The Challenge of Integrating Care in Dual Diagnosis; Anti-NMDA-Receptor Encephalitis; Presentation And Outcome In 3 Cases Referred For Complex Specialist Rehabilitation Services.

The successful implementation of an integrated care pathway (ICP) for any given condition is a challenge. Even more challenging is successful ICP implementation for individuals who have multiple co-morbidities. This is further compounded when there are dual mental health and physical disabilities that require integrated working across multiple disciplines, specialties, institutions and organisations. Anti-NMDA-Receptor encephalitis (aNMDARe) is a relatively new diagnostic entity with patients typically presenting with significant psychiatric symptoms followed by progressive neurological deterioration. In this case series, we describe 3 cases of females with aNMDARe who were referred for complex specialist rehabilitation (CSR) to The National Rehabilitation Hospital. CSR is the total active care of patients with a disabling condition, and their families, by a multi-professional team who have undergone recognised specialist training in rehabilitation, led /supported by a consultant trained and accredited in rehabilitation medicine (RM). These services provide for patients with highly complex rehabilitation needs that are beyond the scope of local services. In these cases, referral to CSR resulted in the construction of a bespoke integrated care pathway (ICP) that transcended the barriers between primary, secondary and tertiary care and across the boundaries of physical and mental health. A care pathway is a complex intervention for the mutual decision-making and organisation of care processes Rehabilitation services acted as the coordinator of services in these cases to ensure implementation of the care plan and to ensure successful transitions of care and supported local specialist and general teams in the management of these complex cases.

Post Stroke Fatigue; Point Prevalence, Characterization, Associations and Radiological Correlation in a Rehabilitation Hospital.

Post stroke fatigue (PSF) is a frequently reported symptom by stroke survivors undergoing rehabilitation. This cross sectional observational study was undertaken in a rehabilitation facility to look at its prevalence and relationship with various variables like personal factors, type of stroke, social context, hemispheric involvement on CT scan and mobility status. The results showed that PSF was present in 83% (25 out of 30) of the patients included in the study. No clear association could be established between PSF, social, radiological and functional characteristics.

Factors influencing discharge placement for Locked-In Syndrome survivors.

The objective of this study was to examine the factors which influence discharge disposition in patients with severe physical disability, due to the Locked-in Syndrome (LIS). This retrospective case series of patients with LIS, examines the extent of recovery, the processes involved in achieving discharge and the discharge destination following rehabilitation at the National Rehabilitation Hospital (NRH), Dublin. Nine LIS patients, 4 male and 5 female, have been referred to the NRH since 1995. Six of the 9 returned to live at home with their families. One patient with LIS, due to metastatic tumour, has since died. The factors which appear to determine the place and timing of discharge in LIS patients are the extent of neurological recovery, input from a specialist rehabilitation team, patient and family wishes, and the financial resources available for home care in the health service area concerned.

Acute hospital discharges of patients with major disability: a review of patients admitted to a young disabled unit.

The aim of this study was to describe a young disabled unit (YDU). These units are increasingly required to serve the needs of people with severe disabilities. Forty-two patients were included in the study; the age range was 22 to 61 years. Traumatic brain injury was the most common diagnosis on admission (13), followed by sub-arachnoid haemorrhage and non-haemorrhagic stroke (11) and non-traumatic brain injury (7). For people with severe acquired brain injuries, the course of neurological recovery often exceeds two years. The prognosis made in the acute hospital setting may need to be revised in the YDU when input from a multidisciplinary rehabilitation team enables patients to further their independence. YDUs need to have their own multidisciplinary team and sessional support from specialists in rehabilitation medicine to provide slow-stream rehabilitation. It is necessary to adequately resource all services for disabled people including inpatient and outpatient rehabilitation services, community services and YDUs. Step-down services without specialised neurological rehabilitation input may fail to achieve the full potential for patients transferred out of acute hospitals.

Hospital services for patients with acute stroke in Ireland: the Volunteer Stroke Scheme survey of consultant opinion.

A national postal survey of hospital based consultants with responsibility for acute care of stroke admissions was performed in November, December 1998. Of 162 survey forms, 140 (86.4%) were returned representing consultants working in all 38 acute general hospitals (total 10,067 hospital beds) of whom 135 indicated that stroke patients were admitted under their care. Patients were admitted under 11 different subspeciality groups to various medical and surgical wards. Only 18.5% of consultants worked in hospitals where there was a physician/neurologist with specific responsibility for stroke, whilst only 19.5% were aware of a policy in their hospital for implementation of minimum standards of care for stroke patients or a recent audit of stroke care (9%). A substantial number of hospitals in certain health board areas have no access to a consultant led rehabilitation unit within their own health board area whilst 18/38 hospitals have no on-site CT brain scanning. Despite the proven value of organised hospital stroke care, this survey documents major deficiencies in this country. We suggest that each health board would review its services to include in each hospital a consultant physician with special responsibility for co-ordination and development of appropriately staffed and funded stroke services.

The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury--observed benefits during gait studies.

The benefits of a functional electrical stimulation (FES) gait programme were assessed in a group of 6 incomplete spinal cord injured subjects. Measurements were made of quadriceps spasticity, lower limb muscle strength, postural stability in standing, spatial and temporal values of gait, physiological cost of gait and independence in activities of daily living. The subjects were assessed before commencement of the programme and after a period of gait training using FES. The benefits derived as a result of the FES gait programme included a reduction in quadriceps tone, an increase in voluntary muscle strength, a decrease in the physiological cost of gait and an increase in stride length.

Reduction of seating pressure using FES in patients with spinal cord injury. A preliminary report.

The aim of this study was to investigate the use of functional electrical stimulation (FES) as a means of pressure sore prevention in seated spinal cord injured (SCI) subjects. Nine SCI subjects took part in tests in which electrical stimulation was applied to the quadriceps with the lower legs restrained. Ischial pressures were measured during periods of quiet sitting and FES application. A strain gauged lever arm was used to measure the knee moment during quadriceps stimulation. The average pressure drop at the right and left buttocks was 44 mmHg and 27 mmHg respectively. In general the greatest reductions occurred in subjects with larger knee moments; however, there was no direct relationship between the pressure reduction obtained and the quadriceps strength. This form of FES may be useful as a prophylactic aid in the management of pressure sores in SCI subjects.

Minimal trauma causing fractures in patients with spinal cord injury.

The osteoporosis that accompanies spinal cord injury renders bones more susceptible to fracture following minor degrees of trauma. Diagnosis is often delayed due to a subtle presentation with non-specific signs. Three cases are reported that illustrate characteristic features of long-bone fractures in spinal cord injury.

The use of functional electrical stimulation to assist gait in patients with incomplete spinal cord injury.

The use of FES (functional electrical stimulation) for gait reproduction in six patients with spinal cord injury is described. Following a detailed neuromuscular assessment the patients commenced a muscle conditioning programme using electrical stimulation applied via surface electrodes. Once patients were strong enough to stand, gait synthesis was initiated in the laboratory utilizing a programmable electrical stimulator. When a satisfactory gait pattern had been achieved, patients used their portable stimulator at home. All six patients became able to stand and walk using the FES system and completed the home phase of the programme. Three patients continue to use the system at home for exercise and walking; the other patients have discontinued using the system, preferring a wheelchair or their original orthoses. We conclude that FES-assisted walking is feasible in patients with incomplete spinal cord injury, even with severe motor loss. Further advances in technology are needed for the system to become applicable to a larger number of patients.

Early mobilisation of patients with cervical cord injury using the halo brace device.

The halo brace device for cervical spine stabilisation has been in use predominantly in North America since 1959. It has not yet found widespread use for the management of the spinal cord injured in the UK. At the Yorkshire Regional Spinal Injuries Unit we have used the device over 2 years on 20 patients with complete and incomplete traumatic cervical spinal cord injuries, and compared our results with those for the previous 20 patients with similar injuries treated with skull calipers and bed rest. Patients using a halo brace device begin more active rehabilitation earlier as they are mobilised on average 5 weeks earlier than those whose traction is administered via skull calipers. Halo brace patients begin weekend leave usually within 7 weeks of their injury compared to 14 weeks post-injury for caliper treated patients and were discharged on average 2 months earlier than the comparison group. We believe that earlier mobilisation, weekend leave and discharge for halo brace patients in the absence of any neurological deterioration afford significant physical, psychological and management benefits.

Quadriplegic care: an assessment of the impact of the carer.

Thirty-three voluntary carers living with dependent quadriplegics completed a questionnaire survey which recorded their views on the assistance they received. Disruption to sex life, wheelchair restrictions, personality change in the quadriplegic person, and problems with bladder care were the features they most disliked. We have introduced a self-help group. Respite care would assist them with the valuable service they provide at considerable personal cost.

The pharmacokinetics of sulphasalazine in young and elderly patients with rheumatoid arthritis.

The clinical pharmacokinetics of enteric-coated sulphasalazine (Salazopyrin-EN) were studied after acute and chronic dosing in 20 patients with 'active' rheumatoid arthritis. 12 elderly (mean age 74.4 +/- 1 yr; range 71-83) and 8 young (mean age 40.5 +/- 1.4 yr; range 35-46) patients were given a single 2 g oral dose of sulphasalazine after an overnight fast. Serum and urine samples were collected at regular intervals over a 96 hour period for estimation of concentrations of sulphasalazine, sulphapyridine and its metabolites. This procedure was repeated after 17 days of continuous treatment with salazopyrin-EN 2 g daily in order to compare the drug's kinetics at 'steady-state'. Whilst the interindividual variation in kinetic parameters was large, age and acetylator status had a significant influence on a number of factors. The elimination half-life of sulphasalazine was prolonged in the elderly whilst renal clearance was increased in slow acetylators at 'steady-state'. The tmax and apparent volume of distribution of sulphapyridine were increased in the elderly after a single drug dosage but these differences disappeared with regular dosing. The Cmax, elimination half-life, 'steady-state' serum concentration, apparent volume of distribution and total clearance of sulphapyridine were all affected by acetylator status. We conclude that old age has only a minor effect on the body's handling of sulphasalazine and sulphapyridine but that acetylator phenotype plays a significant role in determining the 'steady-state' serum concentrations of sulphapyridine. This is likely to have practical implications with regard to some of the drug's adverse effects.

Successful rehabilitation in conversion paralysis.

A rehabilitation programme for patients with conversion paralysis has been introduced in which they are offered physical rehabilitation. During an eight month period between October 1984 and May 1985 six patients who had been diagnosed as dependent on wheelchairs owing to conversion paralysis for a mean of 3 years (range 1-6 years) were entered into the inpatient neurorehabilitation programme. All six patients were able to walk within a mean of 41 days (range 10-70 days), and then relinquished a variety of aids and allowances as a result of their regained mobility. They continued to be independent at outpatient review for a mean of 10 months (range 8-15 months). Successful rehabilitation from wheelchair dependency can be achieved by a cost effective, prolonged, inpatient neurorehabilitation programme.

Hypokalaemia: Bartter's syndrome or pseudo-Bartter's syndrome?

The difficulties in the diagnosis of hypokalaemia are often considerable. This paper reports three patients who presented with hypokalaemia. Investigations are described which may help to distinguish Bartter's syndrome from pseudo-Bartter's syndrome.