The cold hemiplegic arm

BACKGROUND AND PURPOSE: Vasomotor changes occur in the arm after hemiplegic stroke. Previous studies have provided conflicting results, with most showing an increase in skin temperature of the hemiplegic arm. However, a number of patients complain of distressing coldness of the hemiplegic arm. METHODS: Eleven patients with symptomatic coldness and 10 patients with hemiplegia but no coldness were recruited. The severity of the symptom of coldness was compared by questionnaire with other common symptoms after stroke. A thermographic camera was used to record the finger skin temperature response to cold stress. Blood flow to both hands was also measured simultaneously by means of two plethysmographs. In all patients there were no symptoms in the unaffected arm, and this was used as a control. RESULTS: The symptom of coldness rated highly compared with other symptoms. In the symptomatic group the finger temperature on the hemiplegic side was lower at rest (median difference at rest, 0.65 degrees C; P < .0001) and at all times after cold stress. In the asymptomatic group the fingers on the hemiplegic side were colder at rest and after initial cooling (median temperature difference, 0.2 degrees C) but at no other time. Hand blood flow on the hemiplegic side was also decreased in the symptomatic group by 35%. This was not seen in the asymptomatic group. CONCLUSIONS: Coldness of the hand may be a severe and distressing symptom in some patients after hemiplegia. Symptomatic patients have lower finger skin temperatures at rest and after standard cold stress. These symptomatic patients also had reduced blood flow to the hemiplegic hand.     

Open laparoscopy without special instruments or sutures. Comparison with a closed technique

An important advantage of open laparoscopy over closed techniques is the avoidance of placing a sharp trocar blindly into the peritoneal cavity. Although an open technique theoretically minimizes the risk of major retroperitoneal vessel injury and bowel injury, most laparoscopies are performed using a closed technique. In an effort to simplify open laparoscopy, a technique was developed that can be done without special equipment or sutures and nearly as quickly as a closed technique. To compare the effectiveness of this open laparoscopic technique to a closed technique, a prospective, observational, cohort study was carried out on 66 women undergoing laparoscopy for either infertility or pelvic pain. The open technique was performed on 35 consecutive patients and compared to a closed technique performed on 31 patients on a different service during the same period. Evaluation included total duration of the procedure, length of the incision, incidence of CO2 leakage and complications. The open technique took slightly longer, and the incision was slightly longer. CO2 leakage occurred in 5 of 35 of the open cases but in none of the 31 closed cases. Leakage was controlled effectively in every case by application of a towel clip to the skin incision. No complications occurred with either technique. This study suggested that an open technique that requires no special equipment or sutures may be a useful alternative approach for laparoscopy when insertion of a sharp trocar is undesirable.     

The relationship between glycemic control and health-related quality of life in patients with non-insulin-dependent diabetes mellitus

The relationship between glycemic control and health-related quality of life was examined in patients with non-insulin-dependent diabetes mellitus (NIDDM). Within the context of a randomized controlled trial, 275 patients with NIDDM receiving primary care from a Veteran's Administration general medical clinic were enrolled and monitored for 1 year. Glycemic control (glycosylated hemoglobin levels) and health-related quality of life (Medical Outcomes Study Short-Form 36-item Health Survey [SF-36]) were assessed at baseline and at 1 year. Multivariate regression modeling using baseline and change scores during a 1-year period did not find a linear or curvilinear relationship between glycosylated hemoglobin and SF-36 scores (P = .15); this was true even after controlling for five covariates identified a priori (insulin use, number of diabetic complications, duration of diabetes, education, number of hyper-, or hypoglycemic episodes during the preceding month). Health services researchers and clinicians alike need to be aware that these two important outcomes may not be directly related. This lack of association could contribute to the high noncompliance rates observed among patients prescribed complex diabetic regimens. Unless patients perceive a benefit from following such regimens, good glycemic control may continue to be an elusive therapeutic goal, especially in patients with long-standing disease.