Australian health care workers experience of PPE related side-effects. A cross-sectional survey

Introduction

Protection of health care workers (HCWs) is a fundamental aspect of an effective pandemic response. During the COVID-19 pandemic, frequency, and duration of Personal Protective Equipment (PPE) use increased. The experience of PPE-related side-effects has potential to contribute to decreased compliance resulting in breaches in infection prevention and increasing risk of HCW exposure. This study aims were to measure the frequency of PPE-related side-effects amongst HCW in Australia, and to establish if an increased frequency of adverse reactions was related to the significant increase in use and extended duration of time spent in PPE.

Methods

A descriptive cross-sectional survey was used.

Results

Of the 559 respondents the majority were female (83.7%), aged 31-45 years old (33.6%). A pre-existing skin condition was reported by 266 (47.6%). Frequency of PPE related side-effects were: pressure-related 401 (71.7%), skin 321 (57.4%) and respiratory 20 (3.6%). Surgical mask use was significantly associated with pre-exiting skin conditions (β = 1.494 (SE 0.186), df (1), p < 0.001). Side effects to N95 respirator use was more commonly reported by staff working in COVID-19 high-risk areas (β = 0.572 (SE 0.211), df (1), p = 0.007) independent of work duration (β = -0.056 (SE 0.075), df (1), p = 0.456), and pre-existing skin conditions (β = 1.272, (SE.198), df (1), p < 0.001).

Conclusion

The COVID-19 pandemic has seen a significant increase in the use of PPE. While the preventative benefits of PPE are significant, adverse events related to PPE use are frequently reported by HCW. Findings in this study highlight the need for innovation in PPE design to maximize protection while decreasing adverse effects and maintaining adhere to use.

"Building the plane while flying it" Reflections on pandemic preparedness and response; an organisational case study

BACKGROUND

The COVID-19 pandemic provided a unique opportunity to learn about acute health organisations experiences implementing a pandemic response plan in real-time. This study was conducted to explore organisational leader's perspectives and experience activating a COVID-19 pandemic response plan in their health service and the impact of this on service provision, clinicians, and consumers.

METHODS

This study was conducted at a large metropolitan health service in Australia that provides acute, subacute, and residential aged care services. Semi-structured interviews were conducted with 12 key participants from the COVID-19 leadership team between November-January 2021/2022. A semi-structured interview guide was developed to explore how the health service developed a clinical governance structure, policy and procedures and experience when operationalising each element within the Hierarchy of Controls Framework. Thematic analysis was used to code data and identify themes. A cross-sectional survey of frontline healthcare workers on the impacts and perceptions of infection control practices during the COVID-19 pandemic, was also completed in 2021 with 559 responses.

RESULTS

Twelve organisational leaders completed the semi-structured interviews. Key themes that emerged were: (1) Building the plane while flying it, (2) A unified communications strategy, (3) Clinicians fear 'my job is going to kill me', (4) Personal Protective Equipment (PPE) supply and demand, and (5) Maintaining a workforce. When surveyed, front-line healthcare workers responded positively overall about the health services pandemic response, in terms of communication, access to PPE, education, training, and availability of resources to provide a safe environment.

CONCLUSION

Health service organisations were required to respond rapidly to meet service needs, including implementing a pandemic plan, developing a command structure and strategies to communicate and address the workforce needs. This study provides important insights for consideration when health service leaders are responding to future pandemics. Future pandemic plans should include detailed guidance for acute and long-term care providers in relation to organisational responsibilities, supply chain logistics and workforce preparation.

Photodiagnostic services in the UK and Republic of Ireland: a British Photodermatology Group Workshop Report

BACKGROUND

Photodiagnostic investigations are essential for the accurate diagnosis of abnormal cutaneous photosensitivity and provide important information for the management of patients with photodermatoses (cutaneous photosensitivity disorders). Although photodiagnosis has been undertaken since the early 1970s, specialist services in the United Kingdom (UK) and Republic of Ireland are limited and there is no formal guidance on diagnostic approach. Indeed, there is a limited literature in this area of methodology and diagnostic practice.

OBJECTIVES

The primary objective was to undertake a British Photodermatology Group Workshop to review the role and activities of specialist centres in the UK and Republic of Ireland in order to ascertain whether there were consensus practices. Secondary objectives were to identify key priorities for service, training and research.

METHODS

An initial detailed survey review of current activities was undertaken prior to the Workshop and data from this survey were used to inform discussion at the Workshop, which was attended by key photodermatology experts from the UK and Republic of Ireland.

RESULTS/CONCLUSIONS

We have undertaken a detailed review of current Photodiagnostic Services in the UK and Republic of Ireland and report on our findings from the 12 centres and we have identified key areas of consensus practice. This is an important step in the process of standardising and optimising procedures and protocols and defining minimum clinical standards for photodiagnostic investigations, which are of such diagnostic importance in Dermatology.

Digitial endochondroma

A patient with Ollier disease presenting with onycholysis and nail dystrophy related to a subungual enchondroma is presented.

Are results of bariatric surgery different in the Middle East? Early experience of an international bariatric surgery program and an ACS NSQIP outcomes comparison

BACKGROUND

Bariatric operations performed at the Bariatric and Metabolic Institute Abu Dhabi are submitted randomly from the entire surgery volume at Sheikh Khalifa Medical City to the American College of Surgeons (ACS) NSQIP. Our aim is to report our early experience and compare our bariatric surgery outcomes with ACS NSQIP hospitals of similar size.

STUDY DESIGN

We queried the ACS NSQIP database for bariatric surgery codes between August 2009 and August 2012 for hospitals with >500 beds. Statistical analysis was performed (p < 0.05).

RESULTS

We performed 275 bariatric operations compared with a total of 29,715 at other NSQIP hospitals. The ACS NSQIP bariatric surgery cohort at the Bariatric and Metabolic Institute Abu Dhabi represents 275 of 312 (89.3%) of our entire bariatric surgery volume. Our patients were statistically significantly younger (mean age 36 vs 44.8 years), healthier (American Society of Anesthesiologists scores 1 to 2 in 78.6% vs 35.7%), and heavier (body mass index 47.4 vs 45.5). In addition, we had fewer diabetic (18.5% vs 27.3%) and hypertensive (21.1% vs 52.2%) patients. We performed more Roux-en-Y gastric bypass (69.8% vs 54.5%) and sleeve gastrectomy (24.8% vs 17.2%) and fewer laparoscopic adjustable gastric banding (0.8% vs 22.7%). Outcomes were similar with regard to rates of reoperation, wounds, urinary tract infection, bleeding, thromboembolic, respiratory, and overall complications. We had lower septic, cardiac, and renal failure complications; lower mortality, and longer hospital stay by 0.4 days. We achieved 94.9% 30-day follow-up compared with 90.7% at other ACS NSQIP hospitals.

CONCLUSIONS

This is the first report comparing outcomes of an international bariatric surgery program (Bariatric and Metabolic Institute Abu Dhabi) with ACS NSQIP bariatric surgery programs. Our outcomes are equivalent to ACS NSQIP bariatric surgery programs.

Unintended cardiac irradiation during left-sided breast cancer radiotherapy

OBJECTIVE

Cardiac irradiation during left-sided breast radiotherapy may lead to deleterious cardiac side effects. Using image guided radiotherapy, it is possible to exclude the heart from treatment fields and monitor reproducibility of virtual simulation (VS) fields at treatment delivery using electronic portal imaging (EPI). Retrospectively, we evaluate the incidence of cardiac irradiation at VS and subsequent unintended cardiac irradiation during treatment.

METHODS

Patients receiving left-sided radiotherapy to the breast or chest wall, treated with a glancing photon field technique during a four-month period, were included. VS images and EPIs during radiotherapy delivery were visually assessed. The presence of any portion of the heart within the treatment field at VS or during treatment was recorded. Central lung distance and maximum heart distance were recorded.

RESULTS

Of 128 patients, 45 (35.1%) had any portion of the heart within the planned treatment field. Of these, inclusion of the heart was clinically unavoidable in 25 (55.6%). Of those with no heart included in the treatment fields at VS, 41 (49.4%) had presence of the heart as assessed on EPI during treatment.

CONCLUSION

Unintended cardiac irradiation during left-sided breast radiotherapy treatment occurs in a sizeable proportion of patients.

ADVANCES IN KNOWLEDGE

Despite the use of three-dimensional computed tomography simulation and cardiac shielding, sizeable proportions of patients receiving left-sided breast cancer radiotherapy have unintended cardiac irradiation.

The Cochrane review of occupational therapy for cognitive impairment in stroke patients

Cognitive impairment frequently follows stroke and impairs everyday activities. This review aimed to determine whether occupational therapy improves functional performance of basic activities of daily living (ADL) and specific cognitive abilities in people who have cognitive impairment after stroke. In this review, randomised and quasi-randomised controlled trials that evaluated an occupational therapy intervention focused on providing cognitive retraining to adults with clinically defined stroke and confirmed cognitive impairment were included. Searches up to April 2009 were conducted in: the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, PsycBITE, OTseeker, and Dissertation Abstracts. The search also included a review of the reference lists of relevant studies, a hand-search of relevant occupational therapy journals, and contact with key researchers in the area. Two review authors independently examined the abstracts that might meet the inclusion criteria, assessed the methodological quality, and extracted data. Of 17 trials that appeared to be relevant and were reviewed in full text, only one trial (N=33) was finally included in this review. The study was an RCT of cognitive skills remediation training and there was no difference between groups for the two outcomes that were relevant to this review that were measured: improvement in time judgement skills and improvement in basic ADLs on the Barthel Index. The effectiveness of occupational therapy for cognitive impairment post-stroke remains unclear. The potential benefits of cognitive retraining delivered as part of occupational therapy on improving basic daily activity function or specific cognitive abilities, or both, of people who have had a stroke cannot be supported or refuted by the evidence included in this review. More research is required.

Caregiver burden, time spent caring and health status in the first 12 months following stroke

OBJECTIVE

To quantify time caring, burden and health status in carers of stroke patients after discharge from rehabilitation; to identify the potentially modifiable sociodemographic and clinical characteristics associated with these outcomes.

METHODS

Patients and carers prospectively interviewed 6 (n=71) and 12 (n=57) months after discharge. Relationships of carer and patient variables with burden, health status and time analysed by Gaussian and Poisson regression.

RESULTS

Carers showed considerable burden at 6 and 12 months. Carers spent 4.6 and 3.6 hours per day assisting patients with daily activities at 6 and 12 months, respectively. Improved patient motor and cognitive function were associated with reductions of up to 20 minutes per day in time spent in daily activities. Better patient mental health and cognitive function were associated with better carer mental health.

CONCLUSIONS

Potentially modifiable factors such as these may be able to be targeted by caregiver training, support and education programmes and outpatient therapy for patients.

Parental involvement in paediatric cancer treatment decisions

This study investigated parents' information needs and involvement in decision-making processes affecting the care of children diagnosed with cancer. Interviews and questionnaires were used to assess parental satisfaction in 50 mothers and 16 fathers responsible for 58 children in an English Paediatric Oncology Unit. Parents reported that doctors contributed almost twice as much to the decision-making process as they did, but parental satisfaction was positively correlated with the amount of information provided when giving informed consent. Satisfaction about their involvement in this process relied heavily upon the level of support received from others. Parents consenting to their child's involvement in non-randomised trials perceived themselves to be under greater pressure from others during the decision-making process while those whose children were further along the treatment trajectory were more uncertain about decisions previously made. Findings indicate that the accessibility, support, information and degree of control afforded to parents by healthcare professionals impacts upon their satisfaction with both the decision-making process and their confidence in the decisions thus made. Information and support tailored to parents' specific needs may therefore enhance satisfaction with clinical decision making and reassure parents about decisions made in the long-term interest of their child's health.

Atrial natriuretic peptide increases urinary albumin excretion in people with normoalbuminuric type-2 diabetes

BACKGROUND

Atrial natriuretic peptide (ANP) is elevated in patients with type-2 diabetes and microalbuminuria. The purpose of this study is to evaluate if ANP increases Urinary Albumin Eaxcretion Rate (UAER) in type-2 diabetes.

METHODS

Eight normoalbuminuric diabetic subjects underwent a randomised single blind study of 60 min intravenous infusion of ANP or vehicle. Eight non-diabetic controls underwent ANP infusion alone. Seven normoalbuminuric type-2 diabetes subjects received further ANP infusions during euglycaemia and during hyperglycaemia.

RESULTS

ANP increased urinary sodium (191.3 +/- 80.7 to 529.2 +/- 263.4 mumol/min, mean +/- SD, and P < 0.001) and UAER (72.2 +/- 73.4 to 224.9 +/- 182.9.5 mug/min, and P < 0.01) in diabetic subjects. In controls, UAER did not change significantly (P = 0.16); however, the natriuretic response to ANP was similar to diabetic subjects (P = 0.98). Hyperglycaemic did not enhance the albuminuric response to ANP (P = 0.88).

CONCLUSION

ANP increases UAER in normoalbuminuric type-2 diabetic subjects.

A case of haemodialysis-associated pseudoporphyria successfully treated with oral N-acetylcysteine

We report a 33-year-old woman with haemodialysis-associated pseudoporphyria successfully responding to treatment with oral N-acetylcysteine. We briefly review the current literature on bullous skin disorders in end-stage renal disease, and compare and contrast the pathogenesis of pseudoporphyria and porphyria cutanea tarda in this context. We also discuss the antioxidant properties and clinical applications of N-acetylcysteine, including the treatment of haemodialysis-associated pseudoporphyria.

Activating mutations in NOTCH1 in acute myeloid leukemia and lineage switch leukemias

Activating mutations in NOTCH1 are found in over 50% of human T-cell lymphoblastic leukemias (T-ALLs). Here, we report the analysis for activating NOTCH1 mutations in a large number of acute myeloid leukemia (AML) primary samples and cell lines. We found activating mutations in NOTCH1 in a single M0 primary AML sample, in three (ML1, ML2 and CTV-1) out of 23 AML cell lines and in the diagnostic (myeloid) and relapsed (T-lymphoid) clones in a patient with lineage switch leukemia. Importantly, the ML1 and ML2 AML cell lines are derived from an AML relapse in a patient initially diagnosed with T-ALL. Overall, these results demonstrate that activating mutations in NOTCH1 are mostly restricted to T-ALL and are rare in AMLs. The presence of NOTCH1 mutations in myeloid and T-lymphoid clones in lineage switch leukemias establishes the common clonal origin of the diagnostic and relapse blast populations and suggests a stem cell origin of NOTCH1 mutations during the molecular pathogenesis of these tumors.

Elevated plasma concentrations of atrial and brain natriuretic peptide in type 1 diabetic subjects

BACKGROUND

The intravenous infusion of atrial (ANP) and brain (BNP) natriuretic peptides have been shown to increase urinary albumin excretion in type 1 diabetes.

AIMS

To measure plasma ANP and BNP concentrations in patients with type 1 diabetes and to examine the parameters associated with elevated plasma concentrations. Methods We measured plasma ANP and BNP concentrations, UAER, HbA1C systolic blood pressure, and left ventricular mass index. Plasma ANP and BNP were also measured in non-diabetic control subjects for comparison.

RESULTS

Using multivariate regression analysis plasma ANP correlated positively with HbA1C (1.9 + 0.47, p = 0.0002), UAER (0.37 + 0.05, p = 0.00001), SBP (1.26 + 0.5, p = 0.01) and LVMI (00.46 + 0.25, p = 0.07). BNP was positively related with LVMI (0.95 + 0.4, p = 0.02), and UAER (0.56 + 0.08, p = 0.001).

CONCLUSIONS

Plasma concentrations of ANP and BNP are elevated in some patients with type 1 diabetes. Plasma ANP concentrations are closely related to UAER and elevated plasma concentrations are associated with poor glycaemic control and systemic hypertension. Plasma BNP concentration is related to LVMI.

Coexistence of psoriasis and linear IgA disease in a patient with recent herpes zoster infection

We report the case of a 29-year-old man with chronic plaque psoriasis who developed linear IgA disease following herpes zoster infection. There has only been one previous report describing the coexistence of psoriasis and linear IgA disease, which was confirmed by immunopathological studies. In our patient, immunoblotting studies identified IgA antibodies binding to BP180 and BP230 antigens, and IgG autoantibodies binding weakly to the BP180 antigen. This is an interesting case that we believe is an example of epitope spreading in the development of autoimmune subepidermal bullous diseases.

An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report

Summary These guidelines for use of narrowband (TL-01) ultraviolet B have been prepared for dermatologists by the British Photodermatology Group on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment of patients with a variety of dermatoses and photodermatoses, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of background photobiology.

In search of evidence for occupational therapy: A new tool

Where is the evidence that occupational therapy intervention can make a difference? In short, it may be found somewhere among thousands of articles, spread over hundreds of journals. It is not surprising that surveys show that a major difficulty facing occupational therapists implementing evidence-based practice is the limited time they have to locate relevant research (Humphris et al, 2000; Bennett et al, 2003).

Homozygous factor V Leiden mutation in a patient with traumatic leg ulceration

Factor V Leiden mutation is a well-established risk factor for venous thrombosis and ulceration. We report a 20-year-old male patient who presented with a traumatic left leg ulcer that responded poorly to therapy. He had no previous medical history. Following investigation it was discovered that the patient had extensive venous thrombosis of the left leg veins and was homozygous for the factor V Leiden gene mutation. This case demonstrates the need for detailed history taking and thorough investigation of any atypical ulcer in young adults.

The albuminuric action of atrial natriuretic peptide is not modified by ACE-inhibition with perindopril in Type 2 diabetes

AIMS

Atrial natriuretic peptide (ANP) increases urine albumin excretion (UAER) in humans with Type 1 diabetes. The aim of this study was to establish if ANP increases UAER in microalbuminuric subjects with Type 2 diabetes and to examine whether the albuminuric action of ANP was inhibited by pre-treatment with the ACE-inhibitor perindopril.

METHODS

Seven microalbuminuric, normotensive males with Type 2 diabetes were entered into a randomised, double-blind, three-armed study of (i) intravenous infusion of ANP (0.25 microg/kg/min in 0.9% NaCl) after 3 weeks' pre-treatment with placebo, (ii) intravenous infusion of vehicle (0.9% NaCl only) after 3 weeks' pre-treatment with placebo, or (3) intravenous infusion of ANP (0.25 microg/kg/min in 0.9% NaCl) after 3 weeks' pre-treatment with perindopril, 4 mg daily.

RESULTS

Baseline parameters were similar on all three study days. During the placebo/vehicle arm there was no change in urine flow rate (UFR, P=0.61), urine cyclic guanosine monophosphate (UcGMP P=0.48) or UAER (P=0.99). During the placebo/ANP arm there was a rise in UFR [13.7+/-2.8 (mean+/-sd) to 25.7+/-7.7 mL/min, P<0.001], UcGMP (60.0+/-36.6 to 160.8+/-118.5 micromol/mmolCr, P=0.045) and UAER [5.13 [2.4-11.6][median (range)] to 71.6 [21.6-175.1] mg/mmolCr, P<0.001]. Pre-treatment with perindopril did not alter the changes in UFR (P=0.63), UcGMP (P=0.46) or UAER (P=0.99) to infusion of ANP, compared with the placebo/ANP arm.

CONCLUSION

ANP increases UAER in microalbuminuric patients with Type 2 diabetes and the albuminuric action of ANP is not inhibited by pre-treatment with the ACE inhibitor perindopril.

Defining quality of life for Chinese elderly stroke survivors

PURPOSE

This study aimed to identify the constituents and conceptual characteristics of the quality of life (QOL) of Chinese elderly stroke survivors, living in the community in Hong Kong.

METHOD

A triangulated approach was used to identify the QOL components for this population. This process involved a comparison of QOL components gathered from three different methods, namely, focus group interviews, review of the literature and the contents of the generic Hong Kong Chinese version of the World Health Organization Quality of Life Scale (CWHOQOL-HK). Five health professionals were involved in the comparison process. A percentage of inter-judge agreement was used to determine the reliability of the comparisons made between the judges.

RESULTS

This study identified 36 components considered to contribute to the QOL of Chinese elderly stroke survivors in Hong Kong. The conceptual characteristics of their QOL generally concurred with those identified in the literature.

CONCLUSION

Both similarities and differences were found in the QOL components identified in this study when compared to those identified in studies of Western populations who are elderly and had a stroke. The contents of the CWHOQOL-HK scale were found to lack adequacy in representing the QOL of Chinese elderly stroke survivors in Hong Kong. Recommendations are given, based on the findings of this study, to overcome this limitation for its application as a QOL measure for this population.

Keratitis-ichthyosis-deafness syndrome and carotenaemia

Keratitis-ichthyosis-deafness (KID) syndrome is a congenital ectodermal disorder that causes erythrokeratoderma, vascularizing keratitis, and neurosensory deafness. We report a form of this syndrome in a patient with no evidence of keratitis. In addition this individual had clinical and biochemical evidence of carotenaemia. Carotenaemia occurring in association with KID syndrome has not been reported previously.

Rehabilitation outcomes in traumatic spinal cord injury in Australia: functional status, length of stay and discharge setting

STUDY DESIGN

Retrospective, descriptive study.

OBJECTIVES

To describe patients' length of stay (LOS), functional status and discharge setting after rehabilitation and how degree of impairment (complete/incomplete paraplegia/tetraplegia) impacts on these outcomes. To compare actual LOS with estimated LOS. Estimated LOS was based on an Australian model, the Australian National Sub-acute and Non-acute Patient Classification System (AN-SNAP), which classifies patients using admission Functional Independence Measure (FIM trade mark ) scores. To further describe outcomes for each AN-SNAP class by degree of impairment.

SETTING

Spinal Injuries Unit of major Metropolitan hospital in Brisbane, Australia.

METHODS

Retrospective chart review of 167 patients with traumatic spinal cord injury (SCI). Main outcome measures were rehabilitation LOS, discharge FIM trade mark scores and discharge setting. Injury measures were degree of impairment, acute LOS and rehabilitation admission FIM trade mark scores. Standard demographic measures were also collected.

RESULTS

The median rehabilitation LOS was 83 days and mean discharge FIM trade mark scores 102 for all patients. These differed by impairment (incomplete paraplegia LOS 43, FIM 117; complete paraplegia LOS 96, FIM 109; incomplete tetraplegia LOS 64, FIM 100; complete tetraplegia LOS 206, FIM 78). Patients discharged to the community (noncare facility) ranged from 93% with incomplete paraplegia to 73% with complete tetraplegia. For patients in the three AN-SNAP classes with the lowest FIM scores, the actual LOS was up to twice the estimated LOS. A large variability in discharge outcomes was found within individual AN-SNAP classes, despite similar FIM trade mark scores on admission.

CONCLUSIONS

Rehabilitation outcomes differed substantially by impairment. The variability in outcomes for patients within the same AN-SNAP class questions the ability of this system to accurately predict LOS, and therefore cost of rehabilitation services, for patients with traumatic SCI in Australia.

Selegiline enhances erectile activity induced by dopamine injection in the paraventricular nucleus of the hypothalamus in anesthetized rats

Apomorphine delivered in the paraventricular nucleus of the hypothalamus (PVN) induces penile erection in rats, suggesting a role of dopaminergic projection to the PVN in the control of penile erection. We assessed whether the selective inhibitor of monoamine oxidase B, selegiline, could enhance the erectile activity induced by dopamine delivery in the PVN. Intracavernous and blood pressure (ICP and BP) were monitored in anesthetized rats to quantify ICP rises (number and percentage of ICP maximum/mean BP (ICPmax/BP x 100)) elicited by 10 micro g dopamine injection in the PVN after saline or 3 mg/kg i.v. selegiline (8 rats per group). The number of ICP rises (mean+/-s.d.: 4.5+/-2.9 vs 1.4+/-1.9; P=0.017) and their ICPmax/BP x 100 (49+/-8% vs 34+/-9%; P=0.015) were significantly greater upon dopamine injection in the PVN than upon vehicle. Compared to saline i.v., 3 mg/kg selegiline pretreatment significantly increased the number of ICP rises induced by dopamine injection in the PVN (9.4+/-2.6 vs 4.5+/-2.9; P<0.001), without affecting their amplitude. This suggests that drugs potentiating dopaminergic responses in the central nervous system might enhance proerectile commands of supraspinal origin.

Baroregulation of vasopressin release in adipsic diabetes insipidus

Adipsic diabetes insipidus (ADI) occurs in association with a heterogeneous group of conditions. We report vasopressin (AVP) responses to hypotension in nine patients with ADI and nine controls. Hypertonic saline infusion produced absent thirst (1.7 +/- 1.7 to 1.5 +/- 1.7 cm, P = 0.99) and AVP responses (0.3 +/- 0.1 to 0.4 +/- 0.1 pmol/liter, P = 0.99) in the ADI group, who also drank less than the control group (258 +/- 200 ml vs. 1544 +/- 306 ml, P < 0.001). Intravenous infusion of trimetaphan camsylate produced a fall in mean arterial pressure of 31.6% +/- 8.9% in patients and 29.4% +/- 6.1% in controls. Plasma AVP concentrations rose from 1.4 +/- 0.8 to 340.3 +/- 497.4 pmol/liter (P < 0.001) in the control group. In three patients with craniopharyngioma, there was no rise in plasma AVP concentrations (0.3 +/- 0.1 to 0.3 +/- 0.1 pmol/liter, P = 0.96), but plasma AVP rose significantly in response to hypotension in the other six patients (0.4 +/- 0.2 to 204.5 +/- 223.2 pmol/liter, P < 0.001). We concluded that the AVP responses to hypotension in ADI are heterogeneous and reflect the site of the lesion causing the diabetes insipidus.

Guidelines for topical photodynamic therapy: report of a workshop of the British Photodermatology Group

Topical photodynamic therapy (PDT) is effective in the treatment of certain non-melanoma skin cancers and is under evaluation in other dermatoses. Its development has been enhanced by a low rate of adverse events and good cosmesis. 5-Aminolaevulinic acid (ALA) is the main agent used, converted within cells into the photosensitizer protoporphyrin IX, with surface illumination then triggering the photodynamic reaction. Despite the relative simplicity of the technique, accurate dosimetry in PDT is complicated by multiple variables in drug formulation, delivery and duration of application, in addition to light-specific parameters. Several non-coherent and coherent light sources are effective in PDT. Optimal disease-specific irradiance, wavelength and total dose characteristics have yet to be established, and are compounded by difficulties comparing light sources. The carcinogenic risk of ALA-PDT appears to be low. Current evidence indicates topical PDT to be effective in actinic keratoses on the face and scalp, Bowen's disease and superficial basal cell carcinomas (BCCs). PDT may prove advantageous where size, site or number of lesions limits the efficacy and/or acceptability of conventional therapies. Topical ALA-PDT alone is a relatively poor option for both nodular BCCs and squamous cell carcinomas. Experience of the modality in other skin diseases remains limited; areas where there is potential benefit include viral warts, acne, psoriasis and cutaneous T-cell lymphoma. A recent British Photodermatology Group workshop considered published evidence on topical PDT in order to establish guidelines to promote the efficacy and safety of this increasingly practised treatment modality.

Brain natriuretic peptide increases urinary albumin and alpha-1 microglobulin excretion in Type 1 diabetes mellitus

Atrial natriuretic peptide (ANP) increases urinary albumin excretion in Type 1 diabetes mellitus (DM). Brain natriuretic peptide (BNP) is structurally and functionally related to ANP, but its effect on urine albumin excretion rate (UAER) is unknown.

AIMS

To compare the albuminuric effects of intravenous infusion of ANP and BNP, and to assess the effect of both peptides on tubular protein excretion.

METHODS

Eight subjects with Type 1 DM were randomised to a three leg, double blind, and placebo controlled study. On each study day, subjects were euglycaemic clamped and subsequently water loaded (20 mL/kg orally, plus urine losses) to steady state diuresis. When in steady state, creatinine clearance was estimated in three separate 1 hour periods. At the end of the first period, a 1 hour intravenous infusion of either placebo, ANP 0.025 microg/kg/min, or BNP 0.025 microg/kg/min was administered. There followed a 1 hour recovery period. Urine was collected at 15 min intervals for estimation of urine albumin (ACR) and alpha1 microglobulin creatinine ratio (MCR). Results were analysed by anova.

RESULTS

Creatinine clearance was similar on the three study days, and was unaltered by any infusion. ACR was unaltered by placebo (1.3 +/- 0.5-1.2 +/- 0.4 mg/mmol, mean +/- SD, p = 0.81), but increased compared to placebo with infusion of both ANP (1.2 +/- 0.4-9.8 +/- 8.4 mg/mmol, P = 0.0004), and BNP (1.1 +/- 0.4-13.4 +/- 8.6 mg/mmol, P = 0.0001). The MCR was unaltered by placebo infusion (P = 0.89), but increased compared with placebo after infusion of ANP (5.4 +/- 0.9-12.3 +/- 4.2 mg/mmol, P < 0.0001), and BNP (5.4 +/- 0.8-12.1 +/- 2.5 mg/mmol, P < 0.0001).

CONCLUSIONS

Intravenous infusion of BNP and ANP both increase the urine excretion of albumin and the tubular protein alpha1 microglobulin, independent of creatinine clearance.

Hemiplegic shoulder pain: defining the problem and its management

PURPOSE

Hemiplegic shoulder pain can affect up to 70% of stroke patients and can have an adverse impact on rehabilitation outcomes. This article aims to review the literature on the suggested causes of hemiplegic shoulder pain and the therapeutic techniques that can be used to prevent or treat it. On the basis of this review, the components of an optimal management programme for hemiplegic shoulder pain are explored.

METHOD

English language articles in the CINAHL and MEDLINE databases between 1990 and 2000 were reviewed. These were supplemented by citation tracking and manual searches.

RESULTS

A management programme for hemiplegic shoulder pain could comprise the following components: provision of an external support for the affected upper limb when the patient is seated, careful positioning in bed, daily static positional stretches, motor retraining and strapping of the scapula to maintain postural tone and symmetry.

CONCLUSIONS

Research is required to evaluate the effectiveness of the components of the proposed management programme for the prevention and treatment of hemiplegic shoulder pain and to determine in what combination they achieve the best outcomes.

Rehabilitation outcomes for brain injured patients in Australia: functional status, length of stay and discharge destination

This study describes the rehabilitation length of stay (LOS), discharge destination and discharge functional status of 149 patients admitted with traumatic brain injury (TBI) to an Australian hospital over a 5-year period. Hospital charts of patients admitted between 1993-1998 were reviewed. Average LOS over the 5-year time period was 61.8 days and only decreased nominally over this time. Longer LOS was predicted by lower admission motor FIM scores and presence of comorbidities. Mean admission and discharge motor FIM scores were 58 and 79, which represented a gain of 21 points. Higher discharge motor FIM scores were predicted by higher admission motor FIM scores and younger age. FIM gain was predicted by cognitive status and age. Most patients, 88%, were discharged back to the community, with 30% changing their living setting or situation. Changing living status was predicted by living alone and having poorer functional status on admission.

Spinal proerectile effect of oxytocin in anesthetized rats

The spinal cord contains the neural network that controls penile erection. This network is activated by information from peripheral and supraspinal origin. We tested the hypothesis that oxytocin (OT), released at the lumbosacral spinal cord level by descending projections from the paraventricular nucleus, regulated penile erection. In anesthetized male rats, blood pressure and intracavernous pressure (ICP) were monitored. Intrathecal (it) injection of cumulative doses of OT and the selective OT agonist [Thr4,Gly7]OT at the lumbosacral level elicited ICP rises whose number, amplitude, and area were dose dependent. Thirty nanograms of OT and one-hundred nanograms of the agonist displayed the greatest proerectile effects. Single injections of OT also elicited ICP rises. Preliminary injection of a specific OT-receptor antagonist, hexamethonium, or bilateral pelvic nerve section impaired the effects of OT injected it. NaCl and vasopressin injected it at the lumbosacral level and OT injected it at the thoracolumbar level or intravenously had no effect on ICP. The results demonstrate that OT, acting at the lumbosacral spinal cord, elicits ICP rises in anesthetized rats. They suggest that OT, released on physiological activation of the PVN in a sexually relevant context, is a potent activator of spinal proerectile neurons.

Conceptualizing quality of life for elderly people with stroke

PURPOSE

Despite increased interest in quality of life (QOL) as an outcome measure and as a means of identifying client needs in health care, its conceptualisation and the identification of its constituents have been poorly researched for elderly people with stroke in Hong Kong.

METHOD

This article analysed the literature to identify components relevant to the QOL of Chinese elderly people with stroke living in the community in Hong Kong.

RESULTS

While common components of QOL for elderly people with and without stroke and regardless of cultural background were identified, a number were specific to an elderly Chinese stroke population.

CONCLUSION

Recommendations for future research have been made with reference to further exploring and validating these components for the target population. A clear understanding of these aspects is essential for the development of sensitive QOL measures to guide and evaluate service delivery to this population.

Randomised trial of personalised computer based information for patients with schizophrenia

OBJECTIVES

To compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia.

DESIGN

Randomised trial of three interventions. Modelling of costs of alternatives.

PARTICIPANTS

112 patients with schizophrenia in contact with community services; 67 completed the intervention.

INTERVENTIONS

Three interventions of five educational sessions: (a) computer intervention combining information from patient's medical record with general information about schizophrenia; (b) sessions with a community psychiatric nurse; (c) "combination" (first and last sessions with nurse and remainder with computer).

MAIN OUTCOME MEASURES

Patients' attendance, opinions, change in knowledge, and psychological state; costs of interventions and patients' use of NHS community services; modelling of costs for these three, and alternative, interventions.

RESULTS

Rates of completion of intervention did not differ significantly (71% for combination intervention, 61% for computer only, 46% for nurse only). Computer sessions were shorter than sessions with nurse (14 minutes v 60 minutes). More patients given nurse based education thought the information relevant. Of 20 patients in combination group, 13 preferred the sessions with the nurse and seven preferred the computer. There were no significant differences between groups in psychological outcomes. Because of the need to transport patients to the computer for their sessions, there was no difference between interventions in costs, but computer sessions combined with other patient contacts would be substantially cheaper.

CONCLUSIONS

The computer based patient education offered no advantage over sessions with a community psychiatric nurse. Investigation of computer use combined with other health service contacts would be worth while.

Childhood-onset psychotic disorders: magnetic resonance imaging of volumetric differences in brain structure

OBJECTIVE

Although childhood-onset schizophrenia is rare, children with brief psychotic symptoms and prominent emotional disturbances commonly present diagnostic and treatment problems. Quantitative anatomic brain magnetic resonance images (MRIs) of a subgroup of children with psychotic disorder not otherwise specified were compared with those of children with childhood-onset schizophrenia and healthy comparison subjects.

METHOD

Anatomic MRIs were obtained for 71 patients (44 with childhood-onset schizophrenia and 27 with psychotic disorder not otherwise specified) and 106 healthy volunteers. Most patients had been treated with neuroleptics. Volumetric measurements for the cerebrum, anterior frontal region, lateral ventricles, corpus callosum, caudate, putamen, globus pallidus, and midsagittal thalamic area were obtained.

RESULTS

Patients had a smaller total cerebral volume than healthy comparison subjects. Analysis of covariance for total cerebral volume and age found that lateral ventricles were larger in both patient groups than in healthy comparison subjects and that schizophrenia patients had a smaller midsagittal thalamic area than both subjects with psychotic disorder not otherwise specified and healthy comparison subjects.

CONCLUSIONS

Pediatric patients with psychotic disorder not otherwise specified showed a pattern of brain volumes similar to those found in childhood-onset schizophrenia. Neither group showed a decrease in volumes of temporal lobe structures. Prospective longitudinal magnetic resonance imaging and clinical follow-up studies of both groups are currently underway to further validate the distinction between these two disorders.

Acute hyperglycaemia causes elevation in plasma atrial natriuretic peptide concentrations in Type 1 diabetes mellitus

AIMS

To examine the effect of acute hyperglycaemia on atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations in Type 1 diabetes.

METHODS

The study was two limb, randomized, and single-blind. Eight Type 1 diabetes subjects were clamped at euglycaemia by intravenous infusion of insulin. When euglycaemia was established, the insulin infusion rate was left unaltered for the remainder of the protocol, and an intravenous infusion of either 500 ml 0.9% saline or 500 ml 10% dextrose was administered over 1 h. Blood was collected for estimation of plasma glucose, ANP and BNP concentrations at 30 min intervals for 2 h from the start of the infusion period. One week later, each subject received the alternate infusion. Results are expressed as mean +/- standard deviation, and were analysed by ANOVA.

RESULTS

Baseline plasma glucose (P = 0.8), ANP (P = 0.8) and BNP (P = 0.8) concentrations were similar on the study days. Plasma glucose rose with dextrose (6.1 + 0.5-15.1 + 2.8 mmol/l, P = 0.9). Plasma ANP concentrations were unaltered by saline infusion (76.5 +/- 14.7-77.7 +/- 15.2 pg/ml, P = 0.9), but increased with dextrose infusion (79 +/- 14-134 +/- 17.1 pg/ml, P < 0.0001), and were higher with dextrose than saline infusion (P < 0.0001). Plasma concentrations of BNP were not significantly altered by infusion of either dextrose (5.1 +/- 3.9-9.3 +/- 5.4 pg/ml, P = 0.63) or saline (4.3 +/- 3.5-6 +/- 5.2 pg/ml, P = 0.84).

CONCLUSIONS

Plasma concentrations of ANP, but not BNP, rise in response to acute hyperglycaemia in Type 1 diabetes.

Renal resistance to vasopressin in poorly controlled type 1 diabetes mellitus

To investigate the hypothesis that diabetes induces nephrogenic diabetes insipidus, we studied the urine-concentrating ability in response to vasopressin (AVP) in 12 patients with insulin-dependent diabetes mellitus (IDDM) and 12 nondiabetic controls. Subjects were euglycemic-clamped, and after oral water loading, AVP was infused intravenously for 150 min. AVP induced a greater (P<0.001) rise in urine osmolality in controls (67.6+/-10.7 to 720+/-31.1 mosmol/kg, P<0.001) than in IDDM patients (64.3+/-21.6 to 516.7+/-89.3 mosmol/kg, P<0.001). Urinary aquaporin-2 concentrations after AVP infusion were higher in controls (611.8+/-105.6 fmol/mg creatinine) than in IDDM (462.0+/-94.9 fmol/mg creatinine, P = 0. 003). Maximum urine osmolality in IDDM was inversely related to chronic blood glucose control, as indicated by Hb A(Ic) (r = -0.87, P = 0.002). To test the hypothesis that improved glycemic control could reverse resistance to AVP, 10 IDDM subjects with poor glycemic control (Hb A(Ic) >9%) were studied before (B) and after (A) intensified glycemic control. Maximum urine osmolality in response to AVP increased with improved glycemic control (B, 443.8+/-49.0; A, 640.0+/-137.2 mosmol/kg, P<0.001), and urinary aquaporin-2 concentrations after AVP increased from 112.7 +/-69 to 375+/-280 fmol/mg creatinine (P = 0.006), with improved glycemic control. Poorly controlled IDDM is associated with reversible renal resistance to AVP.