the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
Sunday 5 April 2009
METABOLIC SYNDROME
the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
METABOLIC SYNDROME
the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised fasting plasma glucose
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised fasting plasma glucose
Friday 3 April 2009
CASE STUDY
CASE ONE
A mother brings her six-year-old
son to your emergency department.
He was practising his “Power
Ranger” moves in the family’s
split-level living room and leapt
from the upper to the lower level,
landing heavily on his feet. He
complains of neck pain but no
other symptoms.
What features are present on
inspection?
He has a torticollis, and is in some
degree of pain.
What immobilisation is
indicated?
This child would not fit into a collar.
Forcing the issue would create further
pain and distress and may exacerbate
an injury. He should be allowed to
adopt a position of comfort, with
padded support if necessary, and
given simple analgesia as required.
What imaging is indicated?
X-rays are indicated as an initial investigation,
but should be interpreted
with care, with recognition that in
this age-group plain X-rays are
known to be poorly sensitive.
What is the injury?
X-rays showed an anterior subluxation
of C2 on C3. In this particular
case, injury was missed on two presentations,
as the treating doctor interpreted
the X-rays as normal and
assumed a “muscular strain”. Relying
on negative X-rays in this age
group is a classical error – the
history and examination (inspection)
give the diagnosis.
Neck pain after play mishap
X-rays are indicated for the boy but
should be interpreted with care.
A mother brings her six-year-old
son to your emergency department.
He was practising his “Power
Ranger” moves in the family’s
split-level living room and leapt
from the upper to the lower level,
landing heavily on his feet. He
complains of neck pain but no
other symptoms.
What features are present on
inspection?
He has a torticollis, and is in some
degree of pain.
What immobilisation is
indicated?
This child would not fit into a collar.
Forcing the issue would create further
pain and distress and may exacerbate
an injury. He should be allowed to
adopt a position of comfort, with
padded support if necessary, and
given simple analgesia as required.
What imaging is indicated?
X-rays are indicated as an initial investigation,
but should be interpreted
with care, with recognition that in
this age-group plain X-rays are
known to be poorly sensitive.
What is the injury?
X-rays showed an anterior subluxation
of C2 on C3. In this particular
case, injury was missed on two presentations,
as the treating doctor interpreted
the X-rays as normal and
assumed a “muscular strain”. Relying
on negative X-rays in this age
group is a classical error – the
history and examination (inspection)
give the diagnosis.
Neck pain after play mishap
X-rays are indicated for the boy but
should be interpreted with care.
CERVICAL SPINE CLEARING
1. The awake, alert patient, with no other
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.
2. The mentally obtunded patient.
Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.
This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.
2. The mentally obtunded patient.
Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.
This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.
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