Effects of therapeutic exercise on disease severity, balance, and functional Independence among individuals with cerebellar ataxia: A systematic review with meta-analysis

BACKGROUND

Balance impairments are common in cerebellar ataxia. Exercises are beneficial in this population.

OBJECTIVE

Explore the benefits of therapeutic exercises on disease severity, balance and functional independence in cerebellar ataxia.

METHODS

Databases were searched from inception until July 2021. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Newcastle-Ottawa Scale (NOS); and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

Twenty-six studies were included and eight studies of low to high PEDro methodological quality were meta-analyzed. 'Low' to 'moderate' GRADE quality evidence supports the use of therapeutic exercises to reduce disease severity, assessed using the Scale for the Assessment and Rating of Ataxia [weighted mean difference (WMD): -3.3; 95% confidence interval (95%CI): -3.7, -2.8; p < .01]; and improve balance, assessed using the Berg Balance Scale (WMD: 2.6; 95%CI: 1.1, 4.2; p < .01). The effect of therapeutic exercises on functional independence was insignificant (WMD: 1.6; 95%CI: -1.5, 4.6; p = .31).

CONCLUSION

Low to moderate evidence from studies of low to high methodological quality provides some support for therapeutic exercises for reducing disease severity among non-hereditary degenerative cerebellar ataxia and improving balance among acquired cerebellar ataxia. Exercises did not benefit functional independence. Additional studies of large sample size and high methodological quality are necessary to substantiate these findings.

Chronic Obstructive Pulmonary Disease (COPD) management in the community: how could primary care team contribute?

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease commonly encountered in primary care. This study aimed to audit COPD care at primary care clinics of Hong Kong and to work out improvement strategies.

METHOD

All COPD patients aged 40 or above who had been followed up at 13 public primary care clinics of Kowloon Central Cluster (KCC) under the Hospital Authority of Hong Kong (HAHK) were included in this clinic audit. Evidence-based audit criteria and performance standards were established after thorough literature review. Phase 1 was from 1st April 2016 to 31st March 2017, with deficiencies of care identified. It was followed by a one-year implementation phase through which a series of improvement strategies were executed. Outcome of the enhancement was reviewed during Phase 2 from 1st April 2018 to 31st March 2019. Chi-square test and student's t test were used to detect statistically significant changes between Phase 1 and Phase 2.

RESULTS

A total of 2358 COPD cases were identified in Phase 1 where 658 of them were smokers. Of those smokers, 332 (50.5%) had been referred to Smoking Counselling and Cessation Service (SCCS) and 289 (43.9%) actually attended it. 991 cases (42%) received Seasonal Influenza Vaccine (SIV) and 938 cases (39.8%) received Pneumococcal Vaccine (PCV). 698 patients (29.6%) had spirometry done before and 423 patients (17.9%) had been admitted to hospital due to acute exacerbation of COPD (AECOPD). With the concerted effort taken during the implementation phase, Phase 2 data showed significant improvement in nearly all criteria. There was a marked increase in the SIV and PCV uptake rate, spirometry performance rate and most importantly, a significant reduction in AECOPD rate leading to hospital admission (13.5%, P = 0.000043). However, the referral rate and attendance rate of SCCS among smokers remained stagnant (P > 0.05).

CONCLUSION

Via a systematic team approach, COPD care at primary care clinics of KCC under HAHK had been significantly improved for most of the audit criteria, which in turn reduced the burden of the healthcare system.

A Case of Unintentional Methadone Overdose Followed by Hypoglycaemia

Methadone overdose is expected to result in intoxication simulating the other opioids. We report a case of hypoglycaemia following accidental methadone ingestion. A 21-year-old woman presented to a local accident and emergency department 10 hours after ingestion of 800 mg of methadone. She was found to have coma, respiratory suppression, hypotension, prolonged QTc and hypoglycaemia. The hypoglycaemia was reversed by dextrose replacement. The patient required intubation and inotropic support because of cardio-respiratory instability. She eventually recovered without consequence. To date, this is the first reported case of methadone overdose induced hypoglycaemia.

Clinical Audit on Short Stay Emergency Medical Admission

The growth rate of emergency department visit locally is disproportionate to the population growth. The number of emergency hospital admission has also increased leading to congested ward environment. A retrospective clinical audit on short stay (discharged within 24 hours) emergency medical and geriatric admission was done to look at the appropriateness of our emergency medical and geriatric admission. This study was carried out in April 2000. The Appropriateness Evaluation Protocol was employed as an objective tool for initial assessment. A peer panel, composed of Fellows from the Colleges of Physicians and Emergency Medicine, was formed to check for appropriateness of admission for those cases without objective admission criteria. Thirteen out of the 177 cases (7.3%) available for analysis were considered as “inappropriate” admission. If we assume that those emergency admissions that stayed for longer than 24 hours were appropriately admitted, the “inappropriate” admission rate for medical and geriatric cases would be 0.67% (13 out of 1930). Suggestions for further improvement include: (1) longer and intensive observation for selected patients before admission; (2) access to early specialist outpatient review; (3) ad-hoc clinics to be run by other specialists for selected “old” cases; and (4) strengthening of the primary health care service.

Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial

BACKGROUND

There is a lack of evidence on the effectiveness of postnatal depression (PND) screening programmes in reducing morbidity. The aim of this study was to evaluate the effectiveness of a PND screening programme using Edinburgh Postnatal Depression Scale (EPDS) in improving maternal mental health.

METHODS

The randomized controlled trial design was used. Participants were 462 Chinese mothers with 2-month-old babies visiting Maternal and Child Health Centres in Hong Kong. Participants in the intervention group were screened for PND using the EPDS, whereas those in the control group were screened by clinical assessment. In both groups, participants identified with PND were offered follow-up management according to protocol.

RESULTS

Participants in the intervention group had better maternal mental health outcome as assessed by EPDS at 6 months (risk ratio: 0.59; 95% confidence interval: 0.39-0.89). The number needed to screen was 25.

CONCLUSIONS

A PND screening programme comprising the use of EPDS as the screening tool and the provision of follow-up care had resulted in an improvement in maternal mental health at 6 months.

Cefepime versus vancomycin plus netilmicin therapy for continuous ambulatory peritoneal dialysis-associated peritonitis

Cefepime is a cephalosporin with a broad spectrum of activity against most gram-positive and gram-negative pathogens. In this study, we attempted to compare the safety and efficacy of cefepime monotherapy against the potentially more toxic combination of vancomycin and netilmicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD)-associated bacterial peritonitis. Eighty-one consecutive CAPD patients who presented with peritonitis from January 1, 1998, to June 30, 2000, were recruited for study. Patients were randomized to be administered either intraperitoneal (IP) cefepime, 1 g once daily (group A), or intravenous vancomycin and netilmicin at conventional doses (group B) for 10 days. Bacterial growth was obtained in 52 episodes (66%), and pathogens identified included gram-positive organisms (30 episodes; 38%), gram-negative organisms (14 episodes; 18%), mixed organisms (2 episodes; 2.5%), and fungus (6 episodes; 8%). Eight patients were excluded after randomization for various reasons (6 patients, fungal peritonitis; 2 patients, wrong diagnoses). Because of the relatively low peritonitis rate after the use of a disconnect system, the sample size of this study was relatively small, giving a power of 0.45. There were no significant differences in primary response rates and cure rates (no relapse >28 days after completion of antibiotic therapy) between both groups of patients (group A versus group B, 82% [32 of 39 patients] versus 85% [29 of 34 patients] and 72% [28 of 39 patients] versus 76% [26 of 34 patients], respectively; P = not significant). No significant side effect was encountered in either group. Total peritonitis-related hospitalizations were 84 patient-days (1, 7, 8, 11, 20, and 37 patient-days) and 115 patient-days (3, 6, 9, 14, 21, 21, and 41 patient-days), whereas total costs per patient cure were estimated to be US $1,039 and US $1,371 in groups A and B, respectively. We conclude that once-daily 1-g IP cefepime monotherapy is a simple, safe, and cost-effective alternative to vancomycin and netilmicin therapy in the treatment of CAPD-associated bacterial peritonitis.

A new synthesis of chlorins

A new synthesis of chlorins has been developed, based upon the acid-catalyzed condensation of dialdehydes AB with dipyrromethanes CD.

New syntheses of the C,D-ring pyrromethenones of phytochrome and phycocyanin

Pyrromethenone 7, the C,D-ring segment of phytochrome (Pr, 4), has been prepared in an efficient fashion employing three new strategies. Each of these has potential advantages for the synthesis of labeled material. Our first approach is related to the Gossauer synthesis, with the difference that strong alkali is avoided in the condensation of the C- and D-ring components 8 and 17. The key silyloxypyrrole 17 was readily prepared on multigram scales beginning with inexpensive butyrolactone (10). A second synthesis began with 2-acetylbutyrolactone (41). The key steps involved conversion of 41 to the Z-enoltriflate 42, followed by Pd(0)-catalyzed coupling with trimethylsilylacetylene, p-chlorophenylselenide ring opening, and finally, amidation to afford the ring-D synthon 45 having the proper geometry and oxidation state for conversion to 7. Sonogashira coupling of 45 with the iodopyrrole 22, followed by oxidative elimination, and F(-)-induced 5-exo-dig cyclization of the resultant pyrroloalkyne 47, then completed the synthesis. In similar fashion, we have also prepared pyrromethenone 6, the C,D-ring segment of phycocyanin (2).

New strategies for the synthesis of biologically important tetrapyrroles. The "B,C + D + A" approach to linear tetrapyrroles

Linear tetrapyrroles related to phytochrome (1) were prepared in enantiospecific fashion by a new strategy beginning with ring-B,C synthons of type 19 (bis-iododipyrrins). Rings A and D were elaborated by Pd(0)-mediated coupling of 19a with the appropriate alkyne acid or amide derivatives 9 and 20, followed by intramolecular cyclization (method C: BC + D + A --> ABCD).

Polyanionic hydrogel as a gastric retentive system

Gastric emptying of a polyanionic hydrogel, polycarbophil (PC), from the canine stomach was studied using a duodenal cannulation technique. The basis of the study is to employ a certain quantity of swelling hydrogel that, by virtue of its swollen size and viscosity, converts a fasted stomach to a fed state and resists discharge from the stomach for an extended period of time. Different amounts of PC, in 200 ml water plus buffering agents, were administered orally to fasted canines. The gastric emptying lag time was found to increase with the viscosity of the administered dose. Addition of a base, sodium bicarbonate, to PC increased gastric retention via an increase in its apparent viscosity. The polymer mass is retained in the canine stomach until a sufficient quantity of stomach acid secretion reduces the viscosity of the viscous mass, through protonation of polycarbophil, and, at that point, discharge of the hydrogel will commence. Thus, gastric retention of PC hydrogel in the canine stomach can be prolonged by increasing the apparent viscosity of the hydrogel administered.