Comparison of impact on death and critical care admission of acute kidney injury between common medical and surgical diagnoses

Background

Acute Kidney Injury (AKI) is common and associated with increased morbidity and mortality. This retrospective analysis quantified and compared the association between AKI and the risk of death and admission to critical care in acute admissions of different aetiology.

Methods

Data were extracted anonymously from the Trust ‘data warehouse’ for admissions between 2011and 2017. We applied KDIGO AKI criteria to establish AKI stage. Odds ratios (OR) for death and critical care admission were calculated for patients with AKI stage 3 (compared to all other patients), and patients with any stage AKI (compared to non-AKI admissions). Analyses were performed using logistic regression, adjusted for age, pre-existing CKD, co-morbid index, and gender.

Results

There were 26,052 medical and 12,560 surgical patient episodes within sixteen common diagnoses with 3823 medical and 1520 surgical patients with AKI events. The likelihood of AKI was highest in sepsis (31.8%), and the likelihood of death in AKI 3 highest in femoral neck fracture (54.5%). AKI 3 has a OR for death for acute coronary syndrome of 12.8 and a OR of 24.6 in femoral neck fracture. Admission to critical care for any AKI in medical patients has a OR of 9.6, but increases to OR 37.2 for heart failure.

Conclusion

The clinical impact of AKI differs across medical and surgical diagnoses, but is a significant contributor to the risk for death and critical care admission. This body of work may indicate a benefit to a more diagnosis-specific stratified approach to AKI care.

Reducing acute kidney injury incidence and progression in a large teaching hospital

Acute kidney injury (AKI) is a common syndrome that is associated with significant mortality and cost. The Quality Improvement AKI Collaborative at Salford Royal Foundation Trust was established to review and improve both the recognition and management of AKI. This was a whole-system intervention to tackle AKI implemented as an alternative to employing separate AKI nurses. Our aims were to reduce the overall incidence of AKI by 10%, to reduce hospital-acquired AKI by 25% and to reduce the progression of AKI from stage 1 to stage 2 or 3 by 50%. From 2014 to 2016, several multifaceted changes were introduced. These included system changes, such as inserting an e-alert for AKI into the electronic patient record, an online educational package and face-to-face teaching for AKI, and AKI addition to daily safety huddles. On 10 Collaborative wards, development of an AKI care bundle via multidisciplinary team (MDT) plan, do, study, act testing occurred. Results showed a 15.6% reduction in hospital-wide-acquired AKI, with a 22.3% reduction on the collaborative wards. Trust-wide rates of progression of AKI 1 to AKI 2 or 3 showed normal variation, whereas there was a 48.5% reduction in AKI progression on the Collaborative wards. This implies that e-alerts were ineffective in isolation. The Collaborative wards' results were a product of the educational support, bundle and heightened awareness of AKI. A number of acute hospitals have demonstrated impactful successes in AKI reduction centred on a dedicated AKI nurse model plus e-alerting with supporting changes. This project adds value by highlighting another approach that does not require a new post with attendant rolling costs and risks. We believe that our approach increased our efficacy in acute care in our front-line teams by concentrating on embedding improved recognition and actions across the MDT.

A narrative review of the impact of interventions in acute kidney injury

Acute kidney injury (AKI) is independently associated with significant morbidity and mortality, and is thus an important challenge facing physicians in modern healthcare. This narrative review assesses the impact of strategies employed to tackle AKI following the 2009 NCEPOD report on acute kidney injury (Sterwart et al. Acute kidney injury: adding insult to injury, pp 1-22, 2009). There is scarce and heterogeneous research into hard end points such as mortality and AKI progression for AKI interventions. This review found that e-alerts have varying effects on mortality and AKI progression, but decrease the incidence of contrast-induced AKI. The use of AKI bundles delivers statistically significant improvements in mortality and AKI progression. Similarly, AKI nurses generate statistically significant improvements on hospital acquired AKI and mortality. As yet there is no evidence base for the effects of education, sick day rules and smart phone apps. Overall, a combination of e-alerts and AKI bundles supported by education yielded the most effective and statistically significant results. Current practice revolves around reactive rather than preventative behaviour. This narrative review discusses reactive interventions and their impact on the progression and severity of AKI, and on mortality from it. Preventative behaviour, such as risk stratification and early intervention in the deteriorating patient, may be influential in decreasing AKI incidence.

Cerclage position, cervical length and preterm delivery in women undergoing ultrasound indicated cervical cerclage: A retrospective cohort study

Objective

The objectives were to assess whether anatomical location of ultrasound (USS) indicated cervical cerclage and/or the degree of cervical shortening (cervical length; CL) prior to and following cerclage affects the risk of preterm birth (PTB).

Method

A retrospective cohort study of 179 women receiving cerclage for short cervix (≤25mm) was performed. Demographic data, CL before and after cerclage insertion, height of cerclage (distance from external os) and gestation at delivery were collected. Relative risk (RR) and odds ratio (OR) of preterm delivery were calculated according to the anatomical location of the cerclage within the cervix and the CL before and after cerclage as categorical and continuous variables. Partition tree analysis was used to identify the threshold cerclage height that best predicts PTB.

Results

25% (n = 45) delivered <34 weeks and 36% (n = 65) delivered <37 weeks. Risk of PTB was greater with cerclage in the distal 10mm (RR2.37, 95% CI 1.45–3.87) or the distal half of a closed cervix (RR2.16, 95% CI 1.45–3.87). Increasing absolute cerclage height was associated with a reduction in PTB (OR 0.87, 95% CI 0.82–0.94). A cerclage height <14.5 mm best predicts PTB (70.8%). Increasing CL following cerclage was associated with a reduction in PTB (OR0.87, 95% CI 0.82–0.94). Conversely, the risk of PTB was increased where CL remained static or shortened further following cerclage (RR2.34, 95% CI 1.04–5.25).

Conclusion

The higher a cerclage was placed within a shortened cervix, the lower the subsequent odds of PTB. Women whose cerclage is placed in the distal 10mm of closed cervix or whose cervix fails to elongate subsequently, should remain under close surveillance as they have the highest risk of PTB.

Sulfasalazine augments a pro-inflammatory response in interleukin-1β-stimulated amniocytes and myocytes

Preterm birth occurs in 10% of pregnancies and is a major cause of neonatal morbidity and mortality. The majority of cases of early preterm labour are associated with infection/inflammation, which places the fetal central nervous system at risk. Targeting immune activation is therefore an appealing therapeutic strategy for the prevention of preterm labour and neonatal brain injury. The expression of many labour-associated and inflammatory-response genes is controlled by the transcription factors nuclear factor-κB (NF-κB) and activator protein-1 (AP-1), which makes them therapeutic targets of interest. Sulfasalazine (SASP) has been shown to inhibit NF-κB and reduce lipopolysaccharide-induced cytokine concentrations in fetal membrane explants and reduce the rate of Escherichia coli-induced preterm labour in mice. Its effects upon AP-1 in the context of pregnancy are unknown. In this study the effect of SASP on interleukin-1β (IL-1β) -induced NF-κB and AP-1 activity, cytokine production and cyclo-oxygenase-2 (COX-2) expression was examined in amniocytes and myocytes. A supra-therapeutic concentration (5 mm) was required to inhibit IL-1β-induced NF-κB (P < 0·0001) in amniocytes and IL-1β-induced NF-κB (P < 0·01), AP-1 (P < 0·01) and COX-2 (P < 0·05) in myocytes. Despite inhibiting IL-1β-induced cytokines, a basal increase in IL-6 (P < 0·01), IL-8 (P < 0·0001) and tumour necrosis factor-α (TNF-α) (P < 0·001) was seen with 5 mm SASP in amniocytes, and significant cytotoxic effects were seen in myocytes. The therapeutic concentration of 0·015 mm had no inhibitory effects on pro-inflammatory mediators, but led to an augmented response to IL-1β-induced IL-6 (P < 0·01), IL-8 (P < 0·05) and TNF-α (P < 0·05) in amniocytes and IL-8 (P < 0·05) in myocytes. SASP is therefore an unlikely therapeutic candidate for the prevention of inflammation-induced preterm labour.

Specific Lipopolysaccharide Serotypes Induce Differential Maternal and Neonatal Inflammatory Responses in a Murine Model of Preterm Labor

Intrauterine inflammation is recognized as a key mediator of both normal and preterm birth but is also associated with neonatal neurological injury. Lipopolysaccharide (LPS) is often used to stimulate inflammatory pathways in animal models of infection/inflammation-induced preterm labor; however, inconsistencies in maternal and neonatal responses to LPS are frequently reported. We hypothesized that LPS serotype-specific responses may account for a portion of these inconsistencies. Four different Escherichia coli LPS serotypes (O111:B4, O55:B5, O127:B8, and O128:B12) were administered to CD1 mice via intrauterine injection at gestational day 16. Although control animals delivered at term 60 ± 15 hours postinjection (p.i.), those administered with O111:B4 delivered 7 ± 2 hours p.i., O55:B5 delivered 10 ± 3 hours p.i., O127:B8 delivered 16 ± 10 hours p.i., and O128:B12 delivered 17 ± 2 hours p.i. (means ± SD). A correlation between the onset of preterm labor and myometrial activation of the inflammatory transcription factor, activator protein 1, but not NF-κB was observed. Specific LPS serotypes induced differential activation of downstream contractile and inflammatory pathways in myometrium and neonatal pup brain. Our findings demonstrate functional disparity in inflammatory pathway activation in response to differing LPS serotypes. Selective use of LPS serotypes may represent a useful tool for targeting specific inflammatory response mechanisms in these models.

Anti-inflammatory prostaglandins for the prevention of preterm labour

Preterm birth occurs in 10-12% of pregnancies and is the primary cause of neonatal mortality and morbidity. Tocolytic therapies have long been the focus for the prevention of preterm labour, yet they do not significantly improve neonatal outcome. A direct causal link exists between infection-induced inflammation and preterm labour. As inflammation and infection are independent risk factors for poor neonatal outcome, recent research focus has been shifted towards exploring the potential for anti-inflammatory strategies. Nuclear factor kappa B (NFκB) is a transcription factor that controls the expression of many labour-associated genes including PTGS2 (COX2), prostaglandins (PGs) and the oxytocin receptor (OXTR) as well as key inflammatory genes. Targeting the inhibition of NFκB is therefore an attractive therapeutic approach for both the prevention of preterm labour and for reducing neonatal exposure to inflammation. While PGs are considered to be pro-labour and pro-inflammatory, the cyclopentenone PG 15-deoxy-Δ(12,14)PGJ2 (15d-PGJ2) exhibits anti-inflammatory properties via the inhibition of NFκB in human amniocytes, myocytes and peripheral blood mononuclear cells in vitro. 15d-PGJ2 also delays inflammation-induced preterm labour in the mouse and significantly increases pup survival. This review examines the current understanding of inflammation in the context of labour and discusses how anti-inflammatory PGs may hold promise for the prevention of preterm labour and improved neonatal outcome.

The effects of hydrochloric acid on all-ceramic restorative materials: an in-vitro study

OBJECTIVES

The aim of this in-vitro study was to assess the long-term effects of hydrochloric acid on the surface roughness of three all-ceramic restorative materials CEREC VITABLOC Mark II CAD, IPS Empress CAD and IPS e.max CAD.

MATERIALS AND METHODS

Six cylindrical specimens (10mm diameter, 3mm height) of each material type were prepared, using the CEREC CAD/CAM machine. The unpolished samples were immersed in 15ml hydrochloric acid (pH 2) at 37 degrees C. Before immersion (baseline) and at periods of 7.5 hours, 45 hours and 91 hours, the specimens were removed from the acid and two randomised areas (10 microm X 10 microm) were selected and tested on each. The atomic force microscope (Bruker Dimension icon) was used to assess surface roughness and surface area at baseline and after each exposure time. The materials were compared over time with respect to surface roughness and surface area (baseline, 1 month, 6 months, 1 year) in a repeated measures analysis of variance (ANOVA).

RESULTS

Sample groups differed significantly for roughness (p < 0.0001) and surface area (p < 0.0001). For both parameters a significant interaction also existed between material and time (surface roughness: p = 0.0085; surface area: p = 0.0014). CEREC VITABLOC Mark II CAD and IPS Empress CAD had substantially higher levels of roughness and surface area than IPS e.max CAD, which was also affected to a lesser extent over time.

CONCLUSION

The results showed that IPS e.max CAD was least affected by long-term exposure to hydrochloric acid.

EP2 receptor activates dual G protein signaling pathways that mediate contrasting proinflammatory and relaxatory responses in term pregnant human myometrium

Prostaglandin (PG) E2 (PGE(2)) plays a central role in the regulation of smooth muscle contractions. Classically, PGE(2) stimulates contractions via EP1 and EP3 receptors, whereas EP2 and EP4 maintain quiescence. Labor involves a change from myometrial quiescence to contractions with a shift from anti- to proinflammatory pathways. EP2, a Gαs-coupled receptor, is known to mediate its actions via cAMP signaling. However, we have recently shown that EP2 also activates the proinflammatory PG G/H synthase-2 (PGHS-2). Here, we identify the mechanism underlying the ability of EP2 to maintain uterine quiescence and activate a proinflammatory/prolabor response in term-pregnant human myometrium. Human myometrial biopsies for in vivo and in vitro studies were taken at cesarean section at term, before or after the onset of labor. Activation of EP2 increased intracellular levels of cAMP and reduced contractility. Contrastingly, EP2 stimulation increased levels of PGHS-2, membrane-associated PGE synthase-1, and PGE(2). This was entirely dependent on EP2-mediated activation of calcium signaling. Both calcium signaling and up-regulation of PGHS-2 were insensitive to the Gαi inhibitor pertussis toxin but inhibited by small interfering RNA knockdown of Gαq/11. There were no differences in EP2 mRNA or protein levels between upper or lower segment myometrium or between pre- and postlabor myometrium. However, in myocytes taken after the onset of labor, cAMP signaling was markedly attenuated, whereas activation of calcium and PGHS-2 was preserved. Overall, the dual coupling of EP2 to Gαs-cAMP and Gαq/11-calcium pathways underlies its ability to mediate contrasting functions in term pregnancy and the "switching" to a prolabor receptor.

Evaluation of surface characteristics of titanium and cobalt chromium implant abutment materials

INTRODUCTION

Micro-organism adhesion and plaque formation is affected by surface free energy (SFE), surface roughness, hydrophilicity, surface chemistry, surface charge and the presence of proteins.

AIMS

The aim of this study was to assess and compare surface characteristics of surgical grade cobalt chromium alloy (CCM) and of commercially pure titanium (cpTi).

METHOD

Nine metallic cylinders were machined to precise standards from each material. Surface roughness was measured at four different points on each sample and the average Ra value was calculated for each material. Contact angles were obtained using the sessile-drop method and applied in calculating the SFE. Surface hardness was evaluated by means of a Vickers hardness micro-indentation.

RESULTS

Surface roughness was similar for both metals, but total SFE values and Vickers surface hardness scores showed significant differences (p < 0.0001).

CONCLUSION

SFE analysis showed CCM to be more hydrophobic and that oral bacteria might therefore be less adherent than to cpTi. The mean Vickers Hardness scores of the cpTi were significantly lower (p < 0.0001), suggesting that CCM may be more resistant to surface modifications and surface roughening, thus remaining smoother with less plaque accumulation than cpTi. This study demonstrated that CCM might be a suitable alternative implant abutment material.

The CRTH2 agonist Pyl A prevents lipopolysaccharide-induced fetal death but induces preterm labour

We have previously demonstrated that the anti-inflammatory prostaglandin 15-deoxy-Δ 12,14-prostaglandin J(2) (15dPGJ(2)) delays inflammation-induced preterm labour in the mouse and improves pup survival through the inhibition of nuclear factor-κB (NF-κB) by a mechanism yet to be elucidated. 15dPGJ(2) is an agonist of the second prostaglandin D(2) receptor, chemoattractant receptor homologous to the T helper 2 cell (CRTH2). In human T helper cells CRTH2 agonists induce the production of the anti-inflammatory interleukins IL-10 and IL-4. We hypothesized that CRTH2 is involved in the protective effect of 15dPGJ(2) in inflammation-induced preterm labour in the murine model. We therefore studied the effects of a specific small molecule CRTH2 agonist on preterm labour and pup survival. An intrauterine injection of lipopolysaccharide (LPS) was administered to CD1 mice at embryonic day 16, ± CRTH2 agonist/vehicle controls. Mice were killed at 4.5 hr to assess fetal wellbeing and to harvest myometrium and pup brain for analysis of NF-κB, and T helper type 1/2 interleukins. To examine the effects of the CRTH2 agonist on LPS-induced preterm labour, mice were allowed to labour spontaneously. Direct effects of the CRTH2 agonist on uterine contractility were examined ex vivo on contracting myometrial strips. The CRTH2 agonist increased fetal survival from 20 to 100% in LPS-treated mice, and inhibited circular muscle contractility ex vivo. However, it augmented LPS-induced labour and significantly increased myometrial NF-κB, IL-1β, KC-GRO, interferon-γ and tumour necrosis factor-α. This suggests that the action of 15dPGJ(2) is not via CRTH2 and therefore small molecule CRTH2 agonists are not likely to be beneficial for the prevention of inflammation-induced preterm labour.

Chemoattractant receptor homologous to the T helper 2 cell (CRTH2) is not expressed in human amniocytes and myocytes

BACKGROUND

15-deoxy-Δ 12,14- Prostaglandin J2 (15dPGJ2) inhibits Nuclear factor kappa B (NF-κB) in human myocytes and amniocytes and delays inflammation induced preterm labour in the mouse. 15dPGJ2 is a ligand for the Chemoattractant Receptor Homologous to the T helper 2 cell (CRTH2), a G protein-coupled receptor, present on a subset of T helper 2 (Th2) cells, eosinophils and basophils. It is the second receptor for Prostaglandin D2, whose activation leads to chemotaxis and the production of Th2-type interleukins. The cellular distribution of CRTH2 in non-immune cells has not been extensively researched, and its identification at the protein level has been limited by the lack of specific antibodies. In this study we explored the possibility that CRTH2 plays a role in 15dPGJ2-mediated inhibition of NF-κB and would therefore represent a novel small molecule therapeutic target for the prevention of inflammation induced preterm labour.

METHODS

The effect of a small molecule CRTH2 agonist on NF-κB activity in human cultured amniocytes and myocytes was assessed by detection of p65 and phospho-p65 by immunoblot. Endogenous CRTH2 expression in amniocytes, myocytes and peripheral blood mononuclear cells (PBMCs) was examined by PCR, western analysis and flow cytometry, with amniocytes and myocytes transfected with CRTH2 acting as a positive control in flow cytometry studies.

RESULTS

The CRTH2 agonist had no effect on NF-κB activity in amniocytes and myocytes. Although CRTH2 mRNA was detected in amniocytes and myocytes, CRTH2 was not detectable at the protein level, as demonstrated by western analysis and flow cytometry. 15dPGJ2 inhibited phospho-65 in PBMC'S, however the CRTH2 antagonist was not able to attenuate this effect. In conclusion, CRTH2 is not expressed on human amniocytes or myocytes and plays no role in the mechanism of 15dPGJ2-mediated inhibition of NF-κB.

Prevention of preterm labour via the modulation of inflammatory pathways

Pregnancy is characterized by a complex interplay of inflammatory events regulated by both the innate and acquired immune systems. Similarly, parturition can be viewed as the activation of "pro-labour" inflammatory pathways, which drive cervical ripening and myometrial activation. Premature activation of these pathways, for example, by infection, can lead to preterm labour and birth. Nuclear factor κβ is a key modulator of these pathways and functions by regulating the expression of prostaglandins, chemokines and pro-inflammatory cytokines involved in both term and preterm labour. Future design of therapeutics that target key mediators of inflammation and immune activation would therefore be a rational approach for preventing preterm labour and immune-mediated neonatal brain damage.

Vitamin D deficiency and supplementation during pregnancy

OBJECTIVE

Vitamin D is essential for skeletal health and prolonged deficiency results in infantile rickets and adult osteomalacia. The aim of this study is to determine the vitamin D status in pregnancy and to evaluate the effects of daily and of single-dose vitamin D supplementation.

DESIGN

A prospective randomized study at St Mary's Hospital London.

PATIENTS

A total of 180 women (Indian Asian, Middle Eastern, Black and Caucasian) were recruited at 27 weeks gestation and randomized into three treatment groups: a single oral dose of 200,000 IU vitamin D, a daily supplement of 800 IU vitamin D from 27 weeks until delivery and a no treatment group.

MEASUREMENTS

Vitamin D (25-hydroxyvitamin D), PTH and corrected calcium levels in mothers at 27 weeks and at delivery and cord 25-hydroxyvitamin D and corrected calcium levels.

RESULTS

The final maternal 25-hydroxyvitamin D levels were significantly higher in the supplemented group [daily dose (median) 42 (IQR 31-76) nmol/l, stat dose (median) 34 (IQR 30-46) nmol/l vs. median 27 (IQR 27-39) nmol/l in the no treatment; P < 0.0001] and significantly fewer women with secondary hyperparathyroidism in the supplemented group (10% in daily dose vs. 12% in stat dose vs. 27% in the no treatment; P < 0.05). Cord 25-hydroxyvitamin D levels were significantly higher with supplementation [daily dose median 26 (IQR 17-45) nmol/l, stat dose median 25 (IQR 18-34) nmol/l vs. median 17 (IQR 14-22) nmol/l in no treatment; P = 0.001].

CONCLUSION

Single or daily dose improved 25-hydroxyvitamin D levels significantly. However, even with supplementation, only a small percentage of women and babies were vitamin D sufficient. Further research is required to determine the optimal timing and dosing of vitamin D in pregnancy.

A comparison of knee kinematic characteristics of stroke patients and age-matched healthy volunteers

OBJECTIVE

To investigate which knee kinematic characteristics show the greatest differences between stroke patients with minimal residual disability and age-matched healthy volunteers as a first step towards the development of a sensitive, objective measure of performance of movement for use in the clinical setting.

DESIGN

A comparative study.

SETTING

A movement analysis laboratory.

SUBJECTS

Ten patients between 6 and 12 months post stroke aged between 65 and 74 years and 10 age-matched healthy volunteers. All patients had made a good recovery and were able to complete all of the functional tasks.

INTERVENTIONS

Each subject had reflective markers placed on anatomical landmarks and was filmed performing three movement tasks: sit-to-stand, walking, and step on block.

MAIN OUTCOME MEASURES

Knee kinematic characteristics involving timing, joint angle and angular velocity at key points during each task.

RESULTS

Significant differences were found between patients and volunteers for only some of the timing and joint angle characteristics but for all angular velocity characteristics for which the mean differences ranged from 31.85 degrees/s for sit-to-stand (p = 0.013) to 82.5 degrees/s (p = 0.014) for the swing phase of gait.

CONCLUSIONS

These preliminary findings suggest that angular velocity of the knee during functional tasks might have potential as a sensitive, objective measure of performance of movement after stroke for patients with minimal residual disability.

Agreement between physiotherapists on quality of movement rated via videotape

BACKGROUND

Although achieving quality of movement after stroke is an important aim of physiotherapy it is rarely measured objectively or described explicitly.

OBJECTIVE

To test whether physiotherapists agree on a composite measure of quality of movement. SETTING; A movement analysis laboratory

SUBJECTS

Ten stroke patients and 10 healthy age-matched volunteers.

DESIGN

Prospective correlational.

PROCEDURE

All subjects were videofilmed performing three trials of six standardized functional tasks. Two videotapes were made, each with a different randomized order of appearance of the trials. Ten senior physiotherapists independently rated the videotapes twice using a 100-mm visual analogue scale.

ANALYSIS

Analysis of variance models were fitted to transformed data. Estimates of components of variance were calculated and presented as a percentage of the total variance for differences, within subjects (intra-subject), between raters (inter-rater) and within raters (intra-rater). An acceptable percentage was set at less than 10%.

RESULTS

The percentage of intra-subject variance ranged from 1% (pick up box and walking) to 9% (step on block). The percentage of inter-rater variance ranged from 18% (pick up pencil) to 38% (sit to stand). The percentage of intra-rater variance was less than 1% for all tasks.

CONCLUSIONS

Although physiotherapists disagreed with each other on quality of movement they were more consistent in their own scoring.

The unreliability of clinical measures of muscle tone: implications for stroke therapy

BACKGROUND

the central tenet of the neurofacilitatory approach to stroke therapy is that muscle tone needs to be normal before normal movement can occur. A reliable clinical measure of the full spectrum of muscle tone is needed to test: (i) the purported relationship between muscle tone, other motor impairments and disability, and (ii) the effectiveness of stroke therapy to restore movement.

AIM

the purpose of the study was to test the inter-rater reliability of clinical categorization of muscle tone (spastic/normal/flaccid) and also a visual analogue scale with anchor points of 'lowest tone possible' (score 0) and 'highest tone possible' (score 100).

METHODS

four independent raters assessed tone of elbow flexors and knee extensors of 14 stroke rehabilitation inpatients using the categorical scale. Six independent raters assessed tone of elbow flexors and knee extensors of 25 chronic stroke patients and two healthy volunteers using the visual analogue scale. All assessment orders were randomized.

RESULTS

both scales were unreliable, with K coefficients for the categorical scale ranging from -0.046 to 0.56 for the categorical scale, and intra-class correlation coefficients for the visual analogue scale of 0.595 for elbow flexors and 0.451 for knee extensors. Assessment order effects for the visual analogue scale were non-significant for elbow flexors (P= 0.545) and knee extensors (P= 0.911).

CONCLUSIONS

these results, and those of earlier studies, suggest that clinical measures of muscle tone are consistently unreliable. Systematic investigation of the therapy rationale for planning and evaluating treatment is required before relevant clinical measures can be developed.

Outcome measures for the study of activities of daily living in vascular dementia

Decline in functional abilities is a major component of the dementia syndrome. The definition of dementia in the International Classification of Diseases (10th rev.) requires a cognitive impairment sufficient to impair personal activities of daily living (ADL). The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) also requires cognitive deficits sufficiently severe to cause impairment in occupational or social functioning and must represent a decline from a higher level of functioning. However, the term disability is more appropriate than impairment to describe a loss in activities, as opposed to a loss of elementary functions, and is consistent with World Health Organization definitions of impairment, disability, and handicap. There is no doubt that ADL outcomes are required in therapeutic drug studies on vascular dementia, and there is a good rationale and some evidence for the use of ADL scales developed for therapeutic research in Alzheimer disease, favoring scales devoid of items sensitive to physical disabilities. Similarly, ADL-related clinical milestones could be used for longer-term studies aiming predominantly at slowing progression of disease in both early and later stages of dementia. Slower decline in ADL and delay in reaching ADL-related clinical milestones should be considered as valid outcomes by regulatory bodies in the process of dementia drug approval.

A feeding adaptation by an infant with a cleft palate

One of the primary problems in the management and care of infants born with cleft palates is that of achieving an adequate seal of the cleft to allow proper swallowing to take place. This article describes an interesting case in which a 14-month-old baby, who had received no surgical or prosthodontic treatment for her cleft palate, had developed her own 'obturation' mechanism to enable her to swallow efficiently.

Objective measurement of use of the reciprocating gait orthosis (RGO) and the electrically augmented RGO in adult patients with spinal cord lesions

The purpose of the study was to measure objectively the home use of the reciprocating gait orthosis (RGO) and the electrically augmented (hybrid) RGO. It was hypothesised that RGO use would increase following provision of functional electrical stimulation (FES). Five adult subjects participated in the study with spinal cord lesions ranging from C2 (incomplete) to T6. Selection criteria included active RGO use and suitability for electrical stimulation. Home RGO use was measured for up to 18 months by determining the mean number of steps taken per week. During this time patients were supplied with the hybrid system. Three alternatives for the measurement of steps taken were investigated: a commercial digital pedometer, a magnetically actuated counter and a heel contact switch linked to an electronic counter. The latter was found to be the most reliable system and was used for all measurements. Additional information on RGO use was acquired using three patient diaries administered throughout the study and before and after the provision of the hybrid system. Testing of the original hypothesis was complicated by problems in finding a reliable measurement tool and difficulties with data collection. However, the results showed that overall use of the RGO, whether with or without stimulation, is low. Statistical analysis of the step counter results was not realistic. No statistically significant change in RGO use was found between the patient diaries. The study suggests that the addition of electrical stimulation does not increase RGO use. The study highlights the problem of objectively measuring orthotic use in the home.