A diabetes scorecard does not improve HbA(1c), blood pressure, lipids, aspirin usage, exercise and diabetes knowledge over 9 months: a randomized controlled trial.

AIMS: To test (1) whether a diabetes scorecard can improve glycaemic control, blood pressure control, LDL cholesterol, aspirin usage and exercise; (2) if the scorecard will motivate and/or educate patients to improve their scores for subsequent visits; and (3) whether the scorecard will improve rates of clinical inertia. METHODS: Five physicians enrolled 103 patients ≥ 40 years old with uncontrolled Type 2 diabetes [HbA(1c) ≥ 64 mmol/mol (8.0%)] to randomly receive either a diabetes scorecard or not during four clinical visits over a 9-month period. The population was predominantly urban with a disproportionately higher percentage of black people than the general population. Our scorecard assigned points to six clinical variables, with a perfect total score of 100 points corresponding to meeting all targets. The primary outcomes were total scores and HbA(1c) in the scorecard and control groups at 9 months. RESULTS: There were no significant differences between the control and scorecard groups at visits 1 and 4 in total score, HbA(1c) , blood pressure, LDL cholesterol, aspirin usage, exercise or knowledge about diabetic targets. By visit 4 both the control and scorecard groups had statistically significant improvements with their mean total score (9 and 7 points, respectively), HbA(1c) [-9 mmol/mol (-0.8%) and -15 mmol/mol (-1.4%), respectively] and aspirin usage (33% increase and 16% increase, respectively). Rates of clinical inertia were low throughout the study. CONCLUSIONS: A diabetes scorecard did not improve glycaemic control, blood pressure control, LDL cholesterol, aspirin usage, exercise or diabetic knowledge in an urban population with uncontrolled Type 2 diabetes.

Flow-volume relationship at low lung volumes in healthy term newborn infants.

To describe the maximum expiratory flow-volume relationship in newborn infants, we simulated forced expiration by transiently applying positive pressure in a chamber surrounding the infant's body. Maximum expiratory flows were reached at any given lung volume when increases in chamber pressure failed to produce increases in flow. Maximum expiratory flows were achieved in seven of nine healthy newborn infants at lung volumes equal to functional residual capacity (FRC) andin all infants at lung volumes below FRC. The volume expired below FRC (6.4 ml/kg) was roughly equivalent to previously calculated values of expiratory reserve volume in newborn infants (7 ml/kg). The maximum expiratory flow volume curves showed that the infants were able to increase expiratory flow rates well above those achieved during tidal breathing. The convex shape of the curves at low lung volumes is compatible with flow limitation occurring in peripheral airways.

Variability in 28-day outcomes for very low birth weight infants: an analysis of 11 neonatal intensive care units.

A retrospective study of all infants weighing 701 to 1,500 g born at 11 neonatal intensive care centers during 1983 and 1984 was performed to determine whether two specific 28-day outcomes, survival and survival without the need for supplemental oxygen, varied among the centers. Survival without the need for supplemental oxygen was chosen as a reflection of infants surviving without chronic lung disease. There were 1,776 live-born infants delivered during the 2-year study period. Of these infants, 85% (1,512) survived 28 days, a range of 80% to 92% at the individual centers. A total of 60% (1,056) of the infants were alive without supplemental oxygen on day 28, a range of 51% to 70% at the individual centers. Multivariate analysis demonstrated that both survival on day 28 (chi 2 = 23.9, P less than .01) and survival without supplemental oxygen on day 28 (chi 2 = 44.2, P less than .0001) varied significantly among centers after the effects of birth weight, gender, and race were taken into account. Female gender, nonwhite race, and increased birth weight were factors associated with improved rates of survival and survival without supplemental oxygen. The magnitude of outcome variation among centers was estimated by using the logistic regression models to predict what the outcomes would be if each center were to treat a standardized population consisting of all 1,776 study infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases.

STUDY DESIGN: A retrospective analysis of eight cases of delayed spinal infection after elective posterior or combined anterior and posterior spinal instrumentation and fusion. OBJECTIVES: These cases are reviewed to identify risk factors for delayed spinal infection after elective instrumentation and to describe the treatment of this complication. SUMMARY OF BACKGROUND DATA: Delayed spinal infection after elective spinal instrumentation and fusion is uncommon. This diagnosis is frequently difficult. METHODS: Five cases seen in the senior author's practice and three referral cases are reviewed. RESULTS: Of these eight cases, the organisms were Staphylococcus epidermidis in six cases, Propionibacterium acnes in one cases, and in the final patient, all intraoperative cultures were negative. Clinical presentations were variable; however, all patients reported back pain. Seven patients had elevated erythrocyte sedimentation rates, averaging 57 mm/hour. Only two had elevated white blood cell counts. No distant foci of infection were identified in any patient. Five-patients were found to have at least one pseudarthrosis. All patients were treated with debridement, instrumentation removal, and primary wound closure over drains followed by a minimum 6-week course of culture-directed postoperative antibiotics. At an average follow-up of 18 months, no patient has evidence of infection. CONCLUSIONS: The diagnosis of delayed infection after elective spinal instrumentation and fusion requires a high index of suspicion. These infections may have been caused by intraoperative inoculation. All patients were successfully treated with debridement, instrumentation removal, and culture-directed postoperative antibiotics.

Pneumothorax as a function of gestational age: Clinical and experimental studies.

Infants with respiratory distress syndrome are especially prone to pneumothorax and pneumomediastinum as a complication of their disease. In a retrospective clinical analysis of a consecutively delivered population of infants with RDS the data suggested that the less premature infant with RDS was apparently more at risk to develop pulmonary rupture. This clinical observation was confirmed in postmortem studies in premature rabbits. The most immature group of lungs were relatively resistant to pulmonary rupture, owing to high surface forces. Toward term, surface forces were decreased as were lung tissue elastic forces, which predisposed to rupture at lower pressures.

The erythrocyte sedimentation rate in the newborn period.

Determination of the erythrocyte sedimentation rate in capillary blood can be of value in identifying neonates with infection. The normal values for the method described here range from 1 mm/l hour at 12 hours of age to 17 mm/l hour at 14 days of age. Most noninfected neonates with moderate to severe RDS or with other serious illness had values well within the normal range. Infected patients had marked elevations, and the majority of values returned to normal with clinical improvement. Coombs-positive ABO hemolytic disease was also responsible for elevated values. In about half of the infected patients the rise was not seen until 24 to 48 hours after clinical symptoms first appeared. The ESR can be useful in the nursery as a preliminary step in the laboratory evaluation of the sick neonate. Serial determinations may be of aid in identifying the infected infant when the results of bacteriologic cultures are obscured by antibiotic therapy.

Maturational changes of effective elastance in the first 10 days of life.

The effective elastance of the respiratory system (E'rs) is a measure of its ability to resist a change in tidal volume under conditions of changing elastic loads. E'rs was measured while subjects breathed air and 2% CO2 and 4% CO2 in air in two groups of premature infants of different gestational ages at 1 day 3-4 days, and 7-10 days of age. E'rs was shown to decrease with increasing maturation and was independent of changes in control tidal volume. The decrease of E'rs with increased gestational age could be accounted for by differences in calculated thoracic gas volumes in all but one instance, where E'rs was lower in one group on the 3rd day of life. The activity of the Hering-Breuer reflex, as measured by the degree of slowing of inspiratory time after occlusion at FRC, has been previously reported to be normal to increased in similar infants. This suggests that differences related to size account for most of the maturational changes of E'rs in newborns.

Maturational effects on respiratory responses to carbon dioxide in premature infants.

The respiratory responses of 18 premature infants to breathing steady-state levels of carbon dioxide were quantified by conventional minute ventilation measurements and by measuring the pressure generated after end-expiratory airway occlusions. Since no flow or volume changes occur following airway occlusion, the CO2 response obtained by this measurement is independent of vagal stretch receptor influence and mechanical changes in the lungs. When studied at 3-4 days of postnatal age, a group of 29-32-wk gestation infants had a mean slope of ventilatory response to CO2 of 10.8 +/- 5.6 ml-min-1-kg-1-mmHg-1 as compared to 53.5 +/- 10.8 ml-min-1-kg-1-mmHg-1 (P less than 0.005) for a group of 33-36 wk. When these infants were restudied at 7-10 days of age, the slopes were 21.6+/- 6.6 and 58.4 +/- 10.6 ml-min-1-kg-1-mmHg-1 (P less than 0.01), respectively. The mask pressure response paralleled minute ventilation. We conclude that the increase in ventilatory response to carbon dioxide seen with maturation is not due only to changing mechanical features of the lungs, but to increased sensitivity of respiratory centers to carbon dioxide.

Respiratory response to airway occlusion in infants: sleep state and maturation.

The progressive respiratory response to occlusion of the airway at FRC was measured in a group of full-term and premature human infants. The sleep state of the full-term infants was shown to affect the response primarily through variations in the phase of thoracic and abdominal movements. The weakest responses were seen in those infants who demonstrated parodoxical respiration prior to occlusion. Most infants developed paradoxical respiratory movements after occlusion, but this did not affect the strength of the load-compensatory response. An increase in response related to both gestational and postnatal age was observed. This increase could not be accounted for by variations in the amount of paradoxical and in-phase respiration and thus may represent an increase in the sensitivity of infants to chemical stimuli with maturation.

Intrathecal urokinase as a treatment for intraventricular hemorrhage in the preterm infant.

Despite improvements in the care of preterm infants, intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PHH) continue to be frequent occurrences in this patient population. Shunt procedures in these children are frequently complicated by obstruction and/or infection. As the hydrocephalus is usually caused by an obliterative arachnoiditis due to contact of the blood with the basilar meninges, it was postulated that infusion of urokinase into the ventricles of infants who have sustained an IVH would clear the blood, mitigate the arachnoiditis, and prevent the progression of PHH. Accordingly, 18 preterm infants who had sustained IVH and subsequently developed PHH were treated with intraventricular urokinase instilled via a surgically implanted subcutaneous reservoir. There were no complications associated with the urokinase. Infants were divided into two dosage groups: low dose (110,000-140,000 IU total) and high dose (280,000 IU total). One infant in the low-dose group died at 1 month of life of respiratory complications. In the low-dose group, 3 of 8 (37%) infants required shunt placement; in the high-dose group, all 9 required shunt placement. For the total group, the shunt rate was 71%. This compares to a historical control group shunt rate of 92%. While the difference between the treatment group as a whole and control group approaches, but does not reach, statistical significance (p = 0.068), there was a significant reduction in the shunt rate when the low-dose group was considered separately (p < 0.002). For those infants that required shunt placement, there were fewer shunt revisions performed in the treatment group than in the control group during the first 24 months following shunt placement: 0.67 versus 1.5 shunt revisions/shunted child. Initial experience with intraventricular urokinase following IVH and PHH in preterm infants suggests a beneficial effect in reducing the shunt revision rate in both high- and low-dose groups. Reduction in shunt placement rate is seen only in the low-dose group.