeon for thirty-two of thirty-four non-diabetic limbs and a below-the-knee amputation, for two for which no measurements of pressure were available. Local skin-perfusion pressure was measured distal to the knee before amputation, using a standardized photoelectric technique in 203 limbs and systolic blood-pressure measurements in nineteen. Skin-perfusion pressure was also measured above the knee in seventy-six of the 222 limbs in which a pressure was determined below the knee. These measurements were made available to the surgeon for use as an adjuvant guide to clinical assessment in selecting the appropriate level of amputation. Seventy-four patients (ninety-two amputations) had diabetes and 114 patients (130 amputations) did not. The limbs of the diabetic patients had a significantly higher skin-perfusion pressure at the below-the-knee level (p less than 0.001) than did those of the non-diabetic patients. The ratios of below-the-knee to above-the-knee amputations for the diabetic and non-diabetic patients were 3.8 to one and 1.3 to one (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Transcutaneous oxygen tension exercise profile. A method for objectively assessing the results after reconstructive peripheral arterial surgery

Transcutaneous oxygen tension during exercise (TcPo2 exercise profile) was measured on the foot in 10 patients before reconstructive vascular surgery and 9 and 18 months later. The preoperative TcPo2 exercise profiles were abnormal in all 10 patients. In 9 of the patients the reconstructions were successful. In these patients the TcPo2 exercise profiles reverted to normal. In a control group of six healthy persons no significant changes in TcPo2 were observed during the follow-up period of 18 months. The reproducibility determined as the total week-to-week variation of claudicants and controls was 8%. The TcPo2 exercise test is suitable for monitoring the patient after reconstructive surgery, because it is based exclusively on objective data is non-invasive and the measurements are reproducible.

Transcutaneous oxygen tension measurement over the sacrum on various anti-decubitus mattresses

Transcutaneous oxygen tension (tcPO2) was measured over the sacrum of 12 healthy, normal-weight volunteers positioned on five different mattresses. TcPO2 was lower (p less than 0.01) in those on a standard hospital mattress (median 0 mmHg), than in those on a sheep skin (median 22 mmHg), water mattress (median 33.5 mmHg), Spenco mattress (median 52.5 mmHg) or ripple air mattress (median 0/62 mmHg). The tcPO2 for the Spenco mattress was higher (p less than 0.01) than for sheep skin and for the water mattress. No significant difference was found in tcPO2 for the latter two named above. TcPO2 for the ripple air mattress alternated between 0, when inflated under the oxygen sensor, to about full oxygenation, when deflated. We believe that the ripple air mattress theoretically is the best mattress to prevent decubitus ulcers, but due to frequent mechanical failure of pump or mattress, the Spenco mattress is perhaps the best for practical use. Clinical comparative studies will be necessary to confirm that.

Lower limb transcutaneous oxygen tension during aortic bypass grafting

Transcutaneous oxygen tension (tcPO2) was measured continuously at the foot of 10 patients during abdominal aortic bypass grafting. Median tcPO2 before surgery was 38.5 mmHg (range: 14-74 mmHg) increasing to 79.0 mmHg (range 44-104 mmHg) after insertion of the vascular prosthesis (p less than 0.01). Eight successful vascular reconstructions were correctly identified intraoperatively. One was correctly identified as failed and one was correctly identified as unchanged compared with the preoperative clinical status. Our results indicate that tcPO2-monitoring may contribute to quality assurance by intraoperative identification of failed or insufficient vascular reconstructions.

Systemic lupus erythematosus with rectal stenosis simulating tumour or diverticulosis. Case report

A case of systemic lupus erythematosus (SLE) with focal involvement of the rectum is reported. The lesion roentgenologically resembled a malignant tumour and was resected. Histologic examination disclosed only typical SLE changes in a very restricted area, with the remaining gastrointestinal tract unaffected. This appears to be the first report of focal colitis as a complication of SLE. The case points the importance of suspecting symptoms from any organ system in patients with connective tissue disorders to be manifestations of that underlying pathology.

Pneumatic antishock garments (PASG): do they precipitate lower-extremity compartment syndromes?

Pneumatic antishock garments (PASG) are widely used for treatment of hypovolemic shock and for long-term control of bleeding associated with pelvic fractures. Several cases of compartment syndromes (CS) caused by PASG application, and with sequelae such as limb loss, myoglobinuric renal failure, and death have been reported. The aim of this study was to investigate the amount of PASG pressure needed to produce tissue anoxia. Twelve normotensive subjects were investigated, and transcutaneous oxygen tension (TcPO2) was measured beneath a full-length pneumatic splint at the following pressures applied: 0, 10, 15, 20, 25, 30, and 35 mm Hg. Without imposed pressure, mean TcPO2 was 70.6 mm Hg. TcPO2 decreased by increasing pneumatic pressure, expressed by the equation: TcPO2 = 2.3x + 65.7, where x is applied pressure in mm Hg. TcPO2 became zero at a mean applied pressure of 28 mm Hg (25-35). It is concluded that PASG pressures of 30 mm Hg or more applied to the whole limb stop microcirculation and result in tissue anoxia. Even low PASG pressures carry a high risk of precipitating CS. To avoid ischemic injury new guidelines for PASG application are discussed.

Transcutaneous oxygen tension response to exercise in health and in occlusive arterial disease

Transcutaneous oxygen tension (TcPO2) was measured on the foot at rest and during exercise in supine position in 21 clinically healthy controls and in 17 patients with intermittent claudication. All patients had ankle pressure greater than 50 mmHg and arteriographically proven peripheral vascular disease. Resting TcPO2 was significantly lower in the patient group than in the control group, though with considerable overlap between the groups. During exercise, however, TcPO2 showed highly significant decrease in the patient group. The median change following exercise in that group was -90% (range -54 to -100%) of the resting value. In the control group there was no significant fall in TcPO2 during 4 min exercise--median change -8% (range +30 to -34%). During exercise there was no overlap between the patient and the control group. Foot TcPO2 measurement during exercise in supine position is a simple, noninvasive and highly specific test for identifying patients with significant peripheral vascular disease.

The effect of a corticosteroid on the absorption of 131I-albumin from rabbit knee joint

The disappearance rate of 131I-albumin from the knee joint in six rabbits was measured before and after intraarticular injection of 7.5 mg triamcinolonhexacetonide (Lederspan). A significant decrease in the synovial permeability was demonstrated after injection of triamcinolonhexacetonide (average 64 percent). It is concluded that this demonstrates that corticosteroids have a direct effect on the synovial membrane, which may be an important mechanism whereby they exert their therapeutic effect upon joints.

Transcutaneous oxygen measurement in peripheral occlusive disease. An indicator of wound healing in leg amputation

In 42 amputations (28 below-knee and 14 above-knee), healing of the stump was found to correlate with the pre-operative transcutaneous oxygen pressure (tcPO2) measured at the planned site of incision. Of 31 patients with a tcPO2 of 30 mmHg or more, 27 healed primarily, three had delayed healing and one failed to heal; of seven patients with values between 20 and 30 mmHg three healed primarily and four had delayed healing; and all four patients with a value below 20 mmHg had stumps which failed to heal and needed reamputation. It is concluded that a tcPO2 of 20 mmHg or more at the intended site of amputation indicates that the wound will heal.

Inflatable splints: do they cause tissue ischaemia?

The effect of increasing pneumatic splint pressure on cutaneous oxygen tension measured transcutaneously (TcPO2) was investigated in 12 subjects. The mean initial TcPO2 was 70.6 mmHg. TcPO2 decreased linearly on increasing the pressure within the splint. TcPO2 became zero at a mean splint pressure of 28 mmHg. Second, three accepted methods used by the ambulance crew to assess inflation pressures of the splint were investigated and found to be unreliable. In the light of these findings the risk of ischaemic complications as a result of applying pneumatic splints to a fractured limb is discussed. We advocate a recommended maximum splint pressure of 15 mmHg and that the splint should be manufactured with a security blow-off valve set at 15 mmHg.

Facilitated blind intubation using a transtracheal guide wire

A method of tracheal intubation facilitated by using a transtracheal guide-wire is illustrated by three selected case stories. In two cases, the patients were blindly intubated and in the third case, with epiglottitis, the aditus layngis could be identified only by use of the guidewire. Using a laryngoscope and Magill's forceps, intubation was in this case performed without complications. It is suggested that the method applied in cases of difficult intubation may reduce the rate of acute tracheostomies.

Patellectomy--a 20-year follow-up

Twenty-seven patients with 28 patellectomies were re-examined after an average of 20 years. Twelve knees rated as excellent, ten as good and six as fair. Even though 12 patients had strenuous work, only three patients had changed occupation. Quadriceps power was on average two-thirds that of the opposite limb. Radiographs showed incipient femoro-tibial arthrosis in four patients only.

Volkmann's ischaemic contracture due to limb compression in drug-induced coma

A case of Volkmann's contracture secondary to prolonged compression of the limb is presented. The events developed in a patient who had been comatose following an overdose of alcohol and a sedative drug.

Hospital-wide screening improves basis for nutrition intervention

The prevalence of malnutrition and need for nutrition intervention were evaluated at the time of admission for 500 consecutive patients at Cleveland Memorial Hospital, a 300-bed acute-care community hospital, in Shelby, NC. The association between the prescribed diet and the need for special nutrition intervention was emphasized. Results indicate that 31% of patients receiving routine diets (regular, soft, full liquid, clear liquid, NPO) and 33% of patients receiving modified diets were malnourished at the time of admission. Chi-square analysis indicated that there was no significant difference (p less than or equal to .05) in the prevalence of malnutrition or the need for special nutrition intervention between the two groups. Yet, many hospital nutrition services are organized to direct their activities primarily to patients receiving modified diets. It is suggested that dietetic practitioners implement a hospital-wide screening process so that patients with special nutrition needs can be identified and appropriate support regimens can be planned.

Hypokalemic paralysis in Sjögren's syndrome secondary to renal tubular acidosis

A 62-year-old woman with Sjögren's syndrome, distal renal tubular acidosis and hypokalemic muscle paralysis is described. The sicca syndrome was nearly subclinical and went unrecognized for several years. The main and first manifestation to be expressed was that of hypokalemic muscle paralysis secondary to renal tubular acidosis. In the last decade several reports have appeared indicating that renal tubular acidosis is associated with Sjögren's syndrome. The data in this report support the view that adult onset distal renal tubular acidosis is often a disorder of an autoimmune disease, frequently that of Sjögren's syndrome. The complications to renal tubular acidosis such as hypokalemic muscle paralysis or chronic muscle weakness, nephrolithiasis, and osteomalacia can be avoided if the diagnosis of renal tubular acidosis is made and corrective alkali therapy is maintained.

Hypokalemic periodic paralysis secondary to renal tubular acidosis

A 62-year-old woman with distal renal tubular acidosis (RTA) and hypokalemic muscle paralysis is described. As neither the history nor the clinical examination can differentiate between hypokalemic paralysis caused by RTA and that of familial hypokalemic paralysis, and because the emergency as well as prophylactic treatment of the two disorders are quite different, a simple differential diagnostic workup is emphasized.

Self-management in diabetic children

The level of self-management of 157 type I (juvenile-onset, insulin-dependent) children with diabetes was assessed using a self-management assessment tool developed by the investigator and validated by a panel of diabetes experts. Subjects ranged from 7 to 16 yr and attended the 1981 session of Camp Hertko Hollow, a camp for children with diabetes near Boone, Iowa. The extent of knowledge about diabetes was determined for each subject by the knowledge questionnaire developed and validated by the Diabetes Education Program in Nashville, Tennessee. This knowledge score was then correlated with the self-management score to determine the relationship between the two variables. The t test and regression analysis showed a significant association (P less than or equal to 0.05) between knowledge and self-management and indicates that children with diabetes are more likely to achieve effective self-management when an adequate knowledge base of the disease also exists.