Sally Hollis

Psychosocial predictors of outcome in acute and subchronic low back trouble.

Study Design A prospective survey of patients seeking primary care for low back pain. Clinical and psychosocial data, available at presentation, were explored for predictors of outcome at 1 year. Objectives To determine the relative value of clinical and psychosocial variables for early identification of patients with a poor prognosis. Summary of Background Data Current treatment strategies for low back pain have failed to stem the rising levels of disability. Psychosocial factors have been shown to be important determinants of response to therapy in chronic patients, but the contribution from similar data in acute or subchronic patients has not been comprehensively investigated. Methods Two hundred fifty-two patients with low back pain, presenting to primary care, underwent a structured clinical interview and completed a battery of psychosocial instruments. Follow-up was done by mail at 1 year; outcome was measured using a back pain disability questionnaire. Predictive relationships were sought between the data at presentation and disability at follow-up. Results Most patients showed improved disability and pain scores, although more than half had persisting symptoms. Eighteen percent showed significant psychological distress at presentation. Multiple regression analysis showed the level of persisting disability to depend principally on measures in the psychosocial domain; for acute cases outcome is also dependent on the absence or presence of a previous history of low back trouble. Discriminant models successfully allocated typically 76% of cases to recovered/not-recovered groups, largely on the basis of psychosocial factors evident at presentation. Conclusions Early identification of psychosocial problems is important in understanding, and hopefully preventing, the progression to chronicity in low back trouble.

The association between callus formation, high pressures and neuropathy in diabetic foot ulceration

The presence of an ulcer beneath callus on the diabetic foot has been a well‐documented and common clinical finding. We have conducted a prospective study to examine whether callus can be used to predict plantar intrinsic neuropathic diabetic foot ulcer formation. Sixty‐three diabetic patients (43 male, 25 Type 1), median age 62 years (IQ range 52, 67), median diabetes duration 17 years (IQ range 8,25) participated in the study. All had neuropathy and peak plantar foot pressures (measured using a dynamic optical pedobarograph) ⩾10u2009kgu2009cm−2. Calluses and previous ulcers were documented and classified. All ulcers occurring prior to and during the study were recorded, re‐examination was 15.4 (range 10–22) months from baseline. Seven ulcers (6 patients) occurred during the study. Pressures were higher in the ulcer than non‐ulcer sub‐group (pu2009=u20090.04) with a relative risk of developing an ulcer of 4.7 for an area of elevated plantar pressure. This compares with a relative risk of 11.0 for an ulcer developing under an area of callus, and a relative risk of 56.8 for an ulcer developing on a site of previous ulceration. This study confirms that a history of previous ulceration is the highest risk factor for ulceration and demonstrates, for the first time, that the presence of plantar callus is highly predictive of subsequent ulceration. Careful history taking and examination of the foot to detect the presence of callus require no special training or equipment and callus should be recognized as a ‘high risk’ factor for foot ulceration.

Abnormalities on magnetic resonance imaging seen acutely following mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery

Mild traumatic brain injury (MTBI) is a common reason for hospital attendance and is associated with significant delayed morbidity. We studied a series of 80 persons with MTBI. Magnetic resonance imaging (MRI) and neuropsychological testing were used in the acute phase and a questionnaire for post-concussion syndrome (PCS) and return to work status at 6xa0months. In 26 subjects abnormalities were seen on MRI, of which 5 were definitely traumatic. There was weak correlation with abnormal neuropsychological tests for attention in the acute period. There was no significant correlation with a questionnaire for PCS and return to work status. Although non-specific abnormalities are frequently seen, standard MRI techniques are not helpful in identifying patients with MTBI who are likely to have delayed recovery.

THE BEHAVIOURAL RESPONSE TO WHIPLASH INJURY

We studied 50 consecutive patients presenting at an accident department after rear-end vehicle collisions and recorded symptoms and psychological test scores within one week of injury, at three months and at two years. The range of neck movement was noted at three months. Within one week of injury, psychological test scores were normal in 82% of the group but became abnormal in 81% of the patients with intrusive or disabling symptoms at over three months (p < 0.001) and remained abnormal in 69% at two years. The clinical outcome after two years could be predicted at three months with 76% accuracy by neck stiffness, 74% by psychological score and 82% by a combination of these variables. The severity of symptoms after a whiplash injury is related both to the physical restriction of neck movement and to psychological disorder. The latter becomes established within three months of the injury.

A randomised controlled trial of topical glycopyrrolate, the first specific treatment for diabetic gustatory sweating

Summary The treatment of gustatory sweating in diabetes mellitus is usually with oral anti-cholinergic drugs, but these frequently lead to unacceptable side effects. Glycopyrrolate is an anti-muscarinic agent that can be applied topically and is efficacious in gustatory sweating occurring in other conditions. In a double-blind placebo-controlled crossover study, we assessed the value of glycopyrrolate in 13 diabetic patients with gustatory sweating. Sweating was measured by a sweat challenge, and diaries recorded by the patients throughout the 2 weeks of each treatment period. Compared to placebo, glycopyrrolate reduced the sweat response to a challenge by 82 % (p < 0.01). The frequency of episodes of gustatory sweating during the treatment period was also reduced by 51 % (p < 0.01), with a nearly 100 % reduction in the frequency of episodes of severe sweating (p < 0.01). In conclusion, topically applied glycopyrrolate is a very effective treatment in reducing both the severity and frequency of diabetic gustatory sweating. [Diabetologia (1997) 40: 299–301]

Ultrasound screening for hips at risk in developmental dysplasia: IS IT WORTH IT?

Between May 1992 and April 1997, there were 20,452 births in the Blackburn District. In the same period 1107 infants with hip at-risk factors were screened prospectively by ultrasound. We recorded the presence of dislocation and dysplasia detected under the age of six months using Grafs alpha angle. Early dislocation was present in 36 hips (34 dislocatable and 2 irreducible). Of the 36 unstable hips, 30 (83%) were referred as being Ortolani-positive or unstable; 25 (69%) of these had at least one of the risk factors. Only 11 (31%) were identified from the at-risk screening programme alone (0.54 per 1000 live births). Eight cases of late dislocation presented after the age of six months (0.39 per 1000 live births). The overall rate of dislocation was 2.2 per 1000 live births. Only 31% of the dislocated hips belonged to a major at-risk group. Statistical analysis confirmed that the risk factors had a relatively poor predictive value if used as a screening test for dislocation. In infants referred for doubtful clinical instability, one dislocation was detected for every 11 infants screened (95% confidence interval (CI) 8 to 17) whereas in infants referred because of the presence of any of the major at-risk factors the rate was one in 75 (95% CI 42 to 149). Routine ultrasound screening of the at-risk groups on their own is of little value in significantly reducing the rate of late dislocation in DDH, but screening clinically unstable hips alone or associated with at-risk factors has a high rate of detection.

Ultrasound screening for hips at risk in developmental dysplasia

Introduction: The results of a 10 year prospective hip ultrasound surveillance programme of ‘at risk’ or clinically unstable hips are analysed. Method: Between June 1992 and may 2002, there were 34723 births in the Blackburn area. Over this period 2,578 infants with unstable hips and or risk factors for developmental dysplasia of the hip were assessed with bilateral hip ultrasound scans. Clinically unstable hips were imaged within two weeks post natally and those with ‘at risk’ groups within eight weeks. All results were collected prospectively by the senior author. The degree of Dysplasia was classified using Graf’s alpha angle. Dynamic instability or irreductable dislocation was recorded. Results: Early dislocation was present in 77 patients of which 53 (68.8%) were referred as being Ortolani-positive or unstable, only 24 were identified from the screening programme alone. The dislocation rate was 2.6 per 1000 live births. There were 21 irreducible dislocations in 19 infants, a rate of 0.54 per 1000 live births. Only 31.2 % of the dislocated hips belonged to the major ‘at risk’ group. In infants referred for possible clinical instability one dislocation was detected for every 8.5 infants screened, whereas in the ‘at risk’ group this number rose to 1 in 88. From the ‘at risk’ groups those with breech and a positive family history were most likely to reveal a dislocation. There was a 1:45 chance of instability/irreducibility in family history, compared with a 1:70 chance in breech presentation or 1:71 chance in foot abnormality. No patients with oligohydramnios alone had evidence of hip instability or dislocation. If type III dysplasia is assessed there is a 1:22 chance in family history, a 1:43 chance in breech presentation and a 1:61 chance in foot deformity. Discussion: Screening groups with possible risk factors such as oligohydramnios or Caesarian section cannot be justified. Selective ultrasound screening of the clinical instability, family history, breech presentation and foot abnormality groups looking for dislocation or type III dysplasia may be justified on a National basis.

Postural Instability in Diabetic Neuropathic Patients at Risk of Foot Ulceration

Diabetic peripheral neuropathy is believed to cause postural instability due to abnormal proprioception. We assessed body sway in four groups, each of 20 subjects, matched for age, sex, and BMI: non‐diabetic controls, non‐neuropathic diabetic controls, subjects with diabetic neuropathy and no history of foot ulceration, and subjects with diabetic neuropathy and a history of foot ulceration. Postural sway was assessed on a Kistler force plate using the Romberg test, measuring the standard deviation of the centre of pressure in both sagittal (antero‐posterior movement) and frontal (side to side movement) planes with eyes open and closed. The Romberg test results were log transformed and then analysed using analysis of variance followed by Newman‐Keuls test. There was no significant difference in body sway between the two control groups and the first group of subjects with diabetic neuropathy. However, in patients with a history of ulceration, values were significantly higher (pu2009<u20090.05) compared to all other groups in both planes and conditions studied. These results are suggestive of a relationship between impaired body sway control and foot ulceration. Postural instability may have clinical significance and increase the risk of minor trauma and ulceration in patients with diabetic neuropathy.

Measuring clinical performance and outcomes from diabetes information systems: an observational study

Aims/hypothesis. To examine changes in diabetes care provision after the introduction of a district diabetes information system.¶Methods. All patients with diabetes registered on the system between 1993 and 1998 (n = 6544) were included in the analysis. Drop-out cohort analysis was used to handle population changes, logistic regression models with general estimating equations were used to examine changes in clinical performance over time.¶Results. After the introduction of the system, care processes improved appreciably, in both primary and secondary care. The proportion of patients receiving a preventative care review within the calendar year rose from 56 % in 1993 to 67 % in 1998. The proportion of these in whom each process was completed improved in all categories from 1993 to 1998: blood pressure 96 % to 98 %; glycaemic check 67 % to 93 %; lipid check 31 % to 68 %; renal check 46 % to 87 %; fundoscopy 79 % to 92 %; foot screen 87 % to 87 %. Similarly there was an increase in the proportion of patients achieving intermediate outcome treatment targets (HbA1 c≤ 9.0 % from 29 % to 43 %; cholesterol ≤ 5.5 mmol/l 5 % to 19 %; blood pressure ≤ 160/90 37 % to 46 %).¶Conclusion/interpretation. Our results suggest appreciable improvements in diabetes care between 1993 and 1998. These changes apply to an entire population of patients across primary and shared care. We believe that these improvements could, in part, be attributable to the way in which the district diabetes information system has facilitated the structured cascade of diabetes care. [Diabetologia (2000) 43: 836–843]

A comparative study of the Podotrack, a simple semiquantitative plantar pressure measuring device, and the optical pedobarograph in the assessment of pressures under the diabetic foot.

Aims To test the Podotrack, a simple inexpensive semiquantitative footprint mat, for potential use as a screening tool for high plantar pressures, against the optical pedobarograph (a computerized device).