Chronic constipation in hemiplegic patients.

AIM: To assess the prevalence of bowel dysfunction in hemiplegic patients, and its relationship with the site of neurological lesion, physical immobilization and pharmacotherapy. METHODS: Ninety consecutive hemiplegic patients and 81 consecutive orthopedic patients were investigated during physical motor rehabilitation in the same period, in the same center and on the same diet. All subjects were interviewed >= 3 mo after injury using a questionnaire inquiring about bowel habits before injury and at the time of the interview. Patients' mobility was evaluated by the Adapted Patient Evaluation Conference System. Drugs considered for the analysis were nitrates, angiogenic converting enzyme (ACE) inhibitors, calcium antagonists, anticoagulants, antithrombotics, antidepressants, anti-epileptics. RESULTS: Mobility scores were similar in the two groups. De novo constipation (OR = 5.36) was a frequent outcome of the neurological accident. Hemiplegics showed an increased risk of straining at stool (OR: 4.33), reduced call to evacuate (OR: 4.13), sensation of incomplete evacuation (OR: 3.69), use of laxatives (OR: 3.75). Logistic regression model showed that constipation was significantly and independently associated with hemiplegia. A positive association was found between constipation and use of nitrates and antithrombotics in both groups. Constipation was not related to the site of brain injury. CONCLUSION: Chronic constipation is a possible outcome of cerebrovascular accidents occurring in 30% of neurologically stabilized hemiplegic patients. Its onset after a cerebrovascular accident appears to be independent from the injured brain hemisphere, and unrelated to physical inactivity. Pharmacological treatment with nitrates and antithrombotics may represent an independent risk factor for developing chronic constipation.

Pressure sores and blood and serum dysmetabolism in spinal cord injury patients.

STUDY DESIGN: Spinal cord injury (SCI) patients with pressure sores were studied before and after surgical intervention for ulcer healing and compared with matched SCI patients without sores and with patients with pressure sores and other diseases. OBJECTIVE: To analyse the relationship between pressure sores and anaemia and serum protein alteration in SCI patients. To study the pathogenesis of these alterations and suggest appropriate therapy. SETTING: Spinal cord unit in Rome, Italy. SUBJECTS: A total of 13 SCI patients with pressure sores, 13 comparable patients without pressure sores and four patients with other diseases and pressure sores. MAIN MEASURES: Haematochemical parameters. RESULTS: Patients with pressure sore showed significant decreased red cells, decreased haemoglobin and haematocrit, increased white cells and ferritin and decreased transferrin and transferrin saturation; total hypoproteinemia and hypoalbuminemia with increased Alfa-1 and gamma globulins increased erythrocyte sedimentation rate and C-reactive protein were also present. The alterations returned to normal after surgical intervention for pressure sore healing. CONCLUSIONS: Patients with pressure sores suffer from anaemia and serum protein alteration that fells within the range of metabolic alteration of chronic disorders and neoplastic diseases. The alterations depend on a decreased utilisation of iron stores in the reticuloendothelial system and on inhibition of the hepatic synthesis of albumin. With regard to treatment, iron treatment should be avoided because of the risk of haemochromatosis.

One year follow up of spinal cord injury patients using a reciprocating gait orthosis: preliminary report.

OBJECTIVE: To examine the influence of social, physical and psychological factors in determining the usage/non usage of reciprocating gait orthosis (RGO) in spinal cord injury (SCI) patients. DESIGN: Prospective clinical trial. SETTING: A large rehabilitation hospital in Rome, Italy. PARTICIPANTS: Twenty four SCI patients of traumatic aetiology (all fulfilling the criteria to prescribe the device). METHODS: Social, physical and neurological examination according to ASIA standards; psychological enquiry by means of the Eysenck Personality Questionnaire (EPQ) and the scale for self rating anxiety and depression of the Cognitive Behavioural Assessment. RESULTS: After 1 year follow up 11 (46%) of our patients no longer used the RGO. There was no statistically significant difference between patients who used the RGO and those who rejected the orthosis with regard to social and physical data. There was a significant difference (P=0.005 at the end of training and P=0.003 at 1 year follow up) with regard to functional ambulation level. With regard to psychological enquiry RGO-non users showed a higher frequency of values over the mean in the E scale (extroversion) of the EPQ than RGO-users (P=0.05). CONCLUSIONS: None of the identified parameters were useful to predict the use/rejection of the orthosis. Although they need to be confirmed, our psychological data suggest that extensive psychological testing could be useful to sharpen the ability to predict.

Autonomic dysreflexia during urodynamics.

UNLABELLED: Autonomic dysreflexia (AD) is an acute syndrome characterised by inappropriate and massive autonomic response that occurs in patients with spinal cord injury above the T6 level. AIMS: to evaluate the incidence of AD during cystometry and the relationships with clinical and urodynamic features. PATIENTS AND METHODS: Forty-eight spinal cord injury patients were studied by neurological and urological examination and urodynamic evaluation with concurrent recording of blood pressure, heart rate and symptoms and signs of AD. Patients were considered to have AD if blood pressure reached values higher than 150/100 mmHg. RESULTS: All the patients showed a significant increase of both systolic and diastolic blood pressure, although only 20 showed pressure values higher than 150/100 mmHg (in seven of them without AD symptoms). AD was more frequent in cervical patients (P = 0.034), but did not correlate with any other clinical features: sex ratio, age, disease duration, completeness of lesion, incidence of detrusor hyperreflexia/areflexia and detrusor-sphincter dyssynergia, voiding modalities, usage of anticholinergic drugs. In three patients blood pressure increase began when uninhibited contraction started, in 11 it was coincident with uninhibited contraction peak and in the other six it appeared at maximum bladder capacity. CONCLUSIONS: (1) during urodynamic evaluation all the patients with lesion level above T6 showed signs of sympathetic stimulation, although only some showed dangerous blood pressure values; (2) the relationship between urodynamic data and dysreflexia crisis shows that both the presence of detrusor uninhibited contractions and bladder distension are able to stimulate the crisis; (3) treatment with anticholinergic drugs is not sufficient to prevent autonomic dysreflexia starting from the bladder, unless it induces detrusor areflexia. These patients are at risk of developing autonomic dysreflexia following bladder distension.

Sequential treatment of chronic constipation in paraplegic subjects.

Chronic constipation is the main gastrointestinal complaint of spinal cord injury (SCI) patients, and has a significant effect on patients' lives, concerning nursing dependence, morbidity and complications. Many therapies have been proposed to treat chronic severe constipation, most of them with limited effect or being unpredictable in their effect or being expensive or very radical. Ten spinal cord injury patients have been submitted to a therapeutic protocol based on a high residue diet, a standardised water intake, and on the use of a sequential schedule of evacuating stimuli. After four weeks of treatment the patients showed an increased frequency of bowel movements per week, a decreased total gastrointestinal transit time, and a decreased need for oral and rectal laxatives. This treatment seems to be effective in modifying patients' bowel habits, and therefore could be considered as a standardised protocol for the management of severe constipation in those who are paraplegic.

Anaemia and serum protein alteration in patients with pressure ulcers.

The presence of anaemia and serum protein alteration frequently makes the treatment of pressure ulcers more difficult. Several haemato-chemical parameters were observed in 40 patients with sacral pressure ulcers in order to determine the pathogenesis of these complications. All of the patients showed mild-moderate anaemia with low serum iron and normal or increased ferritin and hypoproteinemia with hypoalbuminemia. Our results suggest that both anaemia and serum protein alteration depend on the chronic inflammatory state due to the presence of pressure ulcers. Both anaemia and hypoproteinemia disappeared after pressure ulcer healing. A correct diagnosis is important for the treatment. Iron therapy is useless and potentially dangerous (iatrogenic haemochromatosis) since anaemia is the result of the inability to use iron stores and not iron deficiency. The treatment of serum protein alterations should be based on a dietary therapy rich in protein and calories; the administration of albumin should be reduced, since albumin is low in essential amino-acids and too expensive; albumin administration should be limited to cases with severe hypoproteinemia and oedema.

An electrocardiographic criterion to detect AV dissociation in wide QRS tachyarrhythmias.

A study was carried out on 12 patients with wide QRS tachycardia, 8 of whom presented with atrioventricular (AV) dissociation (Group A) and 4 with 1:1 AV association (Group B). This investigation aimed at assessing whether significant variations occurred in the QRS amplitude between the two groups. Group A showed more marked variations in QRS amplitude (31.7 +/- 13%) compared to Group B patients (6.2 +/- 1.2%) (p less than 0.001). The amplitude changes observed in Group A patients are probably related to variations in telediastolic volume resulting from the occasional contribution of the atrial systole. The findings suggest that variability in QRS amplitude during wide QRS tachyarrhythmias is a reliable sign of the presence of an AV dissociation. The possibility of diagnosing an AV dissociation on a surface ECG without visible P waves is an important finding, which though not pathognomonic of ventricular tachycardia, is a valid ECG criterion for assessing the ventricular origin of arrhythmias. This ECG criterion can be usefully applied in clinical practice along with others already used for the differential diagnosis of wide QRS tachyarrhythmias.