RESUMEN
BACKGROUND: Bowel dysfunction results in a major lifestyle disruption for many patients with severe central neurologic disease. Percutaneous endoscopic sigmoid colostomy for irrigation (PESCI) allows antegrade irrigation of the distal large bowel for the management of both incontinence and constipation. This study prospectively assessed the safety and efficacy of PESCI. METHODS: A PESCI tube was placed endoscopically in the sigmoid colon of 25 patients to allow antegrade irrigation. RESULTS: Control of constipation and fecal incontinence was improved for 21 (84%) of the 25 patients. These patients were followed up for 6-83 months (mean, 43 months), with long-term success for 19 (90%) of the patients. No PESCI had to be removed for technical reasons or for PESCI complications. Late removal of the PESCI was necessary for 2 of the 21 patients. A modified St. Marks Fecal Incontinence Score to assess bowel function before and after PESCI showed a highly significant improvement (P < 0.0001). There were no procedure-related deaths. Complications included minor sepsis at the initial PESCI tube site in four patients and bumper migration in two patients, but there were no complications related to the button device. CONCLUSION: This study showed that PESCI is a simple, safe, and effective technique for distal antegrade irrigation in the management bowel dysfunction for selected patients with central neurologic disease. A successful PESCI is very likely to continue functioning satisfactorily for a long time without technical problems or local complications.
Asunto(s)
Enfermedades del Sistema Nervioso Central/complicaciones , Colon Sigmoide/cirugía , Colonoscopía/métodos , Colostomía/métodos , Estreñimiento/terapia , Incontinencia Fecal/terapia , Adolescente , Adulto , Anciano , Enfermedades del Sistema Nervioso Central/fisiopatología , Colon Sigmoide/fisiopatología , Estreñimiento/etiología , Estreñimiento/fisiopatología , Incontinencia Fecal/etiología , Incontinencia Fecal/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Irrigación Terapéutica , Resultado del TratamientoRESUMEN
Despite the problems posed by diversity of condition and the lack of agreement among researchers over what outcome to measure, there is now increasingly robust evidence for the effectiveness of rehabilitation in brain-injured populations. Meta-analysis has demonstrated clearly that stroke units provide a better outcome than management on a general medical ward, at the level of survival, discharge destination and dependency. The extent of this advantage may be summarized in the following terms. For every 100 patients treated in a stroke unit, four deaths and two institutional admissions are avoided, and five patients are discharged home. This benefit appears to arise from a combination of good-quality acute management and the coordinated input of a multidisciplinary team. Therapy programmes are shown to be of benefit and intensive therapy programmes of somewhat greater benefit. Smaller numbers and heterogeneity among the head-injured population tend to confound randomized controlled trial designs, but there is no good reason to suppose that brain injury resulting from trauma should be less responsive to similar good management principles than that arising from stroke. In any event, we have progressed to a stage where the weight of evidence supports the notion that rehabilitation is effective, and nontreatment controls are ethically no longer acceptable. It is time now to unravel the threads of rehabilitation and consider which are the critical components. There are still many opportunities for comparison of different models for delivery of care, and the existing evidence for these is discussed.
Asunto(s)
Lesiones Encefálicas/rehabilitación , Rehabilitación de Accidente Cerebrovascular , Terapia Conductista , Servicios de Atención de Salud a Domicilio , Humanos , Terapia Ocupacional , Evaluación de Resultado en la Atención de Salud , Modalidades de FisioterapiaRESUMEN
OBJECTIVE: To ascertain whether or not an inpatient multidisciplinary treatment programme for patients with Parkinson's disease or multiple sclerosis resulted in a measurable change in patients' health-related quality of life (HRQL). DESIGN: Assessments of HRQL were made one week before adm ssion and approximately one month post discharge. SETTING: Six-bed Neurological Rehabilitation Unit at Worthing Hospital on the south coast of England. SUBJECTS: Fifty-eight patients with Parkinson's disease and 33 patients with multiple sclerosis. INTERVENTIONS: All patients received an individually adapted, multidisciplinary rehabilitation programme. The programmes lasted from 5 to 10 days. MAIN OUTCOME MEASURES: HRQL scores on the Nottingham Health Profile Part 1 (NHP-1). RESULTS: Overall post-treatment NHP-1 scores were significantly better than overall pretreatment scores for both the Parkinson's group (z= 2.6, p <0.01) and the multiple sclerosis group (z = 2.1, p <0.05). Sixty-four per cent of patients perceived an overall improvement. The strongest improvement was in 'physical mobility' in the multiple sclerosis group (z = 3.0, p <0.01) and in 'emotional reactions' in the Parkinson's group (z = 2.9, p <0.01). CONCLUSIONS: These results suggest that the multidisciplinary inpatient approach in neurological rehabilitation has identifiable short-term benefits for the majority of patients. A randomized trial with longer follow-up is required to confirm this.
Asunto(s)
Indicadores de Salud , Esclerosis Múltiple/rehabilitación , Enfermería/organización & administración , Enfermedad de Parkinson/rehabilitación , Grupo de Atención al Paciente/organización & administración , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de VidaRESUMEN
A first survey of the Brighton and Mid-Downs health districts in Sussex showed a prevalence of multiple sclerosis of 111 per 100,000 (95% confidence interval (95% CI) 103-120) in a population of 596,594 on prevalence day, 1 July 1991. Cases were notified by multiple sources and to maximise case notification patients were not contacted. Cases were classified by hospital and family practitioner notes. The Poser criteria were used for classification. These criteria are precise and exclude cases of isolated spinal cord syndrome. The Allison and Millar criteria used in the surveys in Scotland may lack specificity and it is concluded that the high prevalence of multiple sclerosis in Scotland needs to be reassessed with the more precise criteria. Until this is done, the latitude effect within the United Kingdom remains not proved.
Asunto(s)
Esclerosis Múltiple/epidemiología , Adolescente , Adulto , Factores de Edad , Anciano , Inglaterra/epidemiología , Humanos , Incidencia , Persona de Mediana Edad , Prevalencia , Factores SexualesRESUMEN
Cerebrospinal fluid and serum from 192 patients was analysed for the presence of intrathecally synthesized oligoclonal IgG bands using isoelectric focusing in an immobilized pH gradient pH 7-10. The sensitivity of this method for the diagnosis of multiple sclerosis (MS) was 95% (21 of 22), or 75% if patients with suspected MS were included. The specificity for the diagnosis of MS was 98%, or 96% if the suspected MS patients were included. The very high specificity may be because the intrathecally synthesized oligoclonal IgG associated with MS is more alkaline than IgG from serum and is better detected in an immobilized alkaline pH gradient.