[The management of stroke in Phnom Penh, Cambodia]

Stroke ranks first among nervous pathologies in Kampuchea. It's a main cause of disability and mortality in our country. We conducted a prospective study including 100 patients hospitalized in the service of general medicine at the Calmette hospital in Phnom Penh. We analyzed the principal risk factors, clinical signs, nature of stroke, complications and markers of the vital and functional prognosis. This work shows the difficulties encountered in the initial care of stroke: delay or absence of hospitalization, cost of complementary examinations to be carried out to determine the nature and the aetiology of stroke and very low level of follow-up to ensure secondary prevention and functional rehabilitation. It can be explained in part by the socioeconomic and cultural level. Research like this one which assesses local needs for stroke prevention, treatment and rehabilitation should be conducted in developing countries to inform the planning and allocation of health care resources in order to reduce the burden of illness associated with stroke. The progressive improvement of the medical structures, and of the socioeconomic and cultural level will facilitate stroke care management.

Nombre de lits dédiés à la pathologie vasculaire cérébrale en soins de suite et de réadaptation. Les recommandations nationales sont-elles pertinentes ?

OBJECTIVE

We sought to determine the number of beds necessary for stroke patients in postacute care units and to measure the relevance of the national guidelines on required number of beds.

METHODOLOGY

We conducted an epidemiological follow-up of a cohort, what allowed for evaluating stroke care under real-life conditions. We applied the French guidelines for transfer of patients to postacute care wards.

RESULTS

Of the 605 stroke patients hospitalised, 156 with a mean age of 72 years were included. A total of 64 (41%) could return home directly from the acute care wards and 73 (47%) were referred to postacute care wards. Among the latter patients, 31 (43%) were transferred to a physical medicine and rehabilitation (PMR) unit and 42 (57%) to a geriatric unit. The 19 remaining patients died in acute care. Of the 137 surviving patients, 46.7% returned directly home and 53.2% were referred to postacute care wards. Of patients older than 80 years, 74% were transferred to a geriatric unit, whereas 76% of the patients less than 80 years were transferred to a PMR unit.

DISCUSSION-CONCLUSION

The national guidelines are based on a rate of discharge of about 24% of stroke patients to postacute care wards. In our study, we found that 47% were transferred to such wards. If the guidelines are applied, 19 beds dedicated to stroke patients would be necessary for postacute stroke care on a national level, or double that (36) on a regional level. Of these 36 beds, 16 to 24 should be PMR beds. The calculation of the number of beds necessary often rests on a simple transposition of the results of the studies and not on an objective evaluation according to the local context. Studies of longitudinal follow-up of cohorts such as this seem essential to evaluate needs and measure the relevance of the national guidelines.

Facteurs prédictifs du devenir fonctionnel et du retour à domicile après un premier accident vasculaire cérébral hémisphérique

BACKGROUND AND PURPOSE

Several prognostic factors have been identified for outcome after stroke. We conducted a study to determine early predictive factors of functional outcome one year after stroke and to evaluate which factors are independent predictors, with an aim of specifying the role of age, aphasia, unilateral neglect, cognitive impairment and family social support.

METHODS

Observational cohort study of 156 patients. All patients admitted to the university hospital for initial unilateral hemispheric stroke were included. The study duration was two years (inclusion, one year, and follow-up, one year) . The initial evaluation of stroke was conducted at day 2 and day 15 and included the Motricity Index and Trunk Control Test, New Functional Ambulation Classification, Frenchay arm test, Mini-Mental State Examination, Boston Diagnostic Aphasia Examination, unilateral neglect evaluation, and depression. Data on functional recovery (Barthel Index) were collected at day 360.

RESULTS

The average age of patients was 72 years. Age was correlated to social situation (P<0.01) and previous neurological impairment (P<0.01). A multiple regression analysis, including 14 initial clinical factors correlated with the Barthel Index score at day 360, revealed 4 independent early predictive factors of outcome: initial score of Barthel Index at day 2 and its progression from day 2 to day 15, disorders of the executive functions and previous neurological impairment.

CONCLUSION

In our cohort, in accordance with previous studies, age, cognitive impairment, unilateral neglect, aphasia, depression and social situation are not independent factors of poor outcome after stroke as evaluated by the Barthel Index.

Épidémiologie des pieds varus et/ou équin un an après un premier accident vasculaire cérébral hémisphérique : à propos d'une cohorte de 86 patients

OBJECTIVE

To determine the frequency and the functional consequences of varus equinus in stabilized vascular hemiplegia.

METHODS

Prospective cohort study of 86 hemiplegic patients. All patients consecutively admitted for a first hemispheral stroke between July 2001 and January 2002 were included. The evaluation consisted in a clinical examination and a descriptive study of gait. The functional capacity of patients with and without varus equinus were compared using the Barthel index, the New Functional Ambulation Classification (NFAC), the confortable ten meters gait speed and gait perimeter.

RESULTS

The incidence of varus equinus was 18%. There was no difference in gait speed (0.8 m/s), NFAC or Barthel index between patients with or without varus equinus. Patients with varus equinus had had more specialized, intensive and prolonged rehabilitation. The only prognostic factor that could be identified was the motor impairment and the existence of spasticity.

DISCUSSION

The mechanism of varus equinus is thought to be mainly the over-activity of gastrocnemius and solaris compared to that of the tibialis anterior, associated to the weakness of fibular muscles. The role of tibialis posterior is thought to be less important. The frequency of varus equinus after a first hemispheral stroke was low and the consequences were limited. This could be in part explained by the access of these patients to early, specialized and prolonged rehabilitation care.

[Clinical factors associate with shoulder subluxation in stroke patients]

OBJECTIVE

This study explores whether shoulder subluxation after stroke is related to age, hemiplegic side motor impairment, spasticity, sensory deficit, depression, unilateral neglect and length of stay in acute ward.

METHOD

This prospective study included 57 patients with hemiplegia. The shoulder subluxation was systematically detected by radiography and quantified according to de Bats score. The complete clinical assessment of the upper limb on day 15 analyzed motricity (motricity index), spasticity of shoulder adductors and biceps (Ashworth), sensory deficit, unilateral neglect and depression (MADRS). Age, side of hemiplegia and the aetiology were also noted. We researched relations between shoulder subluxation and these clinical factors. Means were compared using Mann Whitney and chi(2) tests. Coefficients of correlation were estimated between two quantitative variables. A multiple regression analysis was also conducted including all significant parameters, the dependent variable being the shoulder subluxation.

RESULTS

Shoulder subluxation was observed in 32% of hemiplegic patients. After multiple regression analysis, the main clinical factors related to subluxation were motor (p < 0.0001), spasticity of shoulder adductors (p = 0.028) and age (p = 0.036). Statistically, the risk of subluxation was divided by 1.62 (1.07, 2.43) for every five years age growth and by two (1.33, 2.94) when the motricity index went up by ten points.

CONCLUSION

This study shows that the age could play an independent part. The loss of elasticity of the periarticular tissues when ageing could have a protective role.

[The shoulder-hand syndrome after stroke: clinical factors of severity and value of prognostic score of Perrigot]

PURPOSE

The purposes of this study were to evaluate the prognostical factors of reflex sympathetic dystrophy in stroke patients in attempt to improve the Perrigot prognostical score.

MATERIAL AND METHOD

This prospective study included 28 stroke patients with reflex sympathetic dystrophy. An initial clinical assessment including Perrigot score was made at the time of admission (before the end of the first month) and a second evaluation of reflex sympathetic dystrophy at the end of the third month. Patients were assessed using Motricity Index, Ashworth scale, de Bats grading (for glenohumeral alignment), Labrousse criteria (for reflex sympathetic dystrophy severity), and MADRS depression scale. Sensory deficit and unilateral neglect were noted.

RESULTS

The length of stay in acute ward was 16 days. The Perrigot score was correlated with the reflex sympathetic dystrophy severity (r = 0.7, p < 0.0001). It predicted the result of therapy. A significant correlation was found between reflex sympathetic dystrophy severity and motor deficit (r = -0.591, p = 0.0007) and spasticity (p < 0.05). No relation was found with stroke side, unilateral neglect, depression or shoulder subluxation. It wasn't possible to improve the Perrigot prognostical score.

CONCLUSION

Perrigot score predict reflex sympathetic dystrophy severity and the result of therapy. The shoulder subluxation which is not included in this score appears to be not predictive. Shoulder subluxation is simply a marker of a severe paresis.

Radioisotopic control for baclofen pump catheter failure

STUDY DESIGN

Case report of Baclofen pump catheter failure investigated by radioisotope injection.

OBJECTIVES

To report a safe and reliable method for evaluating catheter dysfunction.

SETTING

France.

METHODS

Single case report of failure of Baclofen pump investigated by radioisotope injection.

RESULTS

The injection demonstrated the block in the catheter. The catheter failure was not visualised by plain X-ray nor by filling the pump with radio-opaque solution.

CONCLUSION

Catheter failure is a common cause of intrathecal drug delivery problems and may be difficult to diagnose. When catheter disconnection, kink, or dislodgement is not visible on X-ray, radioisotopic control is a safe and reliable method for assessment.

[Reliability of TcPO(2) measurement in the upper limb]

INTRODUCTION

Several reports suggest the usefulness of transcutaneous oxygen tension (TcPO(2)) in assessing the shoulder hand syndrome in stroke patients. But the literature presents a number of conflicting views on the variation of TcPO(2) values in this case. We found no report demonstrating the reliability of TcPO(2) measurements in the upper limb. The aim of this study was to evaluate the reliability of TcPO(2) measurements and investigate whether TcPO(2) can be used to evaluate the shoulder hand syndrome after stroke.

MATERIAL AND METHODS

The TcPO(2) values were obtained on two separate occasions at one-day interval on 18 normal volunteers. Basal TcPO(2), local vasomotor reflex and reaction to ischemia were assessed.

RESULTS

Thirty-six upper limbs were tested. The reliability was bad. We found that measurements of TcPO(2) varied by an average of 7.89 +/- 7.6 mmHg for a coefficient of variation of 96%.

CONCLUSION

The reliability of TcPO(2) measurement was not sufficient to recommend this method in this indication.

Total body water and percentage fat mass measurements using bioelectrical impedance analysis and anthropometry in spinal cord-injured patients

BACKGROUND AND AIMS

Spinal cord injured patients may be adversely affected by disturbances of nutritional status, particularly malnutrition and fat mass overload. Malnutrition increases the risk for development of pressure sores, and fat mass excess increases the cardiovascular and respiratory risks of these patients, as well as predisposing to the development of diabetes mellitus, pressures sores and bony fractures. Body impedance analysis and anthopometry are easy bedside methods for body composition assessment. The aims of the study were to validate, in 20 spinal cord injured patients, body impedance analysis as a means to estimate total body water, and to validate a skinfold measurement of percentage fat independent of hydration of fat-free mass in the same population.

METHODS

Total body water was measured by (18)O dilution as a reference method. Impedance and anthropometric measurements (four different skinfolds) were obtained. The results of total body water given by impedance analysis and calculated with three formulas were compared to the reference method. The fat mass percentage obtained with each of the skinfolds using the 3-compartment Siri's formula was compared to a reference value using the sum of the skinfolds.

RESULTS AND CONCLUSION

The formula using 100 kHz resistance, height, weight and gender overestimated total body water by only 0.76 +/- 1.85 L, with an acceptable concordance with labeled water results. The formula with 50 kHz resistance was less accurate and concordant. Each skinfold may be used for assessing percentage fat mass. Based on these findings, we feel that the triceps skinfold, whose the variability is the lowest compared to the reference values, can be used alone in clinical practice.

[Proposal for a predictive clinical scale in dysphagia]

The compiling of a predictive clinical scoring system for the risk of a false passage (FP) has its origins in the limitations of tests which explore only the cough reflex, known to be absent or faulty in 40% of patients investigated for problems of deglutition. A raised clinical score is based on the results of an exhaustive prospective study of 140 patients tested for the first time by videofluoroscopy for FP, this being the reference investigation for false passages. Discriminant analysis allowed the most selective variables to be identified and retained. We have identified 2 categories of patients, according to whether or not they have had any ENT past history. The score is obtained by adding the weighted values for the selected clinical signs. For those patients with an ENT past history, 5 clinical variables were retained: the absence of adhesions = 14, the presence of a velar reflex = 8, the capacity for voluntary deglutition = 8, glottic obstruction = 6, the absence of primitive reflexes = 6, giving a total score for the variables of between 0 and 42. If the total exceeds 32 or is less than 26, there is no FP; for scores between 32 and 26, videofluoroscopy is required to give more precise evidence of the risk. When this scoring system was applied prospectively to a series of 105 patients, a correct predictive result was obtained in 54 patients (51.4%), an equivocal result in 42 patients (40%), and a false result in 9 patients (8.6%), 3 of which (2.8%) were false negatives. The predictive score for FP allows evaluation of the risks of FP in at-risk patients, and adaptation of the treatment strategy according to the type of disordered physiology expected from the cause; thus videofluoroscopy can then be reserved for cases where treatment fails, so that the precise deglutition problem can be pinpointed.

[Nutritional status and clinical score of 95 patients examined by radiovideoscopy for deglutition]

Ninety five consecutive patients were examined. One performed swallowing videoradioscopy, swallowing clinical score calculation and nutritional assessment with four different methods: Body Mass Index (BMI), arm muscle circumference, dual frequency bioelectrical impedance analysis and serum albumin level. The easiest and the most reliable method for nutritional assessment, comparing to the others, was BMI, where only weight ant height were necessary to measure. So, the prevalence of protein-energy malnutrition was 24.2%, unlinked neither with the presence of videoradioscopy swallowing disorders nor with clinical swallowing score level. The score level was inversely correlated with the presence of videoradioscopy swallowing disorders, and correlated with feeding types: the highest for per os normal feeding, the lowest for patients with parenteral nutrition. The presence of videoradioscopy swallowing disorders was inversely correlated with feeding types. Swallowing clinical score was validated.

[Rehabilitation of female urinary incontinence]

Perineal rehabilitation is an appropriate alternative to surgery in the treatment of urinary female incontinence. The most important factors influencing the success of this technique is the ability of the patient to identify correctly the muscles of the pelvic floor, to strengthen this muscles using exercises, electrical stimulation and biofeedback, to contract voluntarily the pelvic floor musculature during stress or sensation of voiding for having a preventive effect on loss of urine, and also to change, if necessary, the micturitional and drinking customs. Some conditions are required to complete a good result: strong motivation of the woman, ability of the physiotherapist or the midwife, quality of care and follow-up of the physician who must clearly know the place of this conservative treatment in selected patients, particularly in moderate stress incontinence, without important prolapse, urge incontinence, pregnancy and post-partum, two conditions in which this technique must have a preventive and curative efficiency.

[Urodynamics and perineal rehabilitation in women. Prognosis and results]

It is essential, as far as possible to be able to predict the result of perineal rehabilitation. It seems preferable to complete perineal testing by a clinical functional test for evaluation of the preventive action of voluntary perineal contraction in stress incontinence and to measure urethral pressure in four different conditions: at rest, during stress (coughing), during voluntary perineal contraction, and during both stress and voluntary perineal contraction. These tests and measures provide a better evaluation of active continence, both reflex and voluntary continence, and the ability of voluntary mechanisms to compensate for reflex mechanism during stress. It is also very important to estimate the results of perineal rehabilitation using a lot of objective and subjective tests and taking into account that only the very good results must be considered as successful. According to these criteria the authors estimate the successful results at 50% at the end of rehabilitation and only 25% in the course of the third year after the end of rehabilitation.

Urinary lithiasis induced by sulfamethoxazole in a patient with tetraplegia. Case report

Bladder lithiasis is a frequent complication in paraplegics and tetraplegics. We report on a patient where treatment of a urinary infection with antibacterial sulfamides was the causative factor in the formation of bladder stones.

[Perineal rehabilitation of female urinary incontinence. Long term results]

The results of perineal rehabilitation in 101 women with urinary incontinence are evaluated with a follow-up of 18 months (9-37 months). The authors try to precise the clinicals and urodynamicals initials factors of a bad pronostic.

[Cauda equina syndromes in ankylosing spondyloarthritis, detected urologically]

The authors stress the importance of sphincter disorders especially bladder, in these patients. These disorders may compromise the vital prognosis. An accurate neuro-urological work-up is absolutely necessary. It will guide the functional rehabilitation. Which, as a rule, will improve the patients' comfort and prevent the occurrence of urinary complications, with the use, as in the case reported, of non-sterile intermittent self-catheterization.

Early vesico-ureteral reflux following conus medullaris injury: case report

The authors describe severe vesico-ureteral reflux and simultaneous renal insufficiency which occurred after a spinal cord injury to the conus medullaris. They point out the misleading character of these injuries when there are only minimal neurological signs in the trunk and limbs. The main clinical consequence may be an isolated neuropathic bladder which, if not detected, delays treatment. Additionally, they underline the role of mixed bladder and sphincter lesions in the development of renal insufficiency; also the role of increased intravesical pressure during filling and emptying with bilateral vesico-ureteral reflux.

[Felty's syndrome. A case report. Review of literature (author's transl)]

The authors report a case of Felty's syndrome in which are discussed over the data of literature: clinical features, hematological characteristics with a study of neutropenia mechanism and therapeutic possibilities.

[Syphilitic meningo-encephalitis with probable associated arteritis (author's transl)]

A 21-year-old woman was referred for consultation because of sensory and motor disorders of sudden onset but on lung duration. Neurological examination was normal. Lumbar puncture confirmed the presence of a clear liquid meningitis. Arteriography demonstrated segmental arteritis of the anterior cerebral vessels. Systematic serological tests were positive for syphilis. The authors discuss the relation between arteritis and syphilitic meningitis in this young woman taking oral contraceptives.

[Amiodaron neuropathy: clinical and pathological study of a new drug induced lipidosis (author's transl)]

The authors report a case of amiodaron-induced neuropathy in a seventy one years old man. First signs appeared seventeen months after the treatment was started with 400 mg/day for one year and continued with 200 mg/day. Examination on the 29th month disclosed a severe sensory and motor deficit of the limbs with distal predominancy. Motor nerve conduction velocity was strongly impaired without modification of distal latencies. Fundi were normal. The patient improved quickly after drug withdrawal. The authors review the rare similar cases reported in the literature and attempt to describe the clinical caracteristics of amiodaron neuropathy. Qualitative and quantitative light and electron microscopical studies of nerve, muscle and skin biopsies, including teased fibers preparations were performed and they disclosed a marked reduction of the number of myelinated fibers. Wallerian degeneration predominated (31 p. 100) other segmental demyalination (25 p. 100). Numerous polymorphous lipid-laden lysosomes were present in Schwann cells, fibrocytes, pericytes, endothelial and muscle cells. These previously undescribed morphological findings are similar to those present in perhexiline maleate intoxications. We believe amiodaron neuropathy is a new neuropathy with drug-induced lipidosis.

[Hypopituitarism in the aged. Report of a case revealed by hypoglycemic coma (author's transl)]

The diagnosis of anterior pituitary insufficiency is difficult in the elderly and frequently made when the patient become comatose. At this age hypoglycemia is rarely the exclusive factor of this coma. The authors report a case revealed by hypoglycemic coma and supported by the lack of stimulation by the releasing factors. None etiology was found. With hormone treatment the patient recovered a normal life.

[Neurological disorders and perhexiline maleate therapy. Clinical study of 10 cases. Neuropathological, pharmacocinetic and biochemical studies (author's transl)]

Ten new cases of perhexiline induced peripheral neuropathies are reported. The authors emphasize the possible association of other neurological disorders: cerebellar symptoms in one case, complex tremor in two other cases, marked decrease of photomotor reflexes in one case and disgeusia in another one. The pharmacocinetic study of 4 cases revealed the presence of a low metabolism of the drug in one of them. Polymorphous inclusions have been seen in Schwann cell and endothelial cell cytoplasm in the three patients with electron microscopic study of the nerves. The pathological study of one case showed the demyelination of spinal cord posterior columns. In another case, who died from hepatic coma, the biochemical study of cerebral lipids revealed the low values of cerebrosides and sulfatides in cerebellum and cerebral white matter.

[Eaton-Lambert myasthenic syndrome: clinical, electrophysiologic, histological and ultrastructural study]

In this case, showing the classical features of the Eaton-Lambert myasthenic syndrome, the neuromuscular symptoms appeared 21 months before the bronchial carcinoma was diagnosed. The electrophysiological study demonstrated, beside the marked potentiation under repetitive nerve stimulation at 30 c/sec., some modifications of distal latency, specially after administration of Edrophonium chloride. The muscle biopsy showed changes secondary to a peripheral motor nerve involvement; electronmicroscopic study of the motor end-plates revealed a highly developped subneural apparatus. Long-run treatment by guanidine hydrochloride determined haematologic and renal toxic manifestations. Prednisolone was for a time active on the myasthenic syndrome.