Fluid Balance and Blood Volume Measurement after Aneurysmal Subarachnoid Hemorrhage

Background  Patients with aneurysmal subarachnoid hemorrhage (SAH) are at risk for circulatory volume depletion, which is a risk factor for delayed cerebral ischemia (DCI). In a prospective observational study we assessed the effectiveness of fluid administration based on regular evaluation of the fluid balance in maintaining normovolemia. Methods  A total of 50 patients with aneurysmal SAH were included and were treated according to a standard protocol aimed at maintaining normovolemia. Fluid intake was adjusted on the basis of the fluid balance, which was calculated at 6-h intervals. Circulating blood volume (CBV) was measured by means of pulse dye densitometry (PDD) on alternating days during the first 2 weeks after SAH. Results  Of the 265 CBV measurements, 138 (52%) were in the normovolemic range of 60–80 ml/kg; 76 (29%) indicated hypovolemia with CBV < 60 ml/kg; and 51 (19%) indicated hypervolemia with CBV > 80 ml/kg. There was no association between CBV and daily fluid balance (regression coefficient β = −0.32; 95% CI: −1.81 to 1.17) or between CBV and a cumulative fluid balance, adjusted for insensible loss through perspiration and respiration (β = 0.20; 95% CI: −0.31 to 0.72). Conclusion  Calculations of fluid balance do not provide adequate information on actual CBV after SAH, as measured by PDD. This raises doubt whether fluid management guided by fluid balances is effective in maintaining normovolemia.     

Development of a tool to guide referral of patients with neuromuscular disorders to allied health services. Part two

PURPOSE: The Perceived Limitations and Needs Questionnaire (PLAN-Q) was developed to guide referral for a one-off consultation by occupational therapy (OT), physical therapy (PT), and speech therapy (ST) consultation, to provide a tailor-made advice on allied health interventions. This article reports on the testing of validity and reliability of the PLAN-Q. METHODS: In the validation study, 208 patients with a broad spectrum of neuromuscular disorders completed the PLAN-Q, Medical Outcome Study short-form 36-item version (SF-36), and the Impact of Participation on Autonomy (IPA) questionnaires. A subsection of 51 patients, whose physical condition was stable, participated in the evaluation of the intra-rater reliability of the questionnaire. The theoretical construct was tested with factorial analysis, subscales were constructed and reliability and validity of the PLAN-Q subscales were assessed. RESULTS: Factorial analysis resulted in an 18-item self-report questionnaire. Items were grouped into four subscales ('physical capacity', 'transferring', 'oropharyngeal capacity', and 'hand-use'), each with two dimensions ('capacity' and 'need for help'). The internal consistency of all subscales was good (Cronbach's alpha: 0.77-0.94) as well as the intra-rater reliability of the subscales 'physical capacity' and 'transferring' in the 'capacity' dimension (Kappa: 0.70-0.75). The 'need' dimension showed poor intra-rater reliability suggesting that 'need for help' is a variable phenomenon that changes between two points of measurement. The construct validity of the subscales against the SF-36 and the IPA was satisfactory. CONCLUSION: The PLAN-Q is a valid self-report instrument that measures patients' perception of capacity and needs in domains relevant to referral for a one-off OT, PT, or ST consultation.     

高血压患者常规行眼底镜检查的价值：系统性综述

目的 评价高血压患者常规眼底检查的价值。 设计 系统性综述。 入选患者 ≥19岁的高血压视网膜病变患者。 数据来源 从1990起的Medline、Embase和Cochrane图书馆的数据库。 综述方法 纳入的研究包括：评估了高血压视网膜病变性失明与心血管危险因素之间联系的研究。研究必须由2名或2名以上观察者得出一致评价结果，用K统计分析表示。对于高血压患者，研究高血压视网膜病变与高血压脏器损害之间的联系。对于非选择的血压正常者和无糖尿病高血压患者，评价高血压视网膜病变与心血管危险因素之间的联系。 结果 由于观察者之间的巨大差异限制了对视网膜微血管变化的评价。高血压视网膜病变与血压水平之间的阳性及阴性预测值均较低（分别为47％～72％和32％-67％）。除了视网膜病变与脑卒中之间有联系外，视网膜微血管变化与心血管危险因素之问无明显联系。但在血压正常的视网膜病变患者中同样发现脑卒中增加。这些研究没有对高血压脏器损害的其他预测因子进行调整。 结论 研究表明，高血压患者常规进行眼底检查有额外价值的观点尚缺乏证据。     

Hypocalcaemia may reduce the beneficial effect of magnesium treatment in aneurysmal subarachnoid haemorrhage.

To assess whether magnesium treatment in patients with subarachnoid haemorrhage (SAH) is associated with hypocalcaemia and whether hypocalcaemia in these patients is associated with an increased risk of delayed cerebral ischemia (DCI) and poor outcome. All 137 patients randomized in the clinically controlled "Magnesium in Aneurysmal Subarachnoid Haemorrhage" trial were included. The relationship between mean serum magnesium and mean serum calcium during treatment was assessed with linear regression. The relationship between hypocalcaemia (serum calcium < 2.0 mmol/L) during treatment and the occurrence of DCI and poor outcome was studied with the Cox proportional hazards method and logistic regression, respectively. There was a statistically significant inverse relation between elevated serum magnesium and hypocalcaemia (B = -0.27; 95% CI, -0.33 to -0.20; p < 0.001). Patients with hypocalcaemia during study treatment had an increased frequency of DCI (HR 2.1; 95% CI, 1.0 to 4.3), and an increased risk for poor outcome (OR 2.9; 95% CI, 1.4 to 6.4), but this effect attenuated in the multivariable analysis (OR 1.9; 95% CI, 0.8 to 4.7). In conclusion, prolonged elevated serum magnesium is associated with hypocalcaemia. Hypocalcaemia is associated with an increased risk of DCI and poor outcome and may therefore reduce the potential beneficial effect of magnesium treatment in SAH.     

Logistic support service improves processes and outcomes of diabetes care in general practice

BACKGROUND: Guidelines for type 2 diabetes care in general practice are well known and accepted, but the implementation falls short. OBJECTIVE: To implement these guidelines by introducing a diabetes support service (DSS) to support the care delivered by the GP. METHODS: A controlled, non-randomised study with delayed intervention in the control group; 78 GPs (n=51 for the intervention and n=21 for the control group) in the south of the Netherlands and 613 of their type 2 diabetic patients participated. Data were collected on the frequency, content and results of the check-ups (fasting blood glucose, HbA1c, cholesterol, cholesterol/HDL ratio, triglycerides, creatinine, blood pressure, fundus photography, foot examination, body mass index and smoking status) for 3 years. The year before signing up with the DSS was taken for the pre-measurements and after 2 years of DSS the post-measurements took place. The effect of the DSS was analysed in a mixed model with repeated measurement covariance structure. RESULTS: At baseline the intervention and control group did not differ in control frequency and outcome (HbA1c). After the intervention the percentage of patients that attended four or more quarterly check-ups (with at least testing of fasting blood glucose or HbA1c) increased from 59 to 78%. In contrast, the frequency of check-ups in the control group remained constant. This effect was significant. The HbA1c remained the same in the intervention group while there was a significant deterioration in the HbA1c in the control group. CONCLUSION: Simple logistic support by the DSS proved to have the capacity to implement type 2 diabetes guidelines in general practice.