Simple Bedside Test Research Articles

M13. INCREASED SAFETY SEEKING IN PATIENTS WITH SCHIZOPHRENIA AND PARANOID THREAT

BackgroundSchizophrenia is a disabling disorder with tremendous individual burden, reduced quality of life, leading to intense costs for society. Paranoia is a central feature of schizophrenia. In particular, paranoid experience is thought to be associated with aggressive behaviour, and poor social and functional outcome. Since paranoid threat is sometimes hard to detect in the clinical interview, a simple bedside test to identify patients suffering from paranoid experience was recently proposed: the interpersonal distance test.MethodsFor measuring interpersonal distance in patients with schizophrenia and age-, gender- and education-matched healthy controls, we performed a stop-distance paradigm. To accomplish the paradigm, we positioned experimenter and participant at opposite ends of the room with a distance of seven meters facing each other. The stop-distance paradigm contained four different conditions; two active conditions (i.e. participant is approaching experimenter) and two passive conditions (i.e. experimenter is approaching participant) both, with and without eye contact. Participants were instructed to stop or tell the experimenter to stop at a distance, at which they would start to feel less comfortable. Moreover, we assessed paranoid threat with the Bern Psychopathology Scale. We compared the interpersonal distance between patients with current experiences of paranoid threat, schizophrenic patients without paranoia and healthy controls.ResultsPatients with higher ratings in paranoid experience presented with higher interpersonal distance than patients without paranoid threat and matched healthy controls. This effect was most prominent in the passive conditions. Patients without paranoia did not differ from healthy controls in the interpersonal distance test.DiscussionInterpersonal distance is a reliable indicator of current paranoid threat in patients with schizophrenia. In fact, interpersonal distance is not generally altered in schizophrenia. However, paranoid threat leads to impairments in interpersonal space regulation. This is of particular relevance as interpersonal distance might be predictive of social and functional outcome and aggressive behaviour in schizophrenia.

A systematic review and meta-analysis of the accuracy of the clock drawing test (CDT) in the identification of delirium in older hospitalised patients

Objective: Delirium is a common neurocognitive syndrome among hospitalised older adults. The clock drawing test (CDT) is a relatively simple bedside test of cognitive function. This systematic review and meta-analysis examine the accuracy of the CDT in identifying delirium in hospitalised older adults.Methods: PRISMA guidelines were used to report the identified studies. Pubmed, SCOPUS, and Ovid and EBSCO platforms (including MEDLINE ®, PsycINFO, PsycEXTRA, EMCARE, CINAHL and EMBASE databases) were searched. Studies were assessed for methodological quality using the Downs and Black Tool. Data were extracted regarding the number of delirious/not delirious, number with normal and abnormal CDT, age, and MMSE scores, and information regarding CDT scoring, criteria for diagnosis of delirium and setting of the study. Analysis was carried out with the “Mada” and “Metatron” packages of R software.Results: Fifteen studies were examined. The number of participants was 2199, of whom 597 (27.15%) were diagnosed with delirium. The overall sensitivity of CDT in the absence of any formal cognitive test was 0.76 (0.58–0.87) with specificity of 0.70 (0.51–0.83). When the MMSE was taken into account, the specificity and sensitivity reduced to 0.51. Diagnostic criteria for delirium, scoring method of CDT, age of participants and setting significantly (p < 0.05) affect the sensitivity and specificity of the CDT.Conclusion: Although, the CDT is generally considered to be a simple and easy to administer screening tool for cognitive impairment in older hospitalised adults, when a more formal cognitive test is used its sensitivity and specificity to detect delirium is low.

Comparison of Upper Lip Bite Test with Modified Mallampati Test and Thyromental Distance for Prediction of Difficult Intubation

Introduction: The prediction of difficult intubation using simple bedside test is of great importance to prevent mismanagement of airway. This study was conducted to compare Upper Lip Bite Test (ULBT) with Modified Mallampati Test (MMT) and Thyromental Distance (TMD) for the prediction of difficult intubation.&#x0D; Method: This was descriptive cross-sectional study conducted in 121 patients of American Society of Anaesthesiologists Physical Status (ASA PS) I and II patients scheduled for elective surgery requiring general anaesthesia with endotracheal tube. The airway assessment of the patients was done one day prior to the surgery using Upper Lip Bite Test (ULBT), Modified Mallampati Test (MMT) and measurement of Thyromental Distance (TMD) . On the day of surgery during laryngoscopy, Cormack-Lehane (CL) grading was recorded. The CL grading of III and IV was labeled as difficult intubation. The Sensitivity, Specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Likelihood Ratio (LR) of ULBT, MMT and TMD were calculated and compared.&#x0D; Results: The total percentage of difficult intubation, defined by Cormack-Lehane (CL) III and IV was 16.52 %. The sensitivity, specificity, PPV, NPV and accuracy of Upper Lip Bite Test (ULBT) was 50%, 100%, 100%, 91% and 91.74% respectively. ULBT had a significantly higher sensitivity, specificity and PPV when compared to MMT or TMD or MMT and TMD when combined together.&#x0D; Conclusions: Upper Lip Bite Test (ULBT) is better predictor of difficult intubation and it should be used along with other test during airway assessment.

Comparison of sensitivity, specificity, and accuracy of Wilson's score and intubation prediction score for prediction of difficult airway in an eastern Indian population-A prospective single-blind study.

Introduction:Unidentified difficult airway leads to significant adverse events and therefore prediction of a difficult airway is of importance. Independent bedside tests for the prediction of a difficult airway have poor accuracy. The airway assessment scores have not gained popularity as they are cumbersome to perform at the bedside. They also have a varying degree of interobserver variability because of their subjective parameters. Therefore, there is a need to search for a simple score with objective parameters that can be performed at the bedside.Aim:To determine the diagnostic accuracy of the Wilson score andiIntubation prediction score for predicting difficult airway in the Eastern Indian population.Material and Method:A prospective single-blind study was done including 150 consecutive patients, ASA grade I and II between the ages of 18 and 70 years, undergoing surgery requiring general anesthesia with endotracheal intubation. Preoperatively, the airway was assessed in all patients using Wilson Score and Intubation Prediction Score. General anesthesia with endotracheal intubation was done in all patients. The airway was assessed for ease laryngoscopy and intubation using the Intubation Difficulty Scale. An IDS >5 was taken as difficult airway. The sensitivity, specificity, PPV, NPV, and accuracy of the two predictive tests to predict a difficult was calculated.Results:The sensitivity, positive predictive value and accuracy of Intubation Prediction Score was 77.8%, 58.3%and 90.7% respectively as compared to 38.9%, 25.95% and 78.33% respectively of Wilsons score.Conclusion:Intubation Prediction score with its objective parameters can be preferred as a simple and accurate bedside test to predict a difficult airway in an Eastern Indian population.

Assessing adequacy of collateral foot circulation: A simple bedside test prior to lower extremity arterial cannulation

Assessing adequacy of collateral foot circulation: A simple bedside test prior to lower extremity arterial cannulation

Clinical retrospective analysis of 15 cases of choanal atresia - Our experience.

ObjectiveChoanal atresia is a rare congenital disorder due to failed recanalization of the nasal fossae during fetal development. This article focuses on our experience in dealing with choanal atresia and its management. Here we discuss the varied clinical symptoms that the patients presented with, the clinical tests and investigations that were specific in diagnosing this condition and surgical management of these cases with endoscopic transnasal choanaplasty with stenting and follow up topical Mitomycin C application.Material and methodsThis is a retrospective study based on computerized medical record review of the patients born in Department of ENT of Sur Hospital between 2002 and 2017. The patients were assessed with detailed history, presentation of clinical symptoms and all underwent nasal endoscopy and CT scans for assessing the atretic type. These patients underwent transnasal endoscopic choanaplasty under general anesthesia using microdebrider and stented using endotracheal tube. The patients were regularly followed up for review with nasal endoscopy after discharge between 4th and 7th postoperative period. The parents were educated on nursing care and the stent was removed in 4 weeks, all patients had Mitomycin C applied to the neochoana and were on regular follow up for a year with no recurrence.ResultsFifteen patient records were analyzed, 10 females and 5 males, ages varying from newborns up to 14 years old. Unilateral to bilateral choanal atresia was 4:1 ratio and female-male showed 2:1 ratio. Right malformation was predominant in both sexes in unilateral atresia. Mixed imperforation (bone-membranous) was the most frequently observed type, followed by bone malformation. The commonest symptom during diagnosis was rhinorrhea and the least one was respiratory failure. Majority of cases were diagnosed by CT scans of sinuses. Around 10% patients presented with cardiac problems. None had restenosis in one year follow up.ConclusionsNeonates with acute respiratory insufficiency due to choanal atresia can be diagnosed with simple bedside tests like cold spatula test, less invasive tests like failure to pass intranasal catheter, CT scan. Surgical correction with endoscopic intranasal choanaplasty is the way to address this problem and could avoid radical palatal approach, less morbidity and high success rate.

Vision, Aphasia, Neglect Assessment to Predict Neurosurgical Intervention in Patients with Nontraumatic Intracerebral Hemorrhage

Background and PurposeThe Vision, Aphasia, and Neglect (VAN) screening tool is a simple bedside test developed to identify patients with large vessel occlusion stroke. In the setting of intracerebral hemorrhage (ICH), there are very few bedside predictors of need for neurosurgical interventions other than age and Glasgow Coma Scale (GCS). We aimed to assess the utility of the VAN screening tool in predicting the need for neurosurgical intervention in patients with ICH. MethodsWe accessed sensitivity, specificity, positive predictive value, negative predictive value (NPV), and area under receiver operating characteristics curve of VAN for identifying ICH patients who require neurosurgical intervention. ResultsAmong 228 ICH patients, 176 were VAN positive and 52 were VAN negative. On unadjusted analyses, VAN positive patients had a significantly higher ICH volume, GCS score, and National Institutes of Health Stroke Scale score (P < .001 for all). As compared to VAN negative patients, significantly higher proportion of VAN positive ICH patients (15.4% versus 32.4%) underwent a neurosurgical procedure such as external ventricular drain (EVD) and/or hematoma evacuation with craniotomy or craniectomy. The VAN screening tool had high sensitivity and NPV (100%) in predicting the need for craniectomy or hematoma evacuation, but had lower sensitivity (87.7%) for any neurosurgical procedure, as 15.4% of VAN negative patients received EVD. ConclusionsOur study suggests that VAN screening tool can identify high-risk ICH patients who are more likely to undergo craniotomy or craniectomy but is less sensitive to rule out need for EVD.

COMPARISON OF HESTIA CRITERIA AND SIMPLIFIED PULMONARY EMBOLISM SEVERITY INDEX TO GUIDE SAFE OUTPATIENT TREATMENT IN PULMONARY EMBOLISM PATIENTS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: There is increasing evidence to support the feasibility and safety of outpatient Pulmonary Embolism (PE) treatment for selected low risk patients. American College of Chest Physicians guidelines also supports outpatient management in selected PE patients. Unfortunately, most patients with acute PE (∼98%) in USA get admitted in the hospital for initial management as shown by one multi-center study. The Hestia criteria (HC) and simplified pulmonary embolism severity index (sPESI) are two simple bedside test to determine safety of outpatient treatment of PE patient. They both are well proven and validated screening tools in multiple clinical settings. There have been very few attempts made to compare these 2 criteria. The purpose of this study is to compare HC and sPESI for safe discharge for PE patients at tertiary care center retrospectively. METHODS: This is a retrospective study from a single tertiary care academic center with data collection period from 12/25/2016 through 05/04/2017. All hospital encounters (208) with diagnosis of PE were identified based on DRG codes. 117 Patients were excluded if PE was not diagnosed in emergency room (ER). For 91 patients included in study, all components of HC and sPESI were assessed from chart review to identify low risk patients. For both screening methods, statistical analysis is performed for prediction of 30 days all cause mortality and 30 days major adverse events. Major adverse events are defined as death by any cause, clinically significant bleeding that required stopping anti-coagulation and hospital readmission. RESULTS: 45 patients (49%) and 31 patients (34%) were identified low risk based on HC and sPESI, respectively. No mortality noted in low risk group identified by both sPESI and HC. Sensitivity (100%), Negative predictive value (NPV) (100%) and false negative rate (0%) for 30-days mortality were similar with sPESI and HC. For predicting 30 days major adverse events, sPESI showed significantly higher sensitivity (93% vs 64%), NPV (97% vs 89%) as well as low false negative rate (3% vs 11%) and number needed to screen (4.7 vs 11.9). Both screening methods performed equally well for 30 days mortality prediction in our study cohort. For prediction of 30 days adverse events, sPESI outperformed HC. CONCLUSIONS: - HC and sPESI can be used to screen PE patients for outpatient treatment with good sensitivity. - In our cohort, sPESI shows higher sensitivity for prediction of 30-days major adverse events in comparison to HC along with low false negative rate and less number needed to screen. sPESI is also relatively easy and more objective than HC. CLINICAL IMPLICATIONS: Both sPESI and HC are very effective screening methods to identify low risk PE patient for outpatient treatment. Using these tools, 30-50% new PE patients can be safely managed outpatient. It would reduce health care cost significantly. We recommend sPESI over HC. DISCLOSURES: no disclosure on file for Marvin Balaan; No relevant relationships by Stephanie Baltaji, source=Web Response no disclosure on file for Eric Bihler; No relevant relationships by Kaushal Patel, source=Web Response No relevant relationships by Ekknoor Sahota, source=Web Response

Autonomic manifestations in diabetes mellitus: A case control study in rural population

Autonomic dysfunction is one which is often a disabling complication of Diabetes Mellitus. Failure to recognize the symptoms in a diabetic autonomic dysfunction may lead to a substantial morbidity and mortality, however insidious the onset may be. Thus, knowing its importance, this study features the various clinical manifestations of Autonomic Dysfunction in Diabetes, in the rural area, and by simple bedside tests. This study aims to detect cases of autonomic dysfunction and its significant correlation with Diabetes. This study was carried out on 50 patients with Diabetes Mellitus and 50 healthy controls. Autonomic function bedside tests were conducted on all study participants and the autonomic scores were calculated. Electrocardiograms were taken to calculate the corrected QT-interval. Glycemic profile was measured in all the subjects. Comparison of these parameters were done between the Diabetic and control group. Significant positive autonomic scores were observed in all the tests in diabetic group when compared to the study group. Impotence (36%), postural giddiness (30%) and sweating disturbances (26%) were the common symptoms noted among the diabetic group. Prolonged QTc interval of value greater than >0.44 was seen in 18 subjects (36%) in the diabetic group where it is seen only in 4 subjects (4%) in the control group. Among the diabetic group mean HbA1c for those with negative autonomic scores was 5.98±1.41% as compared to 7.24±2.42% with positive autonomic scores. Thus, there is an increased incidence of autonomic dysfunction among diabetic patients. The increased autonomic scores are suggestive of the same. Keywords: Autonomic function tests, Diabetes Mellitus, HbA1c, QT interval, Autonomic neuropathy.

Snake envenomation: is the 20 min whole blood clotting test (WBCT20) the optimum test for management?

The 20 min whole blood clotting test (WBCT20) is a simple bedside test recommended by World Health Organization (WHO) to assess hemotoxic envenomation and guide administration of polyvalent anti-snake venom (ASV). However, reliability and validity of this test has not been well documented in literature. Sixty consecutive patients with history of snake bite were prospectively evaluated at a teaching hospital in India over 2 years. Envenomation was established by clinical and laboratory criteria. WBCT20 was done at 0, 4 and 12 h using standardized protocol. Prothrombin time (PT) with international normalized ratio (INR) was estimated at similar intervals to detect venom-induced consumption coagulopathy. Sensitivity, specificity and likelihood ratios (LR) were determined for WBCT20 using envenomation criteria as gold standard. WBCT20 was compared with PT/INR at cutoff values of ≥1.4 and ≥1.2. Two observers performed test-retest correlation to determine inter-observer variability of WBCT20. . WBCT20 is a highly sensitive test with excellent reliability for detecting envenomation. However, the false positive rate in this study was 24%. Asymptomatic snake bite patients with a positive WBCT20 but no corresponding clinical signs of envenomation should be tested using PT/INR before receiving ASV to prevent unnecessary waste of anti-venom.

Evaluation of a Computer Program Designed to Assess Psychomotor Recovery after Day Care Anesthesia-Comparison with Clinical Criteria

Background and aims: Day care surgery under general anesthesia offers a number of advantages to patients, health care providers and hospitals. A software program Computer Aided Psychomotor (CAP) test was designed by one of the authors for objective evaluation of cognitive and affective domains in patients recovering from anesthesia. Method: The CAP test was evaluated in 40 adult patients of ASA I or II recovering from general anesthesia after day care surgical procedures. Balanced anesthesia technique was administered to all the patients. A series of ten response time (RT) to the CAP test were recorded in the PAC, in the immediate preoperative period and at 30, 60, 90, 120, 180 and 240 minutes in the postoperative period. For comparison, recovery was also assessed by a clinical recovery score (CRS) at the same time interval. Result: Hierarchical ANOVA (F-test) was used to determine significance of difference between the observations recorded by CAP test and by the clinical method. At each time point, Dunnett's test was applied for comparison. Paired t–test was used for comparison of the two methods. The trends of recovery by the two methods of assessment were similar. However, at one hour and beyond in the recovery period, the CAP test was about 10% more sensitive than the clinical method. At 120, 180 and 240 minutes, the CAP test was able to detect an apparent state of supernormal recovery which was not detectable by clinical method. Conclusion: The CAP test is an alternate method for assessment of recovery of psychomotor skills after day care anesthesia. It is a simple bedside test that can be performed in patients recovering from anesthesia. The CAP test is an objective assessment as against high level of subjective bias that could occur with the clinical method of assessment.

Bilateral choanal stenosis in a craniosynostosis child: a case report

&lt;p class="abstract"&gt;Congenital bilateral choanal stenosis is a rare developmental condition and is highly associated with craniosynostosis syndromes. It can present with life threatening asphyxia. Diagnosis is made clinically using simple bedside tests and nasoendoscopy. Computed tomography of paranasal sinus confirms the diagnosis and facilitates pre-operative planning. Although the definitive treatment is surgery, the surgical options are based on involvement of unilateral or bilateral as well as bony or membranous. We report a rare case of bilateral choanal stenosis in a child with Pfeiffer syndrome who presented with severe respiratory distress at day 32 of life. Clinically, there was failure to insert suction catheter size 6 French through both nasal cavities. A high-resolution computed tomography (HRCT) of paranasal sinus confirmed the diagnosis of bilateral choanal stenosis. Endoscopic repair of the choanal stenosis was performed and stent was inserted for 14 days. Post-operatively, there was no evidence of restenosis after 3 months of clinical follow up.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Performance on bedside tests of attention and organized thinking in patients with dementia free from delirium.

This cross-sectional study was conducted in outpatients and institutionalized patients without delirium representing a wide spectrum of severity of cognitive impairments. Patients with dementia or a cognitive disorder according to DSM IV criteria, after exclusion of (suspected) delirium according to DSM IV criteria. Tests for inattention and disorganized thinking from the CAM-ICU were assessed. The sample included 163 patients (mean age 83 years (SD 6; 64% women)), with Alzheimer's disease as most prevalent (45%) diagnosis and a mean MMSE-score of 16.8 (SD 7.5). False positive rates of the test of attention varied from 0.04 in patients with normal to borderline cognitive function to 0.8 in those with severe dementia. The false positive rate of the test of disorganized thinking was zero in the normal to borderline group, increasing to 0.67 in patients with severe dementia. When combining test results false positive rates decreased to 0.03 in patients with MMSE scores above 9. Use of simple bedside tests of attention and organized thinking for the clinical diagnosis of DSD will result in high rates of false positive observations if used regardless of the severity of dementia. However, if test results are combined they may be useful to exclude DSD in patients with minimal to moderate degrees of dementia, but not in the severe group.

Bedside clinical tests as a screening tool for predicting difficult laryngoscopy and intubation: An observational study

Context: Morphological characteristics of the airway in a population have regional variations making airway assessment and management a crucial aspect of anaesthesia practice. Aims: (1) To determine the incidence of difficult laryngoscopy and intubation using Cormack–Lehane grading and Intubation Difficulty Scale (IDS). (2) To assess the accuracy of bedside clinical tests in predicting difficult laryngoscopy and intubation. Settings and Design: Prospective observational study was carried out on 200 patients aged 18–70 years, undergoing planned surgical procedures under general anaesthesia requiring endotracheal intubation. Pregnant women, patients with head-and-neck pathology, and patients with trauma were excluded from the study. Patients and Methods: All patients underwent preoperative airway assessment and standard induction procedure. Cormack–Lehane grading was noted during first laryngoscopy and process of intubation evaluated by IDS. Statistical Analysis Used: Descriptive statistics used to depict baseline profile. Chi-square, Student t -test and logistic regression used to determine adjusted effects. Analysis was performed using STATA (14.2). Results: The incidence of difficult laryngoscopy was 15.5% and difficult intubation was 12.5%. Univariate analysis showed body mass index (BMI) >25 kg/m 2 , neck circumference (NC) >36 cm and modified Mallampati score 3/4 as significant predictors. Logistic regression showed interincisor gap (IIG) ( P P Conclusions: NC and IIG are rapid, simple bedside tests to predict difficult intubation. Bedside clinical tests have poor discriminative power but still have a role in choosing alternative methods for airway management, making judicious use of time and resources while causing minimum discomfort to the patient.

Attention, vigilance, and visuospatial function in hospitalized elderly medical patients: relationship to delirium syndromal status and motor subtype profile.

A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes. A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories. Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.

Salivary fistula: Blue dye testing as part of an algorithm for early diagnosis.

ObjectiveOrocutaneous and pharyngocutaneous fistula (OPCF) is a debilitating complication of head and neck surgery for squamous cell carcinoma (SCC), resulting in delayed adjuvant treatment and prolonged hospitalization. As yet, there is no established test that can help in prompt and accurate diagnosis of OPCF. This study aims to determine the accuracy of bedside blue dye testing and its role as part of an algorithm for early diagnosis. We also analyze the risk factors predisposing to OPCF.Study DesignRetrospective cohort study from 2012 to 2014.MethodsPatients with head and neck SCC who underwent major resection and reconstruction, at risk of OPCF, were included. Results of blue‐dye and video‐fluoroscopic swallow‐studies (VFSS) testing for OPCF were recorded. For the patients that were noted to develop OPCF, the length of time to diagnosis of fistula and subsequent mode of management were examined.ResultsOf the 93 patients in this study, 25 (26.9%) developed OPCF. Advanced T‐classification (T3/T4) was the only significant predisposing risk factor (p = 0.013). The sensitivity and specificity of the bedside blue dye testing was found to be 36.4% and 100%, respectively. The test positive patients were diagnosed with OPCF at a median of postoperative day (POD) 9.5 as compared to POD 13 for the test negative patients (p = 0.001). Early diagnosis was associated with faster fistula resolution with treatment.ConclusionBlue dye testing is a simple bedside test that can assist in the early diagnosis of OPCF in patients, allowing treatment to be instituted earlier with improved outcomes.Level of Evidence3

A Study of autonomic nervous system dysfunction among patient with diabetes mellitus: a cross sectional study

Background: Neuropathy is a common complication of diabetes mellitus and it may affect both the peripheral nerves and autonomic nervous system. It’s prevalence ranges from 1% to 90%. The present study is therefore designed to investigate autonomic nervous system involvement in diabetes mellitus by using simple bedside tests and to study its association with other diabetic angiopathies.Methods: 100 patients of diabetes mellitus were selected in the study. In Autonomic function tests for evaluating parasympathetic damage E: I ratio, 30:75 ratio and Valsalva ratio test was performed. Sympathetic damage was diagnosed by Blood pressure response to standing test and Blood pressure response to sustained handgrip test.Results: Abnormal E:I ratio was noticed in only 24 patients. The 30:15 ratio was found to be abnormal in 38 patients while the Valsalva Ratio was abnormal in 34 patients. Postural hypotension was observed in only 8% patients. The sustained hand grip test was abnormal in 10 patients. The prevalence of cardiac autonomic neuropathy was 58%. The association between the presence of autonomic neuropathy and peripheral neuropathy was statistically significant. However, the association between autonomic neuropathy and retinopathy and nephropathy was not statistically significant.Conclusions: The overall prevalence of autonomic neuropathy in diabetes mellitus was 58%. There was parasympathetic preponderance over sympathetic nervous system in the involvement of diabetic autonomic neuropathy. There was statistically significant association of diabetic autonomic neuropathy with peripheral neuropathy as compared to retinopathy and nephropathy.

Clinicopathological Study of 55 Cases of Immunobullous Diseases in Jordan

Background: Immunobullous skin diseases are a serious group of skin disorders with variable presentations that need to be diagnosed early for better prognosis. A proper clinical and histopathological evaluation is needed for correct diagnosis, so it is an important issue to share experience and to highlight this hot spot in dermatology. Objective: To have a clinical and histopathological insight into the immunobullous skin diseases as a group to show their distribution in our region and to share experience for proper early diagnosis. Material and Methods: All cases of immunobullous skin diseases that had been diagnosed clinically and histopathologically at referral centers in Jordan, Amman (King Hussein Medical Center, Jordan University hospital) and in private practice from Jan. 2000 to Jan. 2012 were included in this retrospective study. All cases were analyzed clinically and histopathologically. Hematoxylin and Eosin stained sections were used for histopathological analysis. Immunoflourscence study was done on 16 cases only and Tzanck smear examination after staining with Giemsa stain was done on 5 cases. Results: From Jan. 2000 to Jan. 2012 a total number 55 cases of different immunobullous skin diseases had been diagnosed clinically and histopathologically from a total number of 2156 skin biopsies that had been performed for different reasons and examined during that period of time. There were 21 male patient and 34 female patients with M:F ratio 1.2: 2. Age range of the patients is 4-85 yr. The distribution of different immunobullous diseases in decreasing frequency was; bullous pemphigoid 24 patients (44%), Pemphigus vulgaris 14 patients (25%), Pemphigus folaceous 5 cases (9%), Pemphigoid gesatationis 4 patients (7%), dermatitis herpetiformes 3 patients (5%) chronic bullous dermatosis of childhood 2 patients (8%), pemphigus erythematosus, one patient (4%), linear IgA dermatosis, one patient (4%), and lichen planus Pemphigoides one patient (4%). Histopathological features were conclusive in most of the cases. Tazanck smear test was a helpful test in cases of pemphigus group. The study reveals a rare form of pemphigus vulgaris as pemphigus with scalp lesions only. Rare histopathological features of bullous pemphigoid including cell poor blister and festooning were also seen. Conclusion: Immunobullous skin diseases are serious skin diseases that affect all age groups. Proper clinical and histopathological examination is essentially conclusive for diagnosis. In some cases immunoflourscence study is needed for diagnosis. Simple bedside test like Tzanck smear test is helpful in some cases

3-D spatial memory and navigation: functions and disorders.

The aim of this review is to report on the specialized neuronal systems mediating spatial orientation and navigation discovered in animal experiments. These findings have important implications for the clinical management of patients with vestibular disorders or dementia and for translational research in these fields. The following anatomically and functionally separate, but nevertheless cooperative cell types have been characterized: angular head velocity cells and head direction cells, which depend on vestibular input and interact with place cells and grid cells, which represent position and distance. The entire system is thought to encode internal cognitive maps whose spatial data can be utilized for navigation and orientation. Flying and swimming species use spatial orientation and navigation isotropically, i.e., in the earth-horizontal and vertical directions, whereas ground-based species, including humans, perform better in the earth-horizontal plane (anisotropically). Examples of clinical disorders with deficits of spatial orientation and navigation are bilateral peripheral vestibulopathy, mild cognitive impairment, and dementia. Testing spatial orientation and navigation should become an integral part of routine neurological examinations, especially in the elderly. Also desirable are the further development and standardization of simple and reliable smart phone-based bedside tests to measure these functions in patients.

Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery.

Context:Various predictors have been used to predict diabetic patients who are likely to have increased ventilatory hours and an increased length of stay (LOS) in the Intensive Care Unit (ICU) as well as in the hospital after undergoing coronary artery bypass grafting (CABG) surgery, for example, glycosylated hemoglobin (HbA1c). The authors propose a simple bed-side test, i.e., the prayer sign to predict increased ventilatory hours and increased length of ICU and hospital stay.Aims:The aim of the present study was to assess whether any association exists between a positive prayer sign and increased ventilatory hours, length of ICU and hospital stay after CABG surgery in diabetic patients.Settings and Design:This prospective observational study was conducted in a 650-bedded tertiary cardiac center.Subjects and Methods:A total of 501 diabetic patients were recruited in the study over a period of 1 year. Group P consisted of 121 patients with prayer sign positive, whereas Group N consisted of 380 patients with prayer sign negative. HbA1c levels, ventilatory hours, LOS in the postoperative ICU and hospital were compared.Statistical Analysis Used:Unpaired Student's t-test was used to compare the data.Results:The mean HbA1c levels in Group P were 8.01 ± 2.28% as compared to 6.52 ± 2.46% in Group N (P < 0.0001). The mean ventilatory hours in Group P were 9.52 ± 6.46 h, and in Group N were 7.42 ± 8.01 h (P = 0.013). Whereas, the mean length of ICU stay and hospital stay in Group P was 156.42 ± 32.66 h (6.51 ± 1.36 days) and 197.36 ± 32.46 h (8.22 ± 1.35 days), respectively, it was 121.12 ± 29.48 h (5.04 ± 1.22 days) and 178.52 ± 28.52 h (7.43 ± 1.18 days) in Group N (P < 0.0001).Conclusions:A positive prayer sign is a useful bedside test for predicting increased ventilatory hours and increased length of ICU and hospital stay after CABG surgery.