A theoretical investigation of the supersaturation of basic calcium phosphate in serum of dialysis patients.

Extraosseous calcification in hemodialysis (HD) patients consists mainly of biological apatite, idealized as hydroxyapatite. Other suggested calcium phosphates are octacalcium phosphate (OCP) and brushite, both known to be hydroxyapatite precursors. Whatever the mechanisms of mineral deposition are, these mechanisms are always required to produce a supersaturated state, and that state can be calculated from the solubility product (SP) of the relevant mineral. Supersaturation in relation to serum ionized calcium [Ca 2+] and total inorganic serum phosphate (Pi) under normal and hyperphosphatemic conditions has been calculated. While supersaturation with respect to hydroxyapatite and OCP always exists, and supersaturation with respect to Ca5 (PO4)3 (HCO3) . 4H2O is just above the limit, supersaturation with respect to brushite solely occurs under hy-perphosphatemic conditions. In order to avoid supersaturation with respect to brushite the maximum serum phosphate level al-lowed is 1.9 mmol/L (5.8 mg/dl) and the calcium-phosphate product (Ca x P) 4.5 (mmol/L)2 (56 (mg/dl))2 .

Transvaginal ultrasonography and endometrial histology in peri- and postmenopausal women on hormone replacement therapy.

OBJECTIVE: To determine the association between endometrial thickness and endometrial histology in a large sample of women using HRT. DESIGN: Results from three multi-centre studies were combined. PARTICIPANTS: Five hundred and sixty-four climacteric women were treated with either sequential, continuous combined or long-cycle therapy. MAIN OUTCOME MEASURES: The women underwent 717 examinations with both transvaginal ultrasonography and histological examination of the endometrium. Endometrial thickness was measured and associated with the histological findings. RESULTS: Eight cases of endometrial hyperplasia were diagnosed. All the hyperplasias were simple without atypia. Two cases had an endometrial thickness < 4 mm and two a thickness > 8 mm. The > 4 mm threshold for abnormal endometrium had a sensitivity of 75%, a specificity of 47%, a positive predictive value of 2% and a negative predictive value of 99%. CONCLUSION: No association could be found between the endometrial thickness measured by transvaginal ultrasonography and endometrial pathology. In six out of eight women with simple hyperplasia the endometrium measured > 4 mm.

Stroke rehabilitation. 3. Rehabilitation evaluation and management.

This self-directed learning module highlights rehabilitation evaluation and management. Part of the chapter on stroke rehabilitation in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation, this article contains sections on determining the level of rehabilitation needed after stroke, the common disabilities seen after a stroke and their evaluation and management, neurofacilitative approaches in stroke recovery, and the management of dysphagia and bladder and bowel dysfunction in the stroke patient.

Stroke rehabilitation. 4. Psychologic and social implications.

This self-directed learning module highlights important psychologic and social considerations in stroke rehabilitation. Part of the chapter on stroke rehabilitation in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation, this article contains sections on psychologic and social consequences of stroke, the effect of stroke on family and caregivers, reintegration and vocational strategies after stroke, and sexual compensation in the stroke survivor. New advances in cultural aspects of stroke rehabilitation are also presented.

A Swedish version of the Women's Health Questionnaire. A measure of postmenopausal complaints.

We wanted to provide details on the psychometric documentation of the Swedish version of the Women's Health Questionnaire (WHQ), a patient based measure of postmenopausal complaints. The results of two clinical trials in Sweden in which the WHQ had been used as one out of several measurement tools were used to document the reliability, the validity and the responsiveness to change of the WHQ. More than 350 women suffering from postmenopausal complaints were included in the two trials. A factor analysis, using the baseline values of all women in each study, showed that the Swedish version of the WHQ was very close to the English original. The internal consistency reliability was excellent. The clinical validity was confirmed by a significant correlation between change in E2 levels and change in the WHQ during estrogen therapy. A high construct validity was established by the agreement between the WHQ and other quality of life scales. For use in clinical trials the WHQ was sensitive to treatment-induced changes, and added important information to the clinical effect variables.

Is sexual life influenced by transdermal estrogen therapy? A double blind placebo controlled study in postmenopausal women.

Two hundred and forty-two postmenopausal women between 45 and 65 years of age requiring hormone replacement therapy for climacteric symptoms were blindly and randomly allocated to treatment either with transdermal estradiol therapy (Estraderm 50 micrograms/24h) (E) or placebo (P). The patches were changed twice a week and treatment continued for 12 weeks. No progestogen supplement therapy was given during the study. No previous hormone replacement therapy had been given for the last six months and the women had had their last menstruation more than six months ago. As a part of a larger study assessing women's quality of life, a Swedish version of 'McCoy's Sex Scale Questionnaire' was administered at the start of treatment and after 12 weeks. This questionnaire contains nine items regarding different aspects of sexual life. The difference between the scorings at the start of treatment and after 12 weeks were calculated for each item and the values of the E and the P groups were compared. Items regarding 'satisfaction with frequency of sexual activity, sexual fantasies, degree of enjoyment, vaginal lubrication and pain during intercourse' were positively influenced in the E group compared to the P group. Items not affected were 'frequency of orgasm and sexual arousal'. A correlation between improved sexual life and quality of life was also found when the results from the McCoy scale were compared with a battery of quality of life questionnaires.

A new methodological approach to the evaluation of quality of life in postmenopausal women.

An approach employing a range of standardized questionnaires, which included the Nottingham Health Profile (NHP), the Psychological General Well-Being (PGWB) index and the Mood Adjective Check List (MACL), was used to assess health-related quality of life (QoL) in conjunction with a study comparing two doses of transdermal oestrogen (50 or 100 micrograms/24 h) combined with an oral progestogen (5 mg medroxyprogesterone acetate for 14 days each cycle). In addition to the QoL measures, climacteric symptoms were self-rated and also summarized by means of the Kupperman index. In all, 59 women, median age 52 (39-71) years, who completed 4 months of therapy were evaluated. The use of a battery of standardized questionnaires enabled a comprehensive evaluation to be made of perceived health, well-being and day-to-day functioning. Not only was symptomatic relief, e.g. reduced frequency of sweating episodes, sleep disturbance and hot flushes, observed during treatment, but there were also improvements in terms of sleep, energy and emotions. The frequency of health-related problems associated with paid employment, housework, social life, home life and sex life decreased, indicating enhanced ability to take part in daily activities. The PGWB index showed improvement in the subscales representing well-being, anxiety, depression, vitality, health and self-control, while the mood scales indicated that the women experienced less tension and more satisfaction. Although the results of this study need to be further documented on the basis of a placebo-controlled trial, the findings nevertheless imply that the use of a battery of standardized questionnaires optimizes the possibility of evaluating climacteric complaints reliably before and after treatment.

Long-term effect of transdermal hormonal therapy on aspects of quality of life in postmenopausal women.

The long-term effect on aspects of quality of life (QoL) of treatment with transdermal oestrogen for 2 weeks followed by transdermal oestrogen/progestogen norethisterone acetate/oestradiol TTS 0.25/0.05 mg/day for the next 2 weeks was investigated in postmenopausal women within the framework of a 1-year seven-centre trial. Of the 136 women who were included (mean age 53 +/- 4.8 years), 110 completed the study. Aspects of QoL that are of relevance in the perimenopause and postmenopause were evaluated using the Psychological General Well-Being (PGWB) index, the Women's Health Questionnaire (WHQ) and the Sleep Dysfunction Scale before and after 3 and 9 months of therapy in the oestrogen phase. Climacteric complaints were also assessed by means of the Kupperman Index. Improved well-being, i.e. less anxiety and depression, increased vitality and better self-control (P less than 0.0001) were observed, as well as reduced sleep disturbance (P less than 0.0001). The WHQ showed decreased vasomotor and somatic symptoms, and improved sex life, emotions and cognitive function (P less than 0.0001). Improvement was the same at 3 and 9 months. According to the Kupperman Index, climacteric symptoms were alleviated (P less than 0.0001). Relief of vasomotor symptoms was correlated with improvement in the WHQ (r = 0.82), the PGWB index (r = 0.58, P less than 0.0001) and sleep (r = 0.51, P less than 0.0001). Because of the absence of a placebo control group, the results must be regarded with caution until confirmed in a placebo-controlled trial.

Candida pyelonephritis complicating traumatic C5 quadriplegia: diagnosis and management.

We present the first reported case of Candida pyelonephritis in a spinal cord injured patient. In addition to multiple courses of empiric antibiotics, the neurogenic bladder and alteration in cell-mediated immunity found in spinal cord injured patients may have increased this patient's susceptibility to fungal disease. A 50-year-old patient with C5 motor functional quadriplegia developed Candid albicans pyelonephritis while undergoing rehabilitation. The patient had several surgical procedures and multiple courses of antibiotic therapy during acute hospitalization. He continued to have a hectic fever curve, leukocytosis with increased band forms, lethargy, and progressive uremia during rehabilitation. Successful investigation of the patient's condition included assessment of serologic tests for Candida precipitin antigen; multiple blood and urine cultures; exclusion of other causes of hectic fever; abdominal computerized tomogram, which revealed a left kidney hypodensity with irregular margins; and a retrograde pyelogram, which demonstrated multiple renal pelvic-filling defects. Cystoscopically placed ureteral stents, which relieved the genitourinary obstruction, drained gross pus from which Candida albicans was cultured; the patient was treated with amphotericin B and showed clinical improvement. Pathogenesis, presentation, diagnosis, and treatment of Candida pyelonephritis are reviewed.

Continuous infusion of intrathecal baclofen: long-term effects on spasticity in spinal cord injury.

The effects of intrathecal baclofen infusion were studied in 9 spinal cord injury patients whose spasticity had been refractory to oral medications. In a two stage, placebo controlled trial, baclofen was administered into the lumbar intrathecal space and subsequent clinical and neurophysiologic changes were assessed. In stage 1, 9 patients underwent a 5 day percutaneous infusion of baclofen and placebo via an external pump. Ashworth and reflex scores were assessed at time of enrollment, after infusion of that amount of baclofen which provided optimal spasticity control and after intrathecal infusion of placebo. The mean Ashworth grade decreased from 3.78 +/- 1.34 to 1.16 +/- 0.48 (p less than 0.001) while mean reflex score decreased from 3.57 +/- 1.05 to 0.64 +/- 0.87 (p less than 0.001). These values differed significantly from those associated with placebo therapy (Ashworth grade--2.54 +/- 1.04, p less than 0.001; reflex score--2.56 +/- 1.04, p less than 0.01). Objective improvements in functional abilities and independence were noted in 8 patients, while somatosensory and brainstem auditory evoked potentials were unchanged in all patients. Urodynamic evaluation revealed increased bladder capacity in 3 patients, while in 4 no change was observed. In Stage 2, permanent programmable infusion pumps were implanted in 7 patients who demonstrated a good response during Stage 1. In this group, mean Ashworth score decreased from 3.79 +/- 0.69 to 2 +/- 0.96 (p less than 0.001) and mean reflex score decreased from 3.85 +/- 0.62 to 2.18 +/- 0.43 (p less than 0.001). Baclofen dosage increased from 182 +/- 135 to 528 +/- 266 mcg/day over the 3-22 month follow-up period. Most of the dosage increase occurred within the initial 12 months following infusion pump implantation and tended to plateau thereafter. Minor complications such as catheter dislodgement/kinking and nausea occurred infrequently while no device related infections were observed. There was no clinical evidence of any significant baclofen neurotoxicity either in Stage 1 or 2. The only ambulatory patient developed marked lower extremity weakness during Stage 1 intrathecal baclofen infusion and was temporarily unable to walk. We conclude that continuous administration of intrathecal baclofen is an effective and safe modality for spasticity control in patients who are refractory to oral medications.

The measure of balance in sitting in stroke rehabilitation prognosis.

To test the hypothesis that recovering stroke patients with initially good sitting balance or those who develop good sitting balance during rehabilitation have better Barthel Index-based functional assessment outcomes than recovering stroke patients with poor sitting balance, we prospectively studied 24 of 25 consecutive stroke patients admitted to a tertiary-care hospital rehabilitation unit. Sitting balance, a prerequisite for most functional activities, was scored using a four-point scale evaluating static and dynamic sitting balance on admission to the rehabilitation unit and weekly until discharge. Functional status was assessed using the Barthel Index 4 or 12 weeks after the stroke. We found a strong positive correlation between Barthel Index score and each weekly sitting balance score. Multiple evaluations over time identified those patients whose sitting balance improved during rehabilitation in our unit; after grouping the patients into those with normal, improved, and poor sitting balance, we found a significant difference in the Barthel Index scores among the three groups. The group of patients whose sitting balance improved had higher Barthel Index scores than the group whose sitting balance did not improve. Ongoing evaluation of sitting balance can be helpful in anticipating functional status at discharge in stroke patients undergoing comprehensive rehabilitation.

Above-knee amputation with insidious pulmonary embolism and hypercoagulability secondary to protein C deficiency.

Pulmonary embolus can have insidious onset and unusual etiology. This case report of a 35-year-old woman with hyperthyroidism, atrial fibrillation, and an above-knee amputation demonstrates the subtle presentation of pulmonary emboli. On the rehabilitation ward of a tertiary care hospital, the patient developed undulating fever to 39.6C, rapidly worsening peripheral vascular disease, and pulmonary emboli. Eventually, a protein C deficiency was found; institution of appropriate therapy resulted in rapid improvement. This case reminds physiatrists to evaluate thoroughly the cause of pulmonary thrombi. Currently available assays permit rapid elucidation of factor deficiencies in the workup of the hypercoagulable state.