Managing post stroke hyperglycaemia

Post stroke hyperglycaemia (PSH) is prevalent in acute ischaemic stroke (AIS) patients and it has been associated with a dismal outcome of death and disability. Insulin has been proven to attenuate glucose effectively in stroke patients, thus many trials over the years had studied the efficacy of intensive treatment aiming at normalization of blood sugar level in order to improve the bleak outcomes of PSH. However, tight glycaemic control failed to be translated into clinical benefits and the outcomes are no different from the conventional approach, despite the costly healthcare expenditure invested. On the contrary, it brings more significant harm than the intended benefit, as 1 in every 9 treated patients had symptomatic hypoglycaemia. Thus, the benefits of tight glucose control, if any, are overshadowed by this potential risk of hypoglycaemia causing permanent neurological injury. Therefore, international practice guidelines recommend for less aggressive treatment to maintain blood glucose level within an appropriate range in AIS patients. However, there are limited details for stroke-specific glycaemic management and this made management of PSH particularly difficult. This review is to discuss and provide suggestions concerning glycaemic control in acute ischaemic stroke; the direction of its future prospective clinical trials and the treatment strategy required based on recent literature

Analgesic synergism of gabapentin and carbamazepine in rat model of diabetic neuropathic pain

Purpose: To evaluate synergy in the analgesic effects of a combination therapy of carbamazepine (CBZ) and gabapentin (GBP) in diabetic neuropathic pain. Methods: Neuropathic pain was produced in rats by a single intraperitoneal injection of streptozotocin (STZ) at 60 mg/kg. CBZ, GBP, and their combination were orally administered at varying doses (GBP 30 - 180 mg/kg; CBZ 20 - 40 mg/kg) comparable to their therapeutic doses in humans. Nociceptive responses in the diabetic rats were assessed using hot plate test. Results: Hot plate latency significantly increased with oral administration of GBP at a dose of 180 mg/kg when compared with control group (p < 0.05), while at a dose of 90 mg/kg, the increase was not significant. Oral administration of CBZ at doses of 20 and 40 mg/kg did not produce any significant impact on hot plate latency. However, a combination of GBP at 90 mg/kg and CBZ at 20 mg/kg produced significant increase in latency, compared with control group and other groups (p < 0.05), except the group that received 180 mg/kg GBP. The combination of low dose GBP 30 mg/kg and carbamazepine 30 mg/kg had no significant effect on latency (p > 0.05). Conclusion: The results obtained in this study provide useful information on the combination therapy of GBP and CBZ, which may be applied in the treatment of pain in diabetic neuropathy

Bilateral facial nerve palsy secondary to an atypical presentation of Gullain-Barré syndrome

Bilateral simultaneous facial nerve palsy is an extremely rare clinical entity and may occur in association with a variety of neurological, infectious, neoplastic or degenerative disorders. We describe a patient, who presented with facial diplegia and normal reflexes on examination. During the entire hospitalization, he developed no motor weakness and remained ambulatory. Whether treatment is warranted for this and other milder variants of Gullain-Barré syndrome is also discussed. Atypical presentations with preserved or brisk reflexes, can be a diagnostic dilemma

A cross-sectional study on the quality of life of patients with peripheral diabetic neuropathy pain in Hospital Tegku Ampaun Afzan, Kuantan, Malaysia

Purpose: To evaluate the quality of life of patients with peripheral diabetic neuropathy pain (PDNP) in Hospital Tegku Ampaun Afzan (HTAA), Kuantan, Malaysia.Methods: Ninety (90) participants were selected from the Medical Outpatient Department (MOPD) clinic of HTAA. The study adopted a cross-sectional design, and the self-administered Douleur Neuropathy 4 (DN4) and Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaires were used for data collection.Results: The negative impact of diabetes on QoL was clearly reflected in the fact that every domain had a negative mean value. Overall, 27.8 % of the participants reported that DM negatively affected their QoL and 37.8 % expressed the opinion that their QoL would have been higher if they were not diabetic. QoL correlated with marital status and age, with married participants and participants in the age range 50 - 59 years old showing QoL negatively affected (p &lt; 0.05) by DM with PDNP. Apart from diabetes type, all other characteristics significantly affected participants QoL as reflected by the various related domains (p &lt; 0.05).Conclusion: Based on the findings of this study, it seems that individuals with diabetes and PDNP have a low QoL, with regard to “freedom to eat”, “freedom to drink”, “physical health”, “family life”, and “living condition”.Keywords: Quality of life, Diabetes, Peripheral neuropathy pai

Attitudes towards euthanasia and physician-assisted suicide among physicians and patients in a multi-cultural society of Malaysia

Due to globalization and changes in the health care delivery system, there has been a gradual change in the attitude of the medical community as well as the lay public towards greater acceptance of euthanasia as an option for terminally ill and dying patients. Physicians in developing countries come acros situations where such issues are raised with increasing frequency. As euthanasia has gained worldwide prominence, we aim to explore the beliefs and attitude of our patients and physicians towards it and related issues

Mini review: MANAGING POST STROKE HYPERGLYCAEMIA: MODERATE GLYCAEMIC CONTROL IS BETTER? AN UPDATE

ABSTRACT Post stroke hyperglycaemia (PSH) is prevalent in acute ischaemic stroke (AIS) patients and it has been associated with a dismal outcome of death and disability. Insulin has been proven to attenuate glucose effectively in stroke patients, thus many trials over the years had studied the efficacy of intensive treatment aiming at normalization of blood sugar level in order to improve the bleak outcomes of PSH. However, tight glycaemic control failed to be translated into clinical benefits and the outcomes are no different from the conventional approach, despite the costly healthcare expenditure invested. On the contrary, it brings more significant harm than the intended benefit, as 1 in every 9 treated patients had symptomatic hypoglycaemia. Thus, the benefits of tight glucose control, if any, are overshadowed by this potential risk of hypoglycaemia causing permanent neurological injury. Therefore, international practice guidelines recommend for less aggressive treatment to maintain blood glucose level within an appropriate range in AIS patients. However, there are limited details for stroke-specific glycaemic management and this made management of PSH particularly difficult. This review is to discuss and provide suggestions concerning glycaemic control in acute ischaemic stroke; the direction of its future prospective clinical trials and the treatment strategy required based on recent literature

Persistent vegetative state after traumatic brain injury - a case report and review of the literature

Persistent vegetative state (PVS) is a chronic neurological disorder of consciousness, in which patients appear to be awake, but show no behavioural evidence of awareness. It cannot be diagnosed with certainty and misdiagnosis is very frequent. Its management has become one of the most controversial and emotive issues in medical ethics and medical law over the past few decades. The results of recent neuroimaging studies along with well-documented reports of significant late recovery of some PVS patients have challenged the long-held view that restoration of function in the severely traumatic brain injury (TBI) patients is not possible. Some clinicians believe that PVS is a misused term with the potential consequences of withdrawal and withholding of care, and tendency towards less aggressive management. Further naming these patients as “vegetative” has been misinterpreted by many groups that the patient is no more a human but “vegetable” like. Recently there has been an attempt to replace PVS by new, more appropriate name "Unresponsive Wakefulness Syndrome" (UWS). As opposed to brain death, PVS is not recognized by statute as death in any legal system. The context within which end of life decisions are being made for these patients has led to outrage especially if decisions were made to terminate hydration and nutrition. We present a case of young boy who is in a PVS following TBI with the aim to review some of the contemporary issues regarding their management

Do patients’ understanding of diabetes and perception of control predict higher Hba1c and complications?

Patient understanding and perception of diabetes control is important if clinicians were to allow diabetes patients to play a central role in management of their illness. We conducted a survey to see what diabetic patients generally thought of their understanding of disease and glycemic control; if these perceptions were accurate and related to complications. One hundred and eight consecutive patients (mean age 52.7± 13 years, BMI 27±5.2 kg/m2, HbA1c 9.2±2.2 %) attending diabetes clinic participated including 63% women, 60% primary or no education, and 47% duration of diabetes >10 years. 54% claimed to have a good understanding although nearly half answered questions on diabetes management and targets wrongly. 32% perceived their glycemic control to be good and were found to have lower baseline HbA1c (p<0.001), shorter duration of disease (p= 0.013), fewer or no complications (p= 0.06) and smaller 6-month deteriorations in HbA1c (p= 0.024) than patients who perceived poor control. Half of the patients over-estimated their control. Patients who wrongly perceived their diabetes control had significantly higher BMI (p <0.0001). 60% did not known they have diabetic complications. Patient understanding of diabetes remains poor. Continuing patient education is important. Patient perception of glycemic control is also poor and inversely related to complications and deterioration of HbA1c. Overweight patients are more likely to perceive glycemic control wrongly

Factors influencing the severity of pain in patients with peripheral diabetic neuropathy

Objective: The principal aim of this study was to identify factors influencing the severity of peripheral diabetic neuropathy pain (PDNP), a symptom of the common neurological complication of diabetes mellitus, and peripheral diabetic neuropathy. Methods: A cross-sectional study was performed using two self-administered questionnaires among subjects recruited from outpatient clinics at Hospital Tengku Ampuan Afzan, Kuantan, Malaysia. The Neuropathic Pain-4 tool was used to evaluate the presence of PDNP, and the Short-Form McGill Pain Questionnaire (MPQ) was used to characterize and determine the severity of PDNP. Sociodemographic and clinical data were collected from the patients. Results: The MPQ indicated that most patients reported experiencing mild pain for all sensory pain descriptors other than throbbing and aching (mostly reported to be moderate) and hot-burning (mostly reported to be no pain). The severity of pain was found to be significantly related to the length of time for which the patients had suffered from diabetes in those patients who had been diagnosed over 10 years previously (p=0.04). Indian patients reported a higher severity of pain overall (p=0.04). No significant relationship was found between pain severity and any of the following factors: Type of diabetes (I or II), gender, smoking status, alcohol consumption, obesity, medication taken, or presence of other diseases. Conclusion: In this study, most patients with PDNP reported the severity of the pain to be “mild.” The pain severity may be influenced by a patient’s ethnicity and the length of time for which they have suffered from diabetes

A cross-sectional study on the quality of life of patients with peripheral diabetic neuropathy pain in Hospital Tegku Ampaun Afzan, Kuantan, Malaysia

Purpose: To evaluate the quality of life of patients with peripheral diabetic neuropathy pain (PDNP) in Hospital Tegku Ampaun Afzan (HTAA), Kuantan, Malaysia. Methods: Ninety (90) participants were selected from the Medical Outpatient Department (MOPD) clinic of HTAA. The study adopted a cross-sectional design, and the self-administered Douleur Neuropathy 4 (DN4) and Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaires were used for data collection. Results: The negative impact of diabetes on QoL was clearly reflected in the fact that every domain had a negative mean value. Overall, 27.8 % of the participants reported that DM negatively affected their QoL and 37.8 % expressed the opinion that their QoL would have been higher if they were not diabetic. QoL correlated with marital status and age, with married participants and participants in the age range 50 - 59 years old showing QoL negatively affected (p < 0.05) by DM with PDNP. Apart from diabetes type, all other characteristics significantly affected participants QoL as reflected by the various related domains (p < 0.05). Conclusion: Based on the findings of this study, it seems that individuals with diabetes and PDNP have a low QoL, with regard to “freedom to eat”, “freedom to drink”, “physical health”, “family life”, and “living condition”