Post-stroke urinary incontinence

AIM

To provide a comprehensive review of the current evidence on post-stroke urinary incontinence.

METHOD

An electronic database search was performed to identify relevant studies and review articles related to Urinary Incontinence (UI) in the stroke population between the years 1966 and 2012.

FINDINGS

Urinary incontinence following stroke is a common problem affecting more than one-third of acute stroke patients and persisting in up to a quarter at 1 year. It is well established that this condition is a strong marker of stroke severity and is associated with poorer functional outcomes and increased institutionalisation and mortality rates compared with those who remain continent. Despite evidence linking better outcomes to those patients who regain continence, the results of national audits have demonstrated that the management of UI following stroke is suboptimal, with less than two-thirds of stroke units having a documented plan to promote continence.

CONCLUSION

Current evidence supports a thorough assessment to categorise the type and severity of post-stroke urinary incontinence. An individually tailored, structured management strategy to promote continence should be employed. This has been associated with better stroke outcomes and should be the aim of all stroke health professionals.

Mitochondrial electron transport chain complexes, catalase and markers of oxidative stress in platelets of patients with severe aluminum phosphide poisoning

Aluminum phosphide (ALP), a widely used fumigant and rodenticide, leads to high mortality if ingested. Its toxicity is due to phosphine that is liberated when it comes in contact with moisture. The exact site or mechanism of action of phosphine is not known, although it is widely believed that it affects mitochondrial oxidative phosphorylation. Basic serum biochemical parameters, activity of mitochondrial complexes, antioxidant enzymes and parameters of oxidative stress were estimated in the platelets of 21 patients who developed severe poisoning following ALP ingestion. These parameters were compared with 32 healthy controls and with 22 patients with shock due to other causes (cardiogenic shock (11), septic shock (9) and hemorrhagic shock (2)). The serum levels of creatine kinase-muscle brain and lactate dehydrogenase were higher in patients poisoned with ALP, whereas a significant decrease was observed in the activities of mitochondrial complexes I, II and IV. The activity of catalase was lower but the activities of superoxide dismutase and glutathione peroxidase were unaffected in them. A significant increase in lipid peroxidation and protein carbonylation was observed, whereas total blood thiol levels were lower. In patients severely poisoned with ALP, not only cytochrome c oxidase but also other complexes are involved in mitochondrial electron transport, and enzymes are also inhibited.

The 2010 British Association of Stroke Physicians Survey of interventional treatments for stroke in the United Kingdom

INTRODUCTION

The UK National Stroke Strategy (Department of Health 2007) states that patients should have access to a stroke service with neurointerventional capacity. This survey was conducted by the Clinical Standards Committee of the British Association of Stroke Physicians to get a snapshot of the availability of interventional treatments for stroke in the United Kingdom.

METHODS

Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy.

RESULTS

Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2-20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5.2 (2-12) stroke physicians, 2.3 (0-4) interventional neuroradiologists, and 3.6 (0-9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists.

CONCLUSIONS

Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.

Chylous ascites: Why exercise is bad for you

INTRODUCTION

The development of chylous ascites is usually associated with trauma, iatrogenic or otherwise. Blunt abdominal trauma producing hyperextension or hyperflexion may cause disruption to lymphatic vessels causing chylous ascites.

PRESENTATION OF CASE

This report describes the case of a 38-year-old gentleman who presented to the emergency department with severe abdominal pain after completing a triathlon. As the patient was in severe pain, an abdominal CT was performed which demonstrated a possible mid gut volvulus. Subsequent laparotomy noted a significant volume of intra-abdominal chyle with no other abnormalities.

DISCUSSION

This is the first report of chylous ascites occurring without associated abdominal pathology after a period of strenuous exercise.

CONCLUSION

Chylous ascites can occur as a result of hyperreflexion and hyperextension injuries sustained during strenuous exercise.

'Sink or swim': an evaluation of the clinical characteristics of individuals with high bone mass

SUMMARY

High bone mineral density on routine dual energy X-ray absorptiometry (DXA) may indicate an underlying skeletal dysplasia. Two hundred fifty-eight individuals with unexplained high bone mass (HBM), 236 relatives (41% with HBM) and 58 spouses were studied. Cases could not float, had mandible enlargement, extra bone, broad frames, larger shoe sizes and increased body mass index (BMI). HBM cases may harbour an underlying genetic disorder.

INTRODUCTION

High bone mineral density is a sporadic incidental finding on routine DXA scanning of apparently asymptomatic individuals. Such individuals may have an underlying skeletal dysplasia, as seen in LRP5 mutations. We aimed to characterize unexplained HBM and determine the potential for an underlying skeletal dysplasia.

METHODS

Two hundred fifty-eight individuals with unexplained HBM (defined as L1 Z-score ≥ +3.2 plus total hip Z-score ≥ +1.2, or total hip Z-score ≥ +3.2) were recruited from 15 UK centres, by screening 335,115 DXA scans. Unexplained HBM affected 0.181% of DXA scans. Next 236 relatives were recruited of whom 94 (41%) had HBM (defined as L1 Z-score + total hip Z-score ≥ +3.2). Fifty-eight spouses were also recruited together with the unaffected relatives as controls. Phenotypes of cases and controls, obtained from clinical assessment, were compared using random-effects linear and logistic regression models, clustered by family, adjusted for confounders, including age and sex.

RESULTS

Individuals with unexplained HBM had an excess of sinking when swimming (7.11 [3.65, 13.84], p < 0.001; adjusted odds ratio with 95% confidence interval shown), mandible enlargement (4.16 [2.34, 7.39], p < 0.001), extra bone at tendon/ligament insertions (2.07 [1.13, 3.78], p = 0.018) and broad frame (3.55 [2.12, 5.95], p < 0.001). HBM cases also had a larger shoe size (mean difference 0.4 [0.1, 0.7] UK sizes, p = 0.009) and increased BMI (mean difference 2.2 [1.3, 3.1] kg/m(2), p < 0.001).

CONCLUSION

Individuals with unexplained HBM have an excess of clinical characteristics associated with skeletal dysplasia and their relatives are commonly affected, suggesting many may harbour an underlying genetic disorder affecting bone mass.

Listeria monocytogenes: a rare cause for an infected abdominal aortic aneurysm

Infected aneurysms associated with Listeria monocytogenes are rare. We describe a case of an infrarenal abdominal aortic aneurysm infected by Listeria monocytogenes. The aneurysm was diagnosed using a contrast-enhanced computed tomography (CT) scan and the infective organism identified within positive blood cultures. The patient underwent a successful urgent open aortic aneurysm repair and completed a 6-week course of antibiotics.

Glycopyrrolate in toxic exposure to ammonia gas

Ammonia (NH₃) is a highly water-soluble, colorless, irritant gas with a unique pungent odor. Liquid ammonia stored under high pressure is still widely used for refrigeration in cold stores used for storing grains. Severe toxicity may occur following accidental exposure. We report an interesting case of accidental exposure to ammonia treated with glycopyrrolate along with other supportive measures.

Development of tool for the assessment of comprehension of informed consent form in healthy volunteers participating in first-in-human studies

Informed consent is a process that involves providing all pertinent study information to the potential study participant. The information imparted in the form gives all such information as would enable a potential participant to come to a decision regarding his/her participation in the study. Various study related aspects are outlined in the participant information leaflet including the background of the study, the benefits and risks, treatment alternatives; the methodology of the study, follow up schedules, confidentiality of the data, compensations and remunerations and right to not participate or withdraw from the study. We have continued a similar exercise for a phase I, first-in-human study, conducted by our center. Here, the volunteers were asked certain questions pertaining to the trial background, design, patients' rights and miscellaneous categories. They were then assessed and the scores compared to come up with certain conclusions. The median (range) for the entire comprehension score was calculated and statistically analyzed on various aspects. Readability of the ease of reading of the consent form was also analyzed on a Flesch-Kinkaid reading scale. A total of 69 volunteers were screened out of which 50 were enrolled in the study. The median (range) score was 27 (19 to 33) and the mean (S.D.) score was 28.9 (3.1). The maximum correct responses were observed for the questions falling under the volunteers' rights category. The Flesch reading ease score was 54 and the Flesch-Kincaid Grade level score was 9.8. Investigators may be encouraged to incorporate such tools in their informed consent process.

Ferroelectric BaTiO3 thin films on Ti substrate fabricated using pulsed-laser deposition

We report on the fabrication of ferroelectric BaTiO3 thin films on titanium substrates using pulsed laser deposition and their microstructures and properties. Electron microscopy studies reveal that BaTiO3 films are composed of crystalline assemblage of nanopillars with average cross sections from 100 nm to 200 nm. The BaTiO3 films have good interface structures and strong adhesion with respect to Ti substrates by forming a rutile TiO2 intermediate layer with a gradient microstructure. The room temperature ferroelectric polarization measurements show that the as-deposited BTO films possess nearly the same spontaneous polarization as the bulk BTO ceramics indicating formation of ferroelectric domains in the films. Successful fabrication of such ferroelectric films on Ti has significant importance for the development of new applications such as structural health monitoring spanning from aerospace to civil infrastructure. The work can be extended to integrate other ferroelectric oxide films with various promising properties to monitor the structural health of materials.

Do older patients receive adequate stroke care? An experience of a neurovascular clinic

BACKGROUND

National guidelines and government directives have adopted policies for urgent assessment of patients with a transient ischaemic attack or minor stroke not admitted to hospital. The risk of recurrent stroke increases substantially with age, as does the potential benefit of secondary prevention. In order to develop effective strategies for older patients, it is important to identify how stroke care is currently provided for this patient group.

METHODS

Between 2004 and 2006, older patients (>75 years) referred to a neurovascular clinic were compared with younger patients (< or =75 years). Sociodemographic details, clinical features, resource use and secondary prevention in a neurovascular clinic were collected.

RESULTS

Of 379 patients referred to the clinic, 129 (34%) were given a non-stroke diagnosis. Of the remaining 250 patients, 149 (60%) were < or =75 years. Median time from symptom onset to clinic appointment was similar for the two groups (24 (IQR 15-42) vs 24 (IQR 14-43) days; p = 0.58). Older patients were more likely to be in atrial fibrillation (10.1% vs 22.8%, p<0.001) and have lacunar stroke (34.7% vs 22.1%; p = 0.04). CT rates were similar in the two groups (27.8% vs 80.0%, p = 0.75). Scans were performed more quickly in younger patients (p<0.01). MRI scan rates were higher in younger patients (26% vs 4%, p<0.01), as was carotid Doppler imaging (92% vs 77%, p<0.01). There were no differences in prescribed secondary preventive treatments. Older patients experienced less delay for carotid endarterectomy (49 vs 90 days, p<0.01). Younger patients were more likely to be given advice on weight reduction (30.2% vs 12.9%, p<0.01) and diet (46.3% vs 31.7%, p = 0.02) than older patients.

CONCLUSIONS

Older patients were less likely to receive diagnostic investigations and lifestyle modification advice than younger patients. Guidelines need to be adopted to ensure prompt evidence-based stroke care in the outpatient setting.