Peter Goulden

Birth Weight, Stress, and the Metabolic Syndrome in Adult Life

Abstract:  There is now widespread agreement that small size at birth is associated with an increased risk of the metabolic syndrome (glucose intolerance, high blood pressure, and dyslipidemia) and related pathologies, including cardiovascular disease in later life. Evidence is emerging that suggests that programming of hormonal systems in response to an adverse fetal environment may be one of the mechanisms underlying these long‐term consequences of growth restriction in early life. In particular, alterations in neuroendocrine responses to stress may be important. Recent research suggests that increased adrenocortical and sympathoadrenal responses are associated with small size at birth. Epidemiological studies show that such physiological alterations in these neuroendocrine systems may have potent effects on risk of cardiovascular disease through their influence on risk factors, such as plasma glucose and lipid concentrations and blood pressure.

Family Model of Diabetes Education With a Pacific Islander Community

Purpose The purpose of the study was to use a community-based participatory research approach to pilot-test a family model of diabetes education conducted in participants’ homes with extended family members. Methods The pilot test included 6 families (27 participants) who took part in a family model of diabetes self-management education (DSME) using an intervention-driven pre- and posttest design with the aim of improving glycemic control as measured by A1C. Questionnaires and additional biometric data were also collected. Researchers systematically documented elements of feasibility using participant observations and research field reports. Results More than three-fourths (78%) of participants were retained in the study. Posttest results indicated a 5% reduction in A1C across all participants and a 7% reduction among those with type 2 diabetes. Feasibility of an in-home model with extended family members was documented, along with observations and recommendations for further DSME adaptations related to blood glucose monitoring, physical activity, nutrition, and medication adherence. Conclusions The information gained from this pilot helps to bridge the gap between knowledge of an evidence-based intervention and its actual implementation within a unique minority population with especially high rates of type 2 diabetes and significant health disparities. Building on the emerging literature of family models of DSME, this study shows that the family model delivered in the home had high acceptance and that the intervention was more accessible for this hard-to-reach population.

Thrombolysis beyond 3 hours for acute ischaemic stroke

Intravenous thrombolysis is an accepted form of treatment for acute ischaemic stroke when administered within 3 h of symptom onset. However, evidence for its benefit when given beyond this time continues to strengthen. The case history of a young woman is presented with an ischaemic stroke who was successfully thrombolysed with recombinant tissue-type plasminogen activator more than 3 h after presentation. Perfusion CT scanning was used to stratify the likelihood of benefit. Thrombolysis was administered through a combination of intravenous and intra-arterial routes. This case illustrates the advances being made both in the imaging techniques used and the forms of drug administration which can be applied to maximise benefit in this extended therapeutic window. These recent advances are reviewed and their possible impact on current and future practice assessed. While the drive remains the introduction of thrombolysis at a local level for ischaemic stroke within 3 h of symptom onset, it is necessary to consider treatment of subjects presenting beyond 3 h in tertiary centres with the appropriate facilities and expertise.

Cultural Adaptation of Diabetes Self-Management Education for Marshallese Residing in the United States: Lessons Learned in Curriculum Development

Abstract: Background: Type 2 diabetes is a significant public health problem, with U.S. Pacific Islander communities bearing a disproportionate burden. The Marshallese are a Pacific Islander community that has significant inequities in diabetes, yet few evidence-based diabetes interventions have been developed to address this inequity. Objectives: We used a community-based participatory research (CBPR) approach to adapt an evidence-based diabetes self-management education (DSME) intervention for the Marshallese. Methods: Our team used the Cultural Adaptation Process Model, in addition to an iterative process consisting of formative data and previous literature review, and engagement with community and academic experts. Lessons Learned: Specific cultural considerations were identified in adapting DSME components, including the dichotomous versus gradient conceptualization of ideas, the importance of engaging the entire family, the use of nature analogies, and the role of spirituality. Conclusions: We identified key cultural considerations to incorporate into a diabetes self-management program for the Marshallese. The insights gained can inform others’ work with Pacific Islanders.

Spontaneous pituitary apoplexy during the second trimester of pregnancy, with sensory loss

A 32-year-old Hispanic woman at 23 weeks gestation presented with right-sided headache, associated with photophobia and right-sided numbness. She denied visual problems, menstrual irregularities and galactorrhoea. Examination revealed visual acuity 20/40 bilaterally with some blurriness on the left side, decreased right V1-V2 facial sensation and preserved 5/5 power, but decreased sensation over the entire right upper extremity (RUE) and right lower extremity (RLE) to touch and pinprick. Laboratories suggested normal pituitary function, but MRI of the brain revealed enlargement of the pituitary (1.7 cm), with layering haemorrhage posteriorly and mild compression of the optic nerve. The patient underwent emergent evacuation of a pituitary haematoma, and histology revealed minute fragments of adenohypophysis with haemorrhage and fibrosis.

A rare cause of epigastric pain in a middle-aged man

A 50-year-old man presents to the emergency department with epigastric pain and is found to have severe hypertension on clinical examination. After admission to hospital, further investigation with CT imaging reveals the patient has an uncomplicated splenic artery dissection. Conservative management is chosen as advised by a vascular surgery team and the patient was subsequently discharged from hospital with warfarin anticoagulation and antihypertensive medicines. This case report aims to build a profile of a patient who may present with splenic artery dissection and details our recommended management plan.

Diabetes Self-Care Behaviors Among Marshallese Adults Living in the United States

Marshallese experience high rates of type 2 diabetes. Proper management of diabetes requires multiple self-care behaviors, yet little is known about Marshallese’s diabetes-related self-care behaviors. Survey data from 111 Marshallese adults with diabetes were used to examine relationships between self-care behaviors and socio-demographic characteristics. The most common self-care behavior was attending annual doctor visits, while the least common was maintaining a normal weight. Age group, education level, and having a regular doctor were significantly associated with engaging in self-care behaviors. Having a regular doctor had the most effect on performing self-care behaviors (p = 0.006); although, only 38.7% reported having a regular doctor. To minimize diabetes-related complications, efforts to improve self-care behaviors among the Marshallese should be developed. Alternatives to traditional healthcare providers, such as community health workers, may be a viable strategy with this population given only one-third reported having a regular doctor.