[Inquiry among general practitioners' knowledge regarding clean intermittent self-catheterization]

INTRODUCTION

Clean intermittent self-catheterization is the recommended mode of bladder voiding in patients with urinary retention. Hence, this procedure should be well known and understood by the general practitioners (GP) who are responsible for monitoring such patients.

OBJECTIVE

To assess GP' state of knowledge regarding clean intermittent self-catheterization and to make recommendations for dealing with problems that occur during patient follow-up.

METHOD

A questionnaire focusing on the practice of clean intermittent catheterization was sent to 910 family GP in the Franche-Comté region of eastern France.

RESULTS

Two hundred and fourty-six replies were analyzed. Sixty-four percent of GP believed that the appropriate number of bladder catheterizations per day was between two and four. Ninety percent of the GP prescribed perineal cleaning before catheterization and 29% prescribed the use of sterile gloves. Eighty-seven percent of general practitioners considered urinary tract infection to be the main complication of intermittent catheterization. Thirty percent always requested a urine culture in patients performing self-catheterization and 29% prescribed antibiotic therapy in cases of bladder colonization.

DISCUSSION

General practitioners need to receive additional information on the role of clean intermittent catheterization in the prevention of urinary tract infection. In accordance with the French Urology Association guidelines, we produced a practical summary guide on preventing asymptomatic bacteriuria and urinary tract infections and/or preparing for urological investigations.

[EMG support in botulinum toxin treatment]

INTRODUCTION

The aim of this work is to sum up how the use of EMG improves BT therapy.

METHOD

A systematic review of the literature in the Pub Med computer database, along with a manual biography, allowed us to choose the most synthetic and the most pertinent publications according to our own practical experience.

RESULTS

There is no consensus of opinion, but the great majority of authors emphasize the importance of EMG in the different stages of botulinum toxin treatment: before injections, at the time of the injection, and finally during the follow-up after the first injection or after the repeated injections that transient efficiency make necessary.

DISCUSSION

A symptomatic therapeutic means recently recognized in focal dystonias and spasticity, BT is injected locally into the muscles to be treated. EMG can be used: at pre-injection for physiopathological evaluation but above all to establish a diagnosis and precise pre-intervention evaluation; at the moment of injection to provide guidance in precise muscle selection and for maximum efficiency with reduced, therefore less costly, doses. It also limits the risk of product diffusion susceptible of causing iatrogenic side effects and/or auto-immunisation resulting in resistance to the toxin; during follow-up, to understand why treatment failed and to look for changes in the dystonia pattern leading to objective re-evaluations and adapted reinjections. Although neglected by some, electrological logistics seem to us, as to many other practitioners who inject, to be a considerably helpful aid, particularly at the moment of injection when targeting the muscle to be treated.

[Sialorrhea, hyperhidrosis and botulinum toxin]

OBJECTIVE

The first clinical studies indicate that Botox provides effective treatment for hyperhidrosis and sialorrhea. The aim of this work is to sum up current evaluation of this use.

METHOD

A systematic literature search was conducted on the Pub Med database, along with on chapters in other publications. The most interesting articles in relation to our own personal experience were chosen.

RESULTS

Despite recent use of BT to treat focal hyperhidrosis, there have been numerous publications since 1997. However, the injected areas have not been listed so frequently. Axillary hyperhidrosis has been studied most; it is also in this case and in the case of gustatory sweating that the best results have been obtained. Publications about palmar and especially plantar hyperhidrosis are much rarer, almost anecdotic. It has been demonstrated to a lesser extent that BT injections are effective in these cases. Literature about sialorrhea is just beginning. However, the reduction of the production of saliva following intra parenchymatic injection of toxin into the parotid and submandibular glands, thus rarifying drooling, has been demonstrated. For each of the pathological indications, both the injection techniques and the optimal doses remain to be determined.

DISCUSSION

Because BT blocks all cholinergic transmission, including the autonomous nervous system, it was plausible to expect a reduction in sweating and salivation on local injection of the product. In fact, the first publications indicated such efficiency without serious side effects. For hyperhidrosis, there has developed a consensus for making intracutaneous injections only. Of the injections in axillary areas, the palms of the hands, the plantar regions, the face or other cutaneous areas, palmoplantar hyperhidrosis is the least accessible, in any case causes the most technical problems, because of difficulty in pain management. For sialorrhea and the drooling that accompanies certain chronical neurological diseases, BT seems to have very promising effects. However, it has not been precisely determined whether to inject the parotid gland, the submandibular gland, or both. Necessary and sufficient means of targeting are still imprecise. It also remains to be determined the number of sites per gland and the doses to be injected.

[Detrusor-sphincter dyssynergia and botulinum toxin]

OBJECTIVE

Botulinum toxin (BT) injection into the external urethral sphincter is a promising therapy for neurogenic voiding disorders due to detrusor-sphincter dyssynergia (DSD). However the optimal treatment protocol remains unclear.

METHOD

A PubMed reference search and manual bibliography review were performed, along with a search in the Annales de réadaptation et de médecine physique and in the reports of the International French-language Society of Urodynamics and the International Continence Society, which allowed us to select twelve pertinent articles with PubMed, two articles from the Annales and two conference reports. Our analysis gave special emphasis to assessment criteria, application, dosage and BT injection technique.

RESULTS

Used for the first time in 1988 in spinal cord injury patients to reduce outflow obstruction due to DSD, BT injections have been shown to be a valuable alternative management of bladder dysfunction with DSD. They have been proposed in neurological patients unable to perform self-catheterisation, after drug failure and before surgery. Parameters for results assessment are mostly clinical (increased free interval between voiding, decreased post-void residual urine volumes), urodynamic (improvement in bladder emptying, increase in functional bladder capacity and decrease in urethral pressure) and electromyographic (denervation of striated urethral sphincter). The literature data regarding type of BT, dosage and protocol vary widely. Duration of action is from 2 to 12 months. Both transurethral and transperineal injections monitored by EMG are equally effective in improving detrusor-sphincter dyssynergia.

CONCLUSION

With few side effects and satisfactory medium-term results, BT should be recommended as a component of DSD therapies. We propose a practical method for BT use.

[Pelvis obliquity, hip excentration and scoliosis in a population of 120 polyhandicaped adults. Descriptive study]

The objective of this study is to give objective data about neuro-orthopaedic status of the population of polyhandicapped patients for improving both our medical and surgical practices.

MATERIAL AND METHOD

It was a multicentre, cross-sectional study to describe the population of polyhandicapped patients over 15 years of age. Each person was provided with clinical examination and X rays to detect scoliosis, pelvis obliquity and hip excentration (subluxation or dislocation) and other factors associated with polyhandicap. Polyhandicap was defined as a severe handicap linking physical and mental disability and responsible for extreme restriction of autonomy.

RESULTS

One hundred and twelve persons were studied. Mean age was 27.2 years. Etiology of the handicap was neonatal asphyxia (38.3% of patients). 69.0% of patients had no possibility to turn over in lying position. Orthopaedic status was serious : 75.9% scoliosis, 65.2% pelvis obliquity (75% left and 25% right), 19.1% hip dislocation. General condition was precarious : one patient in two had a weight judged lower than normal weight, 32.5% had bedsores, 45.2% suffered from hip pain and only 13.6% received treatment against pain.

DISCUSSION AND CONCLUSION

The description of general and neuro-orthopaedic status of these 120 people with polyhandicap cannot leave us indifferent. Although life expectancy in this population was lower than in normal populations, we are faced with life process and no with accompanying the terminally ill. We urgently need to review preventive care in terms of quality and quantity as well as surgical proposals for treating spasticity in children and adults.

Hip pain in 234 non-ambulatory adolescents and young adults with cerebral palsy: a cross-sectional multicentre study

In orthopaedic clinical practice hip pain is the main complaint of adults with cerebral palsy (CP). The aim of this descriptive study was to specify prevalence of hip pain and to propose methods of care other than surgery. The study was a cross sectional multicentre one based in the Rhĵne-Alpes region. Patients over 15 years of age, with CP who were non-ambulatory were included. Two hundred and thirty-four patients were questioned. Mean age of the patients was 27 years 10 months, median 26 years 1 month, with 59.3% males and 40.7% females. Patients were questioned about pain with precise information about the circumstances of pain, tolerance, and treatment. Pain was judged to be intolerable if it prevented usual activities. Prevalence of hip pain was 47.2%. Pain was judged to be tolerable in 35.6% of the 234 patients, i.e. in 75.5% of patients with hip pain. There were three types of pain: provoked pain, pain linked to position, and spontaneous pain. Medical treatment was given to only 13.6% of patients with hip pain. The first treatment for hip pain is to avoid circumstances where pain occurs; medical treatment is reserved for when daily life cannot be adapted sufficiently to prevent pain. Medical treatment must be appropriate with doses of adequate strength before proposing surgery.

Toe-walking in children younger than six years with cerebral palsy. The contribution of serial corrective casts

Our aim in this retrospective study was to analyse the value of serial corrective casts in the management of toe-walking in children aged less than six years with cerebral palsy. A total of 20 children (10 hemiplegic and 10 diplegic) had elongation of the triceps surae by serial casting at a mean age of four years and one month. The mean passive dorsiflexion of the foot with the knee in extension was 3 degrees (-10 to +5) and 12 degrees (0 to +15) with the knee in flexion. After removal of the cast passive dorsiflexion was 20 degrees (+10 to +30) with the knee in extension, and 28 (+10 to +35) with the knee in flexion. At a mean follow-up of 3.08 years (2.08 to 4.92), passive dorsiflexion was 9 degrees (-10 to +20) with the knee in extension and 18 degrees (0 to +30) with the knee in flexion. Serial corrective casts are useful for the treatment of equinus in young children as the procedure is simple and the results are at least equal to those of other non-operative techniques. It is a safe alternative to surgical procedures especially in young children. If the equinus recurs operation can be undertaken on a tendon which is not scarred.

Toe-walking in children younger than six years with cerebral palsy

Our aim in this retrospective study was to analyse the value of serial corrective casts in the management of toe-walking in children aged less than six years with cerebral palsy. A total of 20 children (10 hemiplegic and 10 diplegic) had elongation of the triceps surae by serial casting at a mean age of four years and one month. The mean passive dorsiflexion of the foot with the knee in extension was 3° (−10 to +5) and 12° (0 to +15) with the knee in flexion. After removal of the cast passive dorsiflexion was 20° (+10 to +30) with the knee in extension, and 28° (+10 to +35) with the knee in flexion. At a mean follow-up of 3.08 years (2.08 to 4.92), passive dorsiflexion was 9° (−10 to +20) with the knee in extension and 18° (0 to +30) with the knee in flexion.

Serial corrective casts are useful for the treatment of equinus in young children as the procedure is simple and the results are at least equal to those of other non-operative techniques. It is a safe alternative to surgical procedures especially in young children. If the equinus recurs operation can be undertaken on a tendon which is not scarred.

[Prevalence and morbidity of hip excentration in cerebral palsy: review of the literature]

PURPOSE OF THE STUDY

Excentration of the hip is one of the main orthopedic complications of ante and perinatal cerebral palsy. Excentration can progress to dislocation even if tenotomy is performed. What is the prevalence and morbidity of hip excentration?

METHODS

We reviewed the pertinent literature on the prevalence and morbidity of hip excentration in patients with cerebral palsy based on the Medline and Reedoc databases.

RESULTS

Data presented in the literature vary greatly. Populations are representative of the referral network of the teams reporting the study rather than the cerebral palsy population in general. Signs reported were pain, difficult nursing procedures, difficult sitting position, pressure sores and fractures, but only one sign can be taken fully into account: 50 p. cent of the dislocated hip joints were painful.

DISCUSSION

No one study gives a precise assessment of the prevalence of hip excentration and displacement and its consequences in patients with cerebral palsy. In a population of quadriplegic patients who do not walk, the question is whether complementary tenotomy should be performed, knowking the difficult operative and postoperative situation of such procedures. In this population, walking is an exceptional goal of bone surgery, pain relief and patient comfort are more common goals. Data in this literature (50 p. 100 of the dislocated hips are painful) suggest a prudent approach. However, there is no known marker which can be used to distinguish hips which will become painful from those which will remain pain free. In addition, irreversible cartilage degeneration can cause pain contraindicating reconstructive surgery.

Predicting the outcome of adductor tenotomy

This study reviewed 57 hips in 30 children (18 girls and 12 boys) with cerebral palsy who had undergone an adductor tenotomy alone or in combination with an anterior obturator neurectomy (23 hips). Results were evaluated by the Reimers migration percentage (MP). The hips were split into three groups: group A (12 hips) a preoperative MP of less than 20%, group B (25 hips) between 20 and 40%, and group C (20 hips) more than 40%. The mean age at the time of surgery was 6 years and 1 month (range: 2.5-13 years). The mean period of review was 6 years and 3 months (2-20 years). The results were considered as "good" when radiographs at the longest follow-up showed a decrease of > 10% of the MP, as "bad" when they showed an increase of > 10%, and as "stable" when the MPs varied less than 10%. At the latest review of group A, 11 were stable (92%) and 1 was bad. In group B, 12 were stable (48%), 7 were good (28%), and 6 were bad (24%). In group C, 7 were stable (35%), and 13 were bad (65%). The preoperative migration percentage provided to be the only predictor of outcome. Age at the time of surgery had no constant significant effect on the outcome, neither had the addition of an anterior neurectomy.

[Ultrasonography in the diagnosis of adrenal tumors (author's transl)]

A prospective study was conducted to assess the value of ultrasonography in the diagnosis of adrenal tumors. A limited number of cases (29 patients) was studied, to reduce the possible effects of human and technological progress. Ultrasonography can detect most adrenal tumors larger than 25 mm in diameter, more easily on the right than on the left. The solid or fluid nature of the tumor can be distinguished, but the benign or malignant etiology of the mass can only be determined when there is local and regional spread. Ultrasonography is particularly useful when a suspicious adrenal mass is seen on nephro-urotomography. The indications for ultrasonography have to be reconsidered, however, as a function of the results obtained with computed tomography.

[The contribution of gallbladders' infusion tomography in the diagnosis of acute cholecystitis (author's transl)]

The detection of opacification of the wall of the gallbladder after the intravenous injection of hydrosoluble iodinated contrast medium (gallbladder parietography) was sought in 82 patients suspected of suffering from acute cholecystitis. In 35 cases, the examination was negative and operation or the clinical course made it possible to eliminate the diagnosis of acute cholecystitis. In 47 cases, it was positive. The diagnosis was confirmed in 39 cases out of 40 patients undergoing surgery. The appearance of the opacification makes it possible to distinguish two types of positive gallbladder parietography: -- with a thin wall and gallbladder of normal size, corresponding to moderate inflammatory lesions; -- with a thickened wall associated with a large gallbladder corresponding to major inflammatory lesions. The examination is simple, reliable, may be carried out as an emergency and combined with intravenous urography. The diagnosis of acute cholecystitis may be made in difficult causes, and appropriate therapeutic steps taken.

[Osteochondritis dissecans of the knee]

For more than 10 years the authors have had a rather differentiated attitude to osteochondritis dissecans. The indication depends on the age, topography of the lesion, its volume and stage of evolution. The results of three techniques are discussed: simple ablation of the sequestrum, re-implantation of the sequestrum after treatment of the niche and cortico-spongiosa grafting.