Anthony Hildreth

Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK Glucose Insulin in Stroke Trial (GIST-UK)

BACKGROUND Hyperglycaemia after acute stroke is a common finding that has been associated with an increased risk of death. We sought to determine whether treatment with glucose-potassium-insulin (GKI) infusions to maintain euglycaemia immediately after the acute event reduces death at 90 days. METHODS Patients presenting within 24 h of stroke onset and with admission plasma glucose concentration between 6.0-17.0 mmol/L were randomly assigned to receive variable-dose-insulin GKI (intervention) or saline (control) as a continuous intravenous infusion for 24 h. The purpose of GKI infusion was to maintain capillary glucose at 4-7 mmol/L, with no glucose intervention in the control group. The primary outcome was death at 90 days, and the secondary endpoint was avoidance of death or severe disability at 90 days. Additional planned analyses were done to determine any differences in residual disability or neurological and functional recovery. The trial was powered to detect a mortality difference of 6% (sample size 2355), with 83% power, at the 5% two-sided significance level. This study is registered as an International Standard Randomised Controlled Trial (number ISRCTN 31118803) FINDINGS The trial was stopped due to slow enrolment after 933 patients were recruited. For the intention-to-treat data, there was no significant reduction in mortality at 90 days (GKI vs control: odds ratio 1.14, 95% CI 0.86-1.51, p=0.37). There were no significant differences for secondary outcomes. In the GKI group, overall mean plasma glucose and mean systolic blood pressure were significantly lower than in the control group (mean difference in glucose 0.57 mmol/L, p<0.001; mean difference in blood pressure 9.0 mmHg, p<0.0001). INTERPRETATION GKI infusions significantly reduced plasma glucose concentrations and blood pressure. Treatment within the trial protocol was not associated with significant clinical benefit, although the study was underpowered and alternative results cannot be excluded.

Swallowing problems in Parkinson disease: frequency and clinical correlates

Background: Changes to the efficiency and integrity of swallowing mechanisms are inevitable in Parkinson disease (PD); however, it remains unclear how many people with PD are at risk of dysphagia. The aim of this study was to establish the frequency of impaired swallowing in people with PD and the relationship between swallowing performance and indicators of disease progression. Methods: A community-based and hospital-based cohort of 137 individuals with PD were asked to drink 150 ml of water as quickly as possible while in an ‘off drug’ state. Results: Thirty-one (23%) patients could not completely drink the full 150 ml. Swallowing rate (ml/sec) fell to more than 1SD below published norms for 115 (84%) patients and to more than 2SD below for 44 (32%) individuals. There were moderate correlations between rate of swallowing and disease severity, depression and cognition, but not between swallowing speed and disease duration. There was poor correlation between subjective reports of dysphagia and performance on the water swallow test. Conclusions: Swallowing problems are frequent in PD. Self-report of ’no difficulty’ is not a reliable indicator of swallowing ability. Studies employing more-objective assessment of aspiration risk to compare with water swallow test performance are advocated.

Prevalence and pattern of perceived intelligibility changes in Parkinson’s disease

Background: Changes to spoken communication are inevitable in Parkinson’s disease (PD). It remains unclear what consequences changes have for intelligibility of speech. Aims: To establish the prevalence of impaired speech intelligibility in people with PD and the relationship of intelligibility decline to indicators of disease progression. Methods: 125 speakers with PD and age matched unaffected controls completed a diagnostic intelligibility test and described how to carry out a common daily activity in an “off drug” state. Listeners unfamiliar with dysarthric speech evaluated responses. Results: 69.6% (n = 87) of people with PD fell below the control mean of unaffected speakers (n = 40), 51.2% (n = 64) by more than −1 SD below. 48% (n = 60) were perceived as worse than the lowest unaffected speaker for how disordered speech sounded. 38% (n = 47) placed speech changes among their top four concerns regarding their PD. Intelligibility level did not correlate significantly with age or disease duration and only weakly with stage and severity of PD. There were no significant differences between participants with tremor dominant versus postural instability/gait disorder motor phenotypes of PD. Conclusions: Speech intelligibility is significantly reduced in PD; it can be among the main concerns of people with PD, but it is not dependent on disease severity, duration or motor phenotype. Patients’ own perceptions of the extent of change do not necessarily reflect objective measures.

Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery.

PURPOSE: To compare the efficacy of intracameral cefuroxime versus subconjunctival cefuroxime in reducing the rate of endophthalmitis after cataract surgery. SETTING: Single‐specialty eye hospital, Sunderland, United Kingdom. METHODS: A retrospective analysis of all presumed infectious endophthalmitis cases from January 1, 2000, to December 31, 2006 was performed. The rate of presumed infectious endophthalmitis in patients receiving subconjunctival cefuroxime was compared with those receiving intracameral cefuroxime at the end of surgery. RESULTS: This study included 36 743 phacoemulsification cataract procedures. The mean rate of presumed infectious endophthalmitis was 0.95 per 1000 cases. The incidence of endophthalmitis was higher in the subconjunctival cefuroxime group than in the intracameral cefuroxime group; the difference was statistically significant with an odds ratio of 3.01 (95% confidence interval, 1.37‐6.63). CONCLUSION: Intracameral cefuroxime was a safe alternative to subconjunctival cefuroxime and led to a lower rate of endophthalmitis.

Factors Influencing Educational Motivation: a study of attitudes, expectations and behaviour of children in Sunderland, Kentucky and St Petersburg

Worldwide concern about educational achievement, fuelled by comparative studies, has resulted in much debate about appropriate pedagogic practices. This article argues, however, that in considering how to raise educational attainment, key attitudinal and other sociocultural factors have been insufficiently considered. To support this position, it reports the findings from a large-scale international investigation of the attitudes, perceptions and orientation towards academic activity of children (aged 14-15 years). Findings indicate that English and American children share a relatively high degree of satisfaction with their current level of academic performance and work rate, place greater emphasis upon effort rather than ability attributions for success, although, somewhat paradoxically, appear to have less real commitment to educational endeavour. Findings from the study are discussed in the light of the childrens differing socio-economic and sociocultural contexts and current educational reform initiatives.

Individualized assessment of quality of life in idiopathic Parkinson's disease.

The purpose of this study was to assess quality of life (QoL) of patients with idiopathic Parkinsons disease (IPD). The Parkinsons Disease Questionnaire (PDQ‐39) was compared with an individualized QoL tool: the Schedule for Evaluation of Individual Quality of Life Direct Weighting (SEIQoL‐DW). One hundred twenty‐three patients underwent interviews using these tools, together with the Mini Mental State examination, Beck Depression Inventory, a qualitative pain assessment, and the Palliative Care Assessment tool (for symptoms). The SEIQoL‐DW was well tolerated and demonstrated that QoL not only was broad and highly individualistic but also was determined more by psychosocial than physical issues. Of the 87 domains nominated by patients, the most common were family (87.8%), health (52.8%), leisure activities (36.6%), marriage (35%), and friends (30.9%). The SEIQoL index score was predicted by depression but not by disease stage. However, the PDQ‐39 was predicted by disease stage, the number of symptoms, and depression. Direct comparison of the tools confirmed that the SEIQoL index score was predicted by the PDQ‐39 domains of social support, cognitive impairment, and emotion. The use of the SEIQoL‐DW challenges current thinking within IPD research regarding QoL and its assessment using the PDQ‐39.

The Comorbidity Symptom Scale: a combined disease inventory and assessment of symptom severity.

OBJECTIVES: To develop and evaluate a scale to quantify the presence and severity of symptoms arising from comorbid diseases in older people.

Swallowing in the first year after chemoradiotherapy for head and neck cancer: clinician- and patient-reported outcomes.

This prospective study evaluated swallowing outcomes prechemoradiotherapy (pre‐CRT) up to 1 year post‐CRT, in a substantial cohort of patients with head and neck cancer and explored factors predicting outcome.

A questionnaire study of the approach to the anorexia–cachexia syndrome in patients with cancer by staff in a district general hospital

Goals of workThis questionnaire study was designed to investigate understanding, assessment and management of cancer-related anorexia–cachexia syndrome (ACS) amongst hospital staff.MethodsQualified nurses and doctors on general medical and surgical wards within a district general hospital were asked to complete a questionnaire enquiring about understanding of the term cachexia, routine assessment of commonly associated symptoms and approaches to management of three commonly associated symptoms (poor appetite, early satiety and dry mouth).Main resultsOne hundred seventeen questionnaires were distributed with 100 returned (86% response rate). Cachexia was most frequently described as weight loss (79%) and anorexia (49%). Some symptoms (including altered appetite, constipation, nausea and vomiting) were routinely assessed during admission or review of these patients. Some common symptoms (including mouth problems, early satiety) were much less likely to be enquired about. Management of the three key symptoms demonstrated a range of approaches with little consistency. Early satiety was particularly poorly managed, with 29% of staff being unable to recognise or treat it.ConclusionsThe study highlights the variable understanding of ACS and the lack of standardised assessment and management tools amongst staff in an acute hospital setting. This is likely to lead to inconsistent, and perhaps inadequate, care of patients with palliative care needs. Greater awareness and basic pathways of care may help to improve the experience of ACS for patients with cancer.

Double masked randomised controlled trial to assess the effectiveness of paracetamol in reducing pain in panretinal photocoagulation

Aim: To assess the effectiveness of pre-emptive analgesia with paracetamol in reducing pain associated with panretinal photocoagulation (PRP) in a prospective, double masked, randomised controlled trial. Method: 60 patients undergoing PRP for the first time were enrolled and randomised to paracetamol or placebo, taken for 2 days starting 24 hours before the laser treatment. The laser treatment was performed following a standardised protocol. Pain during and after treatment was assessed using the McGill pain questionnaire (MPQ) and visual analogue scales (VAS). Results: The statistical analysis looked for differences between the two study groups immediately after the laser surgery and 24 hours later. There was no statistically significant difference in the primary outcome measure of perception of pain during and 24 hours after PRP, between the paracetamol and placebo group. However, none of the patients in the paracetamol group reported increased total pain at 24 hours, whereas six patients in the placebo group reported increased pain; this difference (21%) was significant to p = 0.01. Conclusions: Pre-emptive analgesia with paracetamol did not significantly reduce pain associated with PRP. This study has described for the first time the type of pain associated with PRP, which is perceived mainly as a discomfort. The main attributes of the pain that patients described, were sharp, flashing, tiring, intense, piercing, intermittent, and brief.