The Effect of Hyperbaric Oxygen Therapy on Functional Impairments Caused by Ischemic Stroke.

BACKGROUND: While research suggests a benefit of hyperbaric oxygen therapy (HBOT) for neurologic injury, controlled clinical trials have not been able to clearly define the benefits. OBJECTIVE: To investigate the effects of HBOT on physical and cognitive impairments resulting from an ischemic stroke. METHODS: Using a within-subject design a baseline for current functional abilities was established over a 3-month period for all subjects (n=7). Each subject then received two 4-week periods of HBOT for a total of 40 90-minute treatments over a 12-week period. Subjects completed a battery of assessments and had blood drawn six times over the 9-month total duration of the study. RESULTS: We found improvements in cognition and executive function as well as physical abilities, specifically, improved gait. Participants reported improved sleep and quality of life following HBOT treatment. We also saw changes in serum levels of biomarkers for inflammation and neural recovery. In the functional domains where improvement was observed following HBOT treatment, the improvements were maintained up to 3 months following the last treatment. However, the physiological biomarkers showed a pattern of more transient changes following HBOT treatment. CONCLUSIONS: Findings from this study support the idea of HBOT as a potential intervention following stroke.

Patient navigation for traumatic brain injury promotes community re-integration and reduces re-hospitalizations.

OBJECTIVE: To determine the effectiveness of a Navigation programme for patients with traumatic brain injury. DESIGN: Prospective programme evaluation. SETTING: Inpatient rehabilitation facility and community settings. PARTICIPANTS: Eighteen individuals who suffered a traumatic brain injury (TBI), were between the ages of 16-70 years, and had a Rancho Score greater than IV. INTERVENTION: Patient navigation programme focused on identifying and addressing barriers to positive outcomes, including coordination of care and facilitating communication among the family and healthcare providers, psychosocial support, caregiver support, adherence to treatment, education, community resources and financial issues. MAIN OUTCOME MEASURES: Functional status, re-hospitalizations, falls, neurobehavioral symptom inventory, neuroendocrine status, activities of daily living, community integration and caregiver burden. RESULTS: There was a significant reduction in re-hospitalization and fall rate when comparing individuals who received navigation services and those who did not. We also observed improved adherence treatment plans and a significant increase in community integration, independence level and functional abilities. CONCLUSIONS: This study begins to highlight the effectiveness of a patient navigation programme for individuals with TBI. Future research with a larger sample will continue to help us refine patient navigation for chronic disabling conditions and determine its sustainability.

Predicting and assessing fall risk in an acute inpatient rehabilitation facility.

PURPOSE: Unintentional falls account for 70% of all hospital accidents. The objective of this study was to identify risk factors for falls and develop an assessment tool specific for an inpatient rehabilitation facility setting. DESIGN/METHOD: Diagnosis and Functional Independence Measure (FIM) scores were collected for 174 patients to assess predictors for fall risk. Independent t-tests, chi-square, and logistic regression analysis were conducted to examine differences between fallers and nonfallers. FINDINGS: We identified several risk factors for falls including 4 FIM items: toileting, bed transfer, tub/shower transfer, and stairs; and three diagnoses: right stroke, traumatic brain injury, and amputation. From these findings, we completed initial development of a risk assessment tool. CONCLUSIONS: Evaluation of the tool suggests good specificity with 20%-30% of the patient population identified as high risk and good sensitivity by correctly predicting nearly 90% of patient falls. CLINICAL RELEVANCE: Continued evaluation of this assessment tool is needed to identify effectiveness in predicting patients who are at high risk for falling.

What happens to hemostatic agents in contact with urine? An in vitro study.

BACKGROUND AND PURPOSE: As the indications for topical hemostatic agents increase in urology, the question arises: what happens to these agents when they enter the urinary collecting system? To answer this question, we performed a series of in-vitro experiments mixing three hemostatic agents with normal and sanguineous urine. MATERIALS AND METHODS: Four commercially available topical hemostatic products: oxidized regenerated cellulose (Surgicel; Ethicon, Somerville, NJ), fibrin sealant (Tisseel VH Kit; Baxter Health Care Corporation, Irvine, CA), gelatin matrix hemostatic sealant (FloSeal; Baxter Health Care), and polyethylene glycol (CoSeal; Cohesion Technologies, Palo Alto, CA) were studied. Human urine (10 mL) was added to samples of each substance; this was done in triplicate. The 12 sample tubes were then capped and placed on a tube shaker at slow speed and 37 degrees C. Observations regarding consistency of the material were made at 6, 12, 24, 48, 72, 96, and 120 hours (5 days). Gelatin matrix hemostatic sealant was further tested in urine with various amounts of blood or blood clot; observations were again recorded out to 5 days. RESULTS: Surgicel maintained its solid form when it initially came in contact with urine, but over a period of 5 days, it transformed into a mucoid substance with visible free-floating fibers. It did not dissolve completely in urine within 5 days. Gelatin matrix was immediately transformed by urine into a fine colloidal suspension that did not change over the 5 days of the study. Fibrin glue, after mixing of the two components (fibrinogen and thrombin) directly in the urine, and polyethylene glycol immediately formed a solid clot at the bottom of the test tube on contact with the urine. When the mixture of fibrin sealant was allowed to form for 15 minutes and then added to urine, it again maintained a solid form. After 72 hours, the fibrin glue became a semisolid gelatinous plug. On analysis at 5 days, the fibrin sealant clot had transformed into a cohesive mucoid gel, and the polyethylene glycol clot had not changed. The gelatin matrix hemostatic sealant, when in contact with blood or blood clot, appeared to either become part of a clot or to remain in a colloidal suspension. At 5 days, all clots had dissolved to fine particulate suspensions, and the gelatin matrix appeared as a fine suspension. CONCLUSION: Fibrin glue and oxidized regenerated cellulose maintain a solid form when initially placed in direct contact with urine and then assume a semisolid gelatinous state, which is still present at 5 days. Polyethylene glycol forms a solid clot initially and does not change after 5 days. Only hemostatic gelatin matrix remained as a fine particulate suspension in both normal and sanguineous urine. The implications of these findings with regard to sealing the renal parenchyma or small violations of the collecting system after percutaneous or laparoscopic surgery await in-vivo testing.

One-knot pyeloplasty.

Laparoscopic pyeloplasty represents one of the more advanced reconstructive procedures for the urologist. While early reports were replete with long operative times, there have been several changes that have added to the efficiency of the procedure. In our practice, we have found three changes to be of greatest value: (1) an upper-midline port placement; (2) use of a continuous suture for the anastomosis with a double-armed, knotted suture; and (3) antegrade stent placement.

Intraoperative catheter management during laparoscopic excision of a giant bladder diverticulum.

BACKGROUND: Massive bladder diverticula present a technical challenge to the laparoscopic surgeon. We describe a laparoscopic approach to transperitoneal diverticulectomy, using a specific catheter arrangement to allow excellent control of the various portions of the procedure. METHODS: A 49-year-old male with longstanding frequency was diagnosed with a 1000 cc bladder diverticulum and bladder neck outlet obstruction. Laparoscopic transperitoneal diverticulectomy was performed using a triple catheter arrangement: endoscopic placement of a Councill catheter in the diverticulum, fluoroscopic positioning of an occlusion balloon catheter in the renal pelvis, and placement of a Cope loop suprapubic tube. Additionally, a transurethral incision of the prostate was performed. RESULTS: The procedure was completed laparoscopically using a four port transperitoneal approach. During the procedure, the diverticulum could be filled and emptied as needed; the catheter across the diverticular neck facilitated subsequent closure of the bladder wall defect. The diverticulum was completely excised. The remaining defect in the bladder was then closed in 2 layers. The patient was discharged on postoperative day 3. CONCLUSION: Careful planning and arrangement of catheters in the bladder, ureter, and diverticulum facilitates laparoscopic transperitoneal diverticulectomy of even a very large volume diverticulum.

Sealing percutaneous nephrolithotomy tracts with gelatin matrix hemostatic sealant: initial clinical use.

PURPOSE: Tubeless percutaneous nephrolithotomy (PCNL) has been performed at several centers with good success. However, these cases have been carefully selected with regard to short duration and smaller stone burden to prevent complications associated with the loss of access to the collecting system. We describe the use of gelatin matrix hemostatic sealant (FloSeal Baxter Medical, Fremont, California) as an adjunct to tubeless percutaneous nephrolithotomy to help preclude bleeding complications. MATERIALS AND METHODS: Two patients were treated with PCNL through a single nephrostomy tract. At the satisfactory conclusion of the cases the tract was occluded retrograde with an occlusion balloon catheter and gelatin matrix hemostatic sealant was injected down the nephrostomy tract. An indwelling stent and bladder catheter were placed following which all guidewires were removed and skin sutures were placed. RESULTS: The operative times were 75 and 180 minutes, respectively. Both patients had stable postoperative hemoglobin and no evidence of bleeding or obstruction on postoperative computerized tomography. CONCLUSIONS: Injection of gelatin matrix hemostatic sealant into the nephrostomy tract may be of value in preventing bleeding after PCNL. In this pilot experience it provided immediate and effective hemostasis.