Hypopituitarism following traumatic brain injury

Traumatic brain injury (TBI) is a worldwide public health problem and an important cause of hypopituitarism. The incidence of hypopituitarism following moderate to severe TBI varies in different studies and may occur as multiple or isolated hormonal deficiencies, with gonadotrophin and growth hormone insufficiencies predominating, particularly in the acute setting. Adrenocorticotropic hormone deficiency is also common during the recovery phase. Pituitary function assessment in the acute phase post TBI is subject to multiple caveats and pitfalls due to hormonal alterations which occur as normal physiological responses to critical illness and the effects of drugs that are used in the intensive care unit. Nonetheless, assessment of the hypothalamo-pituitary-adrenal axis is of paramount importance during this period. Predictors of hypopituitarism during the acute phase of TBI remain unclear - further research is warranted.peer-reviewe

Charcot neuroarthropathy : pathogenesis, diagnosis and medical management

Charcot neuroarthropathy (CN) is a progressive degenerative arthropathy which rarely complicates diabetes mellitus. Most commonly, though not exclusively affecting the foot, it seems to be determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines on a calcified peripheral vasculature that maintains its ability to vasodilate despite widespread arteriosclerosis. Although often unrecalled, this arthropathy is probably triggered by trauma. Diagnosis is essentially clinical, given the paucity and non-specificity of radiological and biochemical findings at the acute stage. CN should be considered in the differential diagnosis of any diabetic patient presenting with a warm swollen lower extremity. Bone turnover markers, magnetic resonance imaging and radioisotope scanning may be useful diagnostic aids. Offloading is essential and improves limb survival. There is considerable interest, though limited data, on the benefits of bisphosphonates and calcitonin. The possible roles of ultrasound and radiotherapy need to be assessed in larger trials. Failure to institute corrective measures at an early stage results in a foot that is prone to deformity, ulceration, amputation and loss of function. It is hoped that a better understanding of the aetiopathogenesis at a cytokine level will allow the targeting of new effective agents.peer-reviewe

Metformin revisited : an ‘old’ drug with a ‘new’ beginning

Acting as a weak activator of AMP-activated protein kinase, metformin has established itself as a cost-effective first line agent in the management of type 2 diabetes (T2DM). Besides slowing progression to this condition, its use is associated with improved survival and lower rates of myocardial infarction in T2DM, as well as benefits in stable patients with heart failure. Metformin may play a valuable role in early nephropathy, non-alcoholic fatty liver disease and as adjunct therapy in type 1 diabetes. It is increasingly advocated in patients with gestational diabetes and polycystic ovary syndrome. Its role as an anti-cancer agent remains controversial.peer-reviewe

Aetiology of thyroid autoimmunity

Autoimmune thyroid disease (AITD) is characterised by the development of thyroid autoantibodies, mainly anti-thyroid peroxidase antibodies, anti-thyroglobulin antibodies (primarily involved in the development of Hashimoto’s thyroiditis [HT]) and thyroid stimulating hormone receptor antibodies (mostly involved in the development of Graves’ disease [GD]). While genetic factors provide 70 to 80% of the risk for the development of thyroid autoimmunity (TAI), environmental factors contribute about 20 to 30% to the immunopathogenesis of AITD. Such environmental factors include smoking (predisposes to GD but protects against HT), alcohol (moderate consumption protects against both HT and GD), stress (predisposes to GD) and iodine (possibly increases risk of AITD). Low selenium and vitamin D levels might increase the risk of TAI, although data remains indeterminate and selenium supplementation did not always improve TAI in clinical studies. Additionally, certain drugs, toxic chemicals, infections, birth in winter and autumn and radiation exposure have also been implicated in the development of TAI. Preventive interventions to decrease the risk of AITD are limited and not always feasible, though personal and public health interventions might help with smoking and iodine exposure.peer-reviewe

Transfusion-related acute lung injury : case report and literature review

Blood transfusion is a common procedure that usually goes without complications. However, adverse transfusion reactions should not be overlooked. Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related fatalities and is characterized by the onset of acute respiratory distress in the form of noncardiogenic pulmonary oedema. We hereby report the case of a 28 year old Jamaican lady who developed acute onset dyspnoea, tachycardia and hypoxaemia following transfusion of fresh frozen plasma and red cell concentrates.peer-reviewe

Presentation and management of diabetic ketoacidosis in adults in Malta

Aim: The aim of this audit was to assess adherence to local guideline in the management of Diabetic Ketoacidosis (DKA). Method: Patients admitted with DKA between April 2013 and March 2015 were identified and data was retrospectively collected from patients’ confidential files and Isoft®. Data collected included initial parameters recorded and biochemical investigations taken (initial and subsequent assessment of pH, HCO3-, blood glucose, potassium levels and urinary ketones), insulin regime started and intravenous fluid administered. Results: During the established time period 40 cases of DKA were identified in 18 patients. Median age was 33 years with a female preponderance of 60%. Six patients had newly diagnosed diabetes mellitus while 8 patients had more than one admission of DKA. All cases had capillary blood glucose monitoring (BGM) and/or venous random blood (plasma) glucose (RBG) checked and pH and HCO3- recorded on admission. 0.9% sodium chloride was the intravenous fluid started in all cases (as recommended by the guideline) and a median of 6.75L was prescribed during the first 24 hours. The median time spent on intravenous insulin infusion was 42.7 hours while the median time to pH >7.30, HCO3- >15mmol/L and negligible urinary ketones were 6.88, 12.83 and 34.5 hours respectively. Subcutaneous insulin was started at a median time of 48.21 hours from initiation of DKA protocol. Conclusion: This audit showed good adherence to local guideline. The great discrepancy between the time to pH >7.3 and the time to negligible urinary ketones highlights the need to introduce tools to measure systemic ketone production in the management of DKA with an update in the current local clinical practice guideline.peer-reviewe

THE GERMAN VOCATIONAL EDUCATION SYSTEM: INSTITUTIONAL COMPLEMENTARITIES AND CONTEMPORARY CHALLENGES

The goal of this study is to analyze the functioning of the skill formation regime in Germany in the light of institutional complementarities, as well as to verify the responses that the actors involved in its operation have been presenting to adapt it to changes in economic reality. It was possible to verify that the collectivist functioning of the system is being pressured through the reduction of participation in the number of companies and the flexibilization and modularization of qualification regimes, with the creation or strengthening of new qualification modalities that escape the state regulatory capacity. However, faced with this diagnosis, there is an active posture of the government and social partners participating in the management of the Federal Institute of Qualification in seeking solutions including state support for the provision of vacancies by small and medium-sized enterprises and attempts to increase the incidence on unregulated forms of qualification

The prevalence of musculoskeletal injuries in tennis players : a case study

Tennis is a popular sport both globally and locally. It is characterised by repeated strokes and explosive movements, which places the athlete at a high – risk of injuries. This study aimed at gathering data on the prevalence of tennis-related musculoskeletal injuries and injury characteristics from a local Maltese tennis club and analyse the impact of using different injury definitions on the number of collected injuries. Through this case study, an adapted version of the OSTRC questionnaire was distributed via email to members of one Maltese amateur tennis club. Using the ‘all physical complaints’ injury definition data on the prevalence and characteristics of musculoskeletal injuries suffered in the previous 6 months was gathered. Results were then analysed via SPSS and Microsoft Office Excel. A total of 61 injuries from 106 participants were recorded, with a point prevalence of 57.5%. 11 out of these 61 injuries were ‘time-loss’ injuries, and 33 were substantial injuries. The most injured locations were the elbow, knee, and ankle. Gradual onset were the most common, with most of them occurring in the elbow (41%). The ankle was mostly impacted by sudden onset injuries (36.3%). Following injury severity calculations, sudden onset injuries to the thigh and gradual onset injuries to the elbow and knee were the most burdensome. Through this study, an overview of injury prevalence and awareness from a small group of tennis players from one club has been obtained, setting recommendations for a local wide scale study to investigate the total population prevalence, information which will provide more insight for physiotherapists to help with injury prevention programmes, especially focusing on the elbow and knee, seeing that both were most frequently recorded and most burdensome.peer-reviewe