No difference between wearing a night splint and standing on a tilt table in preventing ankle contracture early after stroke: a randomised trial

QUESTION: Is wearing a night splint as effective as standing on a tilt table in preventing ankle dorsiflexion contracture and promoting the ability to stand up early after stroke? DESIGN: Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: 30 patients undergoing rehabilitation who were not yet walking and within three weeks of their first stroke. INTERVENTION: For four weeks, one group wore a splint with the affected ankle at plantargrade, 7 nights per week, while the other group stood on a tilt table for 30 min with the ankle at maximum dorsiflexion, 5 times per week. This was followed by a period of no intervention for six weeks. Both groups received inpatient and outpatient rehabilitation emphasising mobility. OUTCOME MEASURES: The primary outcome was contracture measured as maximum passive ankle dorsiflexion. RESULTS: The night splint group had the same amount of ankle dorsiflexion as the tilt table group by Week 4 (mean difference 1 deg, 95% CI -5 to 7), and by Week 10 (mean difference 3.5 deg, 95% CI -3 to 10). CONCLUSION: When added to early rehabilitation, wearing a night splint on the affected ankle in stroke patients appears to be as effective as standing on a tilt table in preventing contracture at the ankle. However, since there was no control group, the prevention of contracture may have been due to other factors.     

Design of the REVEAL registry for US patients with pulmonary arterial hypertension

The Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) has been designed to meet the need for current information about patients with pulmonary arterial hypertension (PAH). The main objectives of REVEAL are to better define and understand PAH and to assess the consequences of treatment strategies. REVEAL is collecting clinically relevant data from 3500 consecutively enrolled patients with confirmed PAH diagnoses. Outcomes will be evaluated longitudinally and compared according to the baseline classification of PAH. The primary outcome for group comparisons will be survival. Collected data include World Health Organization functional class, 6-minute walk distance, cardiopulmonary exercise testing, pulmonary function test results, hemodynamic measurements, functional status, hospitalizations, and death. REVEAL will be the richest source of data on patients with World Health Organization group I PAH.     

When do seizures usually improve with the ketogenic diet?

PURPOSE: Parents often expect immediate seizure improvement after starting the ketogenic diet (KD) for their children. The purpose of this study was to determine the typical time to seizure reduction as well as the time after which it was unlikely to be helpful in those children started on the KD. METHODS: Records of all children started on the KD at Johns Hopkins Hospital, Baltimore (n = 83) and Children's Memorial Hospital, Chicago (n = 35) from November 2003 to December 2006 were examined to determine the first day in which seizures were reportedly improved. RESULTS: Of the 118 children started on the KD, 99 (84%) had documented seizure reduction. The overall median time to first improvement was 5 days (range: 1-65 days). Seventy-five percent of children improved within 14 days. In those children who were fasted at KD onset, the time to improvement was quicker (median 5 vs. 14 days, p < 0.01) with a higher percentage improving within 5 days (60% vs. 31%, p = 0.01). No difference was identified between fasting and nonfasting in regards to long-term outcomes, however. DISCUSSION: The KD works quickly when effective, typically within the first 1-2 weeks. Starting the KD after a fasting period may lead to a more rapid, but equivalent long-term seizure reduction, confirming prior reports. If the KD has not led to seizure reduction after 2 months, it can probably be discontinued.     

Cardiopulmonary bypass induces enduring alterations to host neutrophil physiology: a single-center longitudinal observational study

Studies during and immediately post-cardiopulmonary bypass (CPB) surgery have revealed that neutrophils (PMNs) are pivotal to post-CPB inflammation and innate immunity. The aim of this study was to investigate the effects of CPB on the PMN phenotype and respiratory burst function over a longer post-CPB period (up to day 5). Blood samples were collected pre-CPB and on days 1, 3, and 5 post-CPB from 20 patients. Changes to PMN surface expression of CD16, CD62L, CD11b, CD18, and CD43, and PMN respiratory burst activity were measured, together with the white blood cell count and absolute PMN count. Cardiopulmonary bypass induced neutrophilia on days 1 and 3. One day post-CPB, CD16 expression reached a nadir (P = 0.001), and platelet-activating factor-induced CD18 increase was depressed (P < 0.05). Three days post-CPB, CD43 expression peaked (P < 0.05), with a concomitant resistance to N-formyl-Met-Leu-Phe-induced CD11b upregulation (P < 0.05). The PMN respiratory burst activity declined continuously post-CPB until day 5. Neutrophilia on days 1 and 3 was associated with changes to surface molecules expression that may reduce PMN activation response. This study demonstrated that CPB depresses the respiratory burst activity of host PMNs for an extraordinarily longer period of at least 5 days even after neutrophilia had resolved. Collectively, the changes portray an autoprotective yet responsive homeostatic balance.     

Building capacity for the clinical placement of nursing students

The current workforce crisis mandates that education providers increase the number of graduates from nursing courses. In a practice-based profession however, any growth in student numbers is constrained by the ability of clinical venues to accept students for clinical experience. Factors within the operating environment such as bed capacity, staffing mix and shortage of experienced clinicians to act as preceptors, clinical teachers, mentors or role models; limit the number of students that can be accommodated and both the quality and level of educational support provided. These factors are compounded in rural hospitals, where opportunities for placements can be also overlooked or ineffectively utilised. This paper reports on a project undertaken by a rural health service, two universities and a TAFE institute. It demonstrates that a greater number of students can be accommodated when all major stakeholders accept responsibility and agree to work together to create a learning community and find ways to overcome barriers and impediments that constrain capacity. It is concluded that the capacity of a rural hospital to accept students for placement can be increased when cancellation rates are reduced, the clinical timetable rationalised and more collaborative approaches to clinical education are implemented.