Appraisal of "rigid" blood glucose control during pregnancy in the overtly diabetic woman

The degree of maternal glucose control achieved during the third trimester of pregnancy was evaluated for 120 overtly diabetic women hospitalized on a high-risk pregnancy ward. "Rigid" blood glucose control, defined as a mean preprandial plasma glucose concentration less than 115 mg/dl was achieved in only 14% of these women. Although mean preprandial plasmal glucose concentrations ranged between 115 and 172 mg/dl in 66% of women and exceeded 172 mg/dl in 20%, the perinatal salvage rate was greater than 95%. Pregnancies of those women whose mean plasma glucose levels exceeded 172 mg/dl required earlier intervention for signs of fetal jeopardy, but the degree of glucose control was not significantly related to either perinatal death or neonatal morbidity. These results suggest that maternal hyperglycemia exceeding a mean preprandial glucose concentration of 172 mg/dl is to be avoided, whereas, at the other extreme, mean glucose levels less than 115 mg/dl or "rigid" control is unnecessary for a successful perinatal outcome.     

Acquired pendular nystagmus: its characteristics, localising value and pathophysiology

Investigations were made of 16 patients with acquired pendular nystagmus and a further 32 cases reported in the literature were reviewed. Amongst our own patients two thirds had multiple sclerosis, almost one third a cerebrovascular accident or angioma and two had optic atrophy with squint. The nystagmus took forms which could be monocular or binocular, conjugate or disconjugate and could involve movements about single or multiple axes. Spectral analysis was used to characterise the amplitude and frequency of the movements and to estimate the degree of relationship (coherence) between movements of the two eyes or between movements of one eye about several axes. The oscillations ranged in frequency from 2·5 Hz to 6 Hz, with typical amplitudes between 3° and 5°. In a given patient all oscillations, regardless of plane, were highly synchronised. Somatic tremors of the upper limb, face and palate associated with the nystagmus were often at similar frequencies to the eye movement. The other ocular signs common to all our patients were the presence of squint with failure of convergence. Most patients also had skew deviation or internuclear ophthalmoplegia or both. The major oculomotor systems, that is, saccades, pursuit, optokinetic and vestibulo-ocular reflexes could be intact. It is inferred that the mechanism responsible for the pendular nystagmus lies at a level which is close to the oculomotor nuclei so that it can have monocular effects but is not part of the primary motor pathways. It is possible that this mechanism normally subserves maintenance of conjugate movement and posture of the eyes. The periodicity of the nystagmus is likely to arise from instability in a certain type(s) of neurone, for the associated somatic tremors have similar characteristics and yet involve very different neuronal muscular circuitry. Prognosis for cessation of the nystagmus is poor. In five patients with multiple sclerosis it was suppressed by intravenous hyoscine with, however, unacceptable subsequent side effects.     

Total replacement of the first metatarsophalangeal joint

Various prostheses for total replacement of the first metatarsophalangeal joint for painful hallux valgus and hallux rigidus are briefly discussed. Altogether, the results of eighty-six replacements in sixty-nine patients have been recorded after an average interval of two years. In seventy-eight operations a Silastic* prosthesis as designed by Swanson for the replacement of metacarpophalangeal joints was used, with no case of fracture or deep infection up to date. Overall, the assessment of pain showed that 98 per cent of operations gave either complete or considerable relief. For hallux valgus, the objective assessment showed excellent or good results in 79 per cent, fair in 16 per cent and poor in 5 per cent. For hallux rigidus the corresponding figures were 86, 14 and 0. The technique of replacement described promises to be most satisfactory, especially for hallux rigidus. In selected cases of hallux valgus, a basal osteotomy of the first metatarsal should be added.     

Cerebral activation during hypnotically induced and imagined pain

The continuing absence of an identifiable physical cause for disorders such as chronic low back pain, atypical facial pain, or fibromyalgia, is a source of ongoing controversy and frustration among pain physicians and researchers. Aberrant cerebral activity is widely believed to be involved in such disorders, but formal demonstration of the brain independently generating painful experiences is lacking. Here we identify brain areas directly involved in the generation of pain using hypnotic suggestion to create an experience of pain in the absence of any noxious stimulus. In contrast with imagined pain, functional magnetic resonance imaging (fMRI) revealed significant changes during this hypnotically induced (HI) pain experience within the thalamus and anterior cingulate (ACC), insula, prefrontal, and parietal cortices. These findings compare well with the activation patterns during pain from nociceptive sources and provide the first direct experimental evidence in humans linking specific neural activity with the immediate generation of a pain experience.     

Exploring quality of life following high spinal cord injury: a review and critique

STUDY DESIGN: Review. OBJECTIVES: To explore the concept of quality of life (QOL), critique the practice and problems of assessing QOL following spinal cord injury (SCI) and to review the findings of studies into QOL for people with SCI both below and above the level of C4. METHODS: Relevant articles were identified from the Medline and CINAHL databases for approximately the period 1990-2003, cross-indexing 'spinal cord injury' or 'quadriplegia/tetraplegia' with 'quality of life', 'life satisfaction', 'social adjustment' or 'psychological adaptation'. This search was augmented through papers identified in reference lists. Articles were excluded if they were designed solely to examine the impact of a specific intervention upon QOL; or if they examined satisfaction with various life domains without explicitly linking these to perceptions of QOL. Papers were also accessed that addressed the philosophical and epistemological issues involved in QOL conceptions and assessment. RESULTS: Review of the literature highlights the philosophical and methodological difficulties associated with the quantitative measurement of a qualitative experience; and with the assessment of life domains chosen by researchers. Analysis of QOL research undertaken among people with all levels of SCI demonstrates that dissatisfaction with life following injury arises primarily from social disadvantage. However, little research has been conducted specifically to ascertain perceptions of QOL among people with high SCI. CONCLUSIONS: Ensuring the relevance of future research into QOL following high SCI requires qualitative methodology and mixed methods. Further research is needed to determine how rehabilitation professionals can act on the findings of their QOL assessments and enhance the QOL experienced by people with spinal cord injury in the context of their environments. SPONSORSHIP: The early phase of this study was supported by: University of British Columbia Graduate Fellowship; Rick Hansen Man in Motion Foundation (studentship); Social Sciences and Humanities Research Council of Canada: doctoral fellowship.     

Sequential FISH analysis of oocytes and polar bodies reveals aneuploidy mechanisms

OBJECTIVES: Constitutional aneuploidy occurs in at least 5% of recognised pregnancies, with apparent preferential involvement of the X chromosome and the smaller autosomes. Molecular cytogenetic investigations of cleavage-stage embryos have revealed anomalies affecting all sizes of chromosomes. The aim was to investigate the variety of anomalies arising during maternal meiosis I by analysis of unfertilised oocytes and polar bodies to gain insight into aneuploidy mechanisms. METHODS: Sequential FISH analysis was carried out with specific probes derived from eight chromosomes, representing all sizes. Only imbalance due to a gain of a whole chromosome or chromatid, represented by extra signals, was counted to avoid artefact. RESULTS: Data were obtained on 236 eggs from 124 patients of average age 32.5 years (range 22-44). Ten patients (average 32.6 years) had abnormal eggs. The abnormality rate for oocytes and for polar bodies was close to 4% for each. Fourteen hyperploidies were found, seven involving additional single chromatids. The abnormalities affected chromosomes 13,16,18, 21 and X but not chromosomes 1, 9 or 12. CONCLUSION: The data provide evidence for several mechanisms leading to aneuploidy, including classical non-disjunction of whole univalents; pre-division of chromatids prior to anaphase I, leading to imbalance detected at metaphase II; gonadal mosaicism for a trisomic cell line and preferential involvement of the smaller chromosomes. Monosomy for the large autosomes is not uncommon in cleavage-stage embryos and may additionally arise from anaphase lag preferentially affecting such chromosomes.