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Early vs Late Reduction of Cervical Spine Injury

Ghulam Farooq , Alisha Sial
OBJECTIVE: To determine outcome of early (<72hours) surgical intervention in subaxial (C3-C7) cervical spine injury through anterior approach among adults.
OPERATIONAL DEFINITION
Primary Outcome:
The ASIA impairment scale is a validated tool to describe a patient’s functional impairment as a result of their cervical spinal cord injury (attached as annex).The principal investigator will determine it by physical examination of patient and assign grades as complete (A), incomplete (B, C, D) or normal (E) on date of admission and on completion of 2 months.
Finally outcome will be assessed as good and poor.
Good: May have improved up to grade D or complete recovery grade E.
Poor: Moderately disable, not to perform daily activities independently or have neurological deficit, will be graded as either A, B or C.
MATERIAL AND METHODS
STUDY DESIGN: Case series
SETTING: Department of Neurosurgery at the Jinnah Postgraduation Medical Centre Karachi.
DURATION OF STUDY: Nine months from 12th May 2010 to 11th January 2011
SAMPLE SIZE: It is calculated as:
P=success rate:24% 10
d=margin of error:10%
Confidence interval:95%
n=Sample size came out to be 50 patients.
Methods and materials: 50 adults age greater than 17, cervical trauma patients having subaxial cervical spine trauma were reviewed retrospective to determine surgical out operated within 72 hous of presentation. Patients with history of trauma within 24 hours of presentations and age greater than 17 years were enrolled in this study. Patients with old history of trauma, bony tumors and any congenital anomaly were excluded from the study. Work up included plain X-Ray anterioposterior, lateral view and odontoid views,ct scan with 3d reconstruction and Magnetic Resonance Imaging (MRI) of cervical spine at neurosurgery department of Jinnah Postgraduation Medical Centre Karachi.Patients were explained the purpose of study and informed consent was sought for participation.Neurological assessment was done on ASIA Impairment Scale as follows
A: complete: no motor or sensory function is preserved in sacral segments S4-5
B: Incomplete: sensory but no motor function is preserved below the neurologic level and extends through the sacral segments S4-5
C: Incomplete: motor function is preserved below the neurologic level; most key muscles below neurologic level have a muscle grade less than 3
D: Incomplete: motor function is preserved below the neurologic level; most key muscle below the neurologic level have muscle grade above 3.
E: normal: motor, sensory function is normal.
on the date of admission and completion of two months and assign grades as complete (A), incomplete (B, C, D) or normal (E). Final outcome were assessed by single senior fellow of FCPS neurosurgeon as a good or poor as follows
Good: Have improved to grade D or normal Grade E
Poor: Have neurologic deficits, grade A, B or C.
Cervical spine traction was applied to reduce the fractures initially in emergency department by senior fellow and neuro exam documented afterward. Final data were collected on preformed Performa and results were compiled. Confounding variable like age and gender were controlled by stratification.
Data were analyzed on SPSS version 16.0. Frequency and percentage were computed for qualitative variable like gender and final outcome. Age was presented by mean and standard deviation. Stratification was done to control effect modification like age, gender to observe effect on outcome.
RESULTS A total of 50 cases with recent history of trauma within 24 hours were included in this study. Most of the patients were between 31 to 50 years of age and the average age of the patients was 38.54±5.47 years (95%CI 37.45 to 39.12) as presented in figure 1 and table 1.
Out of 50 cases, 38(76%) were male and 12(24%) were female as shown in figure. We were able to recognize four pattern of injuries,Fracture 66%,fracture with dislocation20%,dislocation 12%,disco ligamentous injury2%. Most common mode of trauma was road traffic accident that was observed in 56% cases followed by fall 24% and assault 20% as presented in table 2.
Regarding single level of injury of the patients is presented in table 3. C-5/6 level of injury was observed in 42%, C-6/7 level was 30% similarly C-4/5 was observed in 22% and C-3/4 level of injury was 6% cases. Two grade improvements was observed in 18 cases( 18 divided by 47 into 100 equals 38%) and one grade ASIA scale improvement was observed in 29(62%) cases in our while 3 patients were expired in which 2 expired due to diabetic mellitus and hypertension one was expired due to operative complication. Out of 47 cases, 34(72.34%) was good surgical outcome and 13(27.65%) was poor outcome after second months as presented in figure 3. Outcome with respect to age groups and gender are also presented in table 5 a
FIGURE 1
AGE DISTRIBUTION OF THE PATIENTS
n=50

TABLE 1
DESCRIPTIVE STATISTICS OF THE VARIABLES
Variables
Age (Years)
Mean ± SD
38.54±5.47
95% Confidence Interval
37.45 to 39.12
Median
(IQR)
39(5)
60-18

FIGURE 2
GENDER DISTRIBUTION
n=50

TABLE 2 MODE OF TRAUMA
n=50
Mode of Trauma
Male
Female
Total
R.T.A
21
7
28(56%)
Fall
8
4
12(24%)
Assault
7
3
10(20%)
TABLE 3
LEVEL OF INJURY
n=50
Level of Injury
No. Of patients
Percentage
C-5/6
21
42%
C-6/7
15
30%
C-4/5
11
22%
C-3/4
3
6%
TABLE 4
ASIA SCALE WITH RESPECT TO FOLLOW-UP
n=47
No of Patients
ASIA Scale On Admission
ASIA Scale After 2 Months
Two Grade Improvement
10
C
E
8
B
D
One Grade Improvement
15
B
C
9
A
B
5
B
C
FIGURE 3
FINAL OUTCOME AFTER 2ND MONTH OF DISCHARGE
n=47
TABLE 5
OUTCOME WITH RESPECT TO AGE GROUPS
Age Groups
n
Good
Poor
? 30
4
3(75%)
1(25%)
31 to 40
24
18(75%)
6(25%)
41 to 50
14
9(64.28%)
5(35.71%)
51 to 60
5
3(60%)
2(40%)
Younger patients (age less than 40yrs) did well (75%) compared to patients with age less than 40 years (60 t0 64 %).According to our study increasing age was associated with decreasing post operative out come. This was not significant however. Stratification of age on outcome.
TABLE 6
OUTCOME WITH RESPECT TO GENDER
Gender
n
Good
Poor
MALE
38
28(73.68%)
10(26.31%)
FEMALE
12
8(66.66%)
4(33.33%)
Proportion of the male having good outcome was higher than female (73.68% and 66.66%.)
DISCUSSION:
STRENGTHS AND LIMITATIONS: The strengths of our study included a prior sample size calculation scientifically, based on the prevalence of acceptable outcomes from previous studies. The single complete objective along with operational definitions and well clear predictors and outcome variables increases the worthiness of the study. This stringent inclusion and exclusion criteria along with a single acceptable criterion for the selection of outcome assessors decrease bias and helps in control for confounders. The study also included stratification for control of effect modification. Our study has few limitations, the selection of weak study design case series decreases the reliability, strength and worthiness of the study. The use of non- probability purposive sampling also decreases the generalizability of results applicability of study results to even similar geographical, cultural and demographic settings. The case series study also do not require a prior calculation of sample size, further the selection of few outcome variables limits the scope of the study.
CONCLUSION: The results of our study are similar to previous studies showing high anatomical and functional outcome with acceptable differences related to geographical, cultural and quality of expertise and management differences. However considering the strengths and limitations of our study we recommend future studies should be conducted with hierarchy of study designs and multiple outcomes and settings with larger sample sizes to reach any firm conclusion.

Public Health Issues: Type 2 Diabetes

Abhishek Kumar
Is type 2 diabetes a public health emergency?
Definition:
The term “diabetes mellitus” describes a metabolic disorder of multiple aetiology characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both . The effects of diabetes mellitus include long-term damage dysfunction and failure of various organs.(WHO)
Types of diabetes:
There are two main types of Diabetes:
Type 1 diabetes (T1B) which usually develops in childhood and adolescence and the patients require lifelong insulin injections for survival.
Type 2 diabetes (T2B) usually develops in adulthood and is related to obesity lack of physical activity and unhealthy diets. This is the more common type of diabetes (representing 90% of diabetes cases worldwide) and treatment may involve lifestyle modifications and weight loss alone or oral medicines or even insulin injections.
Other categories of diabetes: There are other categories of diabetes which includes gestational diabetes (a state of hyperglycaemia which develops during pregnancy) and other rarer causes (genetic syndromes, acquired processes such as pancreatitis, diseases such as cystic fibrosis, exposure to certain drugs, viruses and unknown causes).
Burden of diabetes:
The development of diabetes is projected to reach pandemic proportions over the next 10-20 years.
International diabetes federation data indicates that by the year 2025 the number of people affected will reach 333 million – 90 % of the population will type 2 diabetes
In most western societies the overall prevalence has reached 4-6 % and is high as 10-12% among 60-70 year old people.
The annual health costs caused by diabetes and its complications accounts for around 6-12% of all health care expenditure.
South Asian, African- Caribbean, black African and Chinese descent, and people from a lower socio- economic background have a higher incidence of type 2 diabetes than in the general population (Nice, 2011).
Around 2.8 million people are affected by type 2 diabetes in the UK (90 %). Diabetes is estimated to account for at least 5% of UK healthcare expenditure, accounting for around 7 % of the total NHS drugs budget (Type 2 diabetes). The incidence for serious complication is also on the rise. They are cardiovascular disease (CVD), foot problems (ulceration and gangrene) and blindness in people of working age in the UK (due to the condition called retinopathy).
The prevalence of type 2 diabetes in children ranges from 4.1 per 1000 (12- 19 year olds) in the US to 50.9 per 1000 (15-19 year olds) in Pima Indians of Arizona. Between 8 % and 45 % of children (recently diagnosed cases) and adolescents cases in the United States is type 2 diabetes, and the magnitude of this disease may be underestimated. The prevalence of the disease is increasing in North America and its incidence doubled in Japan between 1976-80 to 1991-5 from 7.3 to 13.9 per hundred thousand junior high school children (these trends coincide with the rising prevalence of overweight and physical).
The South Asian origin in the UK are at a high risk (6 times more likely) of developing type 2 diabetes. People from lower socioeconomic groups are three and a half times more likely to experience ill health.
Diabetes affects both children and adults. Around 300, 000 people have this disease in Sweden. Diabetes entails everyday problems and can lead to an impaired quality of life as a consequence. Its risk of complication is large and its life expectancy is shorter than among the rest of the populations. In the past years the media expressed apprehension regarding a ‘’diabetes explosion’’ in consequence of increased obesity.
The chronic metabolic disorder diabetes mellitus is a fast growing global problem with huge social, health and economic consequences. It is estimated that in 2010 there were globally 285 million people (apparently 6.4 % of the adult population) suffering from this disease. This number is estimated to increase to 430 million in the absence of better control or cure.An ageing population and obesity are the two main reasons for the increase. Furthermore it has been shown that almost 50% of putative diabetes are not diagnosed until 10 years after the onset of the disease hence the real prevalence of global diabetes must be astronomically high. This essay elaborates the clinical features,complications ,management and recommendations for the diabetes which has become a public health emergency.
Type 2 diabetes (T2D):
Etiology-
It is associated with obesity and decreased physical activity, and unhealthy diets. It occurs in individuals with hypertension ,dyslipidemia (abnormal cholesterol profile) and central obesity and hence it is a component of metabolic syndrome.
It often runs in the females and is a complex disease caused by mutations in more than one gene, as well as environmental factors.
Clinical Features-
In the type 2 diabetes the signs and symptoms may not be so obvious as the condition develops slowly over a period of years and may only be picked up in a routine medical check up ,symptoms are quickly relieved once diabetes is treated and under control .
The main symptoms of undiagnosed diabetes include:
Passing urine more often than usual especially at night .
Increased thirst..
Extreme tiredness .
Unexplained weight loss .
Genital itching or regular episodes of thrush.
Slow healing of cuts and wounds .
Blurred vision.
Complications of diabetes type 2:
Type 2 diabetes affects many major organs including your heart, blood vessel, nerves,eyes and kidneys. Controlling the blood sugar levels can help prevent these complications.
Although long term complications of diabetes develop gradually they can eventually be disabling or even life threatening. Some of the potential complications of diabetes include:
Heart and blood vessel disease: diabetes dramatically increases the risk of various cardiovascular problems including coronary artery disease and chest pain ,heart attack ,stroke ,narrowing of arteries (atherosclerosis) and high blood pressure. The risk of stroke is two to four times higher for people with diabetes.
Nerve damage (neuropathy): Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves especially in the legs ( This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spread upwards.
Kidney damage (nephropathy): The kidneys contain millions off tiny blood vessels cluster that filter waste from your blood.Diabetes can damage this delicate filtering system, severe damage can lead to kidney failure.
Eye damage: Diabetes can damage the blood vessels of the retina (diabetes retinopathy) potentially leading to blindness.
Several studies showed a link between cognitive deficit and diabetes. Research showed that those with the disease have greater rate of decline in cognitive function
Diagnosis:
The diagnosis of type 2 diabetes mellitus is made by the presence of classic symptoms of hyperglycemia and an abnormal blood test.
Fasting blood glucose test: The patient needs to fast overnight before having the test. Glucose level of 7.0 mml/ litre or greater suggest one has diabetes type 2.
Two hour blood glucose test (glucose tolerance test ). This test is used in measuring how your patient’s blood glucose level changes over time after one has taken a sugary drink.The patient has to fast overnight before having this test . Glucose level of 11.1mmol/litre or greater suggests type 2 diabetes .
Glycosylated haemoglobin (HbA1C) test: The HbA1c is a protein that is produced when the patient has high blood glucose level over a long period of time. HbA1C level of 48nmol/mol or greater suggests that the patient is suffering from type 2 diabetes .
If the blood test results suggest that the patient has type 2 diabetes he/she needs to have a repeated blood tests before the diagnosis is confirmed.
Treatment:
Treatment of type 2 diabetes requires is a lifelong commitment to:
Blood sugar monitoring: The patient of diabetes should have their blood sugar level checked either once a day or several times a week . This careful monitoring is the only way to make sure that the blood sugar remains within the target range.
Healthy Eating : Contrary to population perception there is no diabetic diet till date . However it is important to centre your diet on these high fibre, low fat foods like fruits, vegetables and whole grains. A registered dietician can help the patient put together a meal plan that fits the health goal, food preferences and lifestyle of the patient .To keep the blood sugar on an even level one should eat the same amount of food with the same proportion of carbohydrates, proteins and fats at the same time every day .
Regular Exercise: The patient with the help of their doctor should start an exercise program,which they enjoy like walking, swimming or biking. The aim should be of at least 30 minutes of aerobic exercise most days of the week. The word of caution is that as physical activity lowers blood sugar so the patient should check there blood sugar level before any exercise and eat a snack before exercising to help prevent low blood sugar.
Diabetes medication and insulin therapy: Type 2 diabetes gets worse over time even if they work at first diet and exercise may not be enough to control the blood glucose levels, So the patients eventually need medicines that reduce high levels of blood glucose.
It is generally in the form of tablets but maybe a combination of more than one type of tablets, it may also include insulin which is in injectable form. The oral hypoglycaemic drugs can be classified into following types:
Metformin.
Sulphonylureas .
Glitazones
GLP-1 agonist
Acarbose.
Nateglinide and Repaglinide.
Similarly the insulin can also be classified as :
Rapid acting Insulin.
Short acting Insulin.
Intermediate acting insulin.
Long acting insulin
Conclusion:
Large population based studies in China, Finland, and USA have recently demonstrated the feasibility of preventing, or delaying the onset of diabetes in overweight subjects with mild glucose intolerance (IGT). The studies suggest that even moderate reduction in weight and only half an hour of walking each day reduced the incidents of diabetes by more than one half.
Diabetes is a serious and costly disease which is becoming increasingly common especially in developing countries and in disadvantaged minorities. However there are ways of preventing it and controlling its progress. Public and professional awareness of the risk factors and symptoms of diabetes are an important step towards its prevention and control. Some of the measures which can be taken to reduce the burden of diabetes are described below.
Prevention-
Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes .To help prevent type 2 diabetes and its complications people should:
Achieve and maintain healthy body weight.
To be physically active –atleast 30 minutes of regular moderate – intensity activity on most days .More activity is required for weight control.
Eat a healthy diet of between three and five servings of fruits and vegetables a day and reduce sugar and saturated fat intake;
Avoid tobacco use – Smoking increases the risk of cardiovascular diseases.
Diagnosis and Treatment-
Early diagnosis can be accomplished through relatively inexpensive blood testing.
Treatment of diabetes involve lowering blood glucose and the level of other known risk factors that damage blood vessels .Tobacco use cessation is also important to avoid complications.
Intervention that are best cost saving and feasible in developing countries includes-
Moderate blood glucose control people with type 1 diabetes require insulin, people with type 2 diabetes can be treated with oral medication but may also require insulin.
Blood pressure control.
Foot care.
Other cost saving interventions include-
Screening and treatment for retinopathy (which cause blindness).
Blood lipid controls (to regulate cholesterol levels).
Screening for early signs of diabetes –related kidney disease.
These measures should be supported by healthy diet ,regular physical activity, maintaining a normal body weight and avoiding tobacco use.

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