Evaluation of physiotherapy and speech therapy treatment in patients with apraxia: a systematic review and meta-analysis

Apraxia affects 20% of the right brain-damaged patients and 50% of the left brain-damaged patients. This disorder of motor programming reduces patients' independence and there are few guidelines on the rehabilitative treatment in the physiotherapy and speech therapy field.The aim of this study was to assess which therapeutic interventions are the most effective in stroke patients with apraxia in considering the mentioned purviews. Four databases were systematically searched in order to detect all available studies investigating the physical and speech rehabilitation of patients. The literature research produced five studies including 168 patients for the physiotherapy and 50 for speech therapy fields; two were eligible for meta-analysis. Quality was rated with Jadad, PEDro scale and Cochrane Risk Of Bias Tool. Both for physiotherapy and speech therapy fields, the RCTs interventions obtained statistically significant results for outcomes of interest. Despite this, it is still not possible to determine the best approach due to the low number of patients involved, the lack of maintenance of the results at follow up and the timing of the revaluation period being very short to confirm the efficacy of treatments.

Oedema in Chronic Venous Insufficiency: Physiopathology and Investigation

Aim:

To review the physiology of the venous system in the leg and the events in the microcirculation of the skin leading to development of the symptoms of chronic venous insufficiency (CVI).

Method:

A review of current literature in the field of CVI has been conducted, with particular reference to the microcirculation and the means of investigating this.

Synthesis:

Venous valvular incompetence and obstruction in the lower limb causes damage to the microcirculation of the skin. The resulting venous hypertension is resisted by the microcirculation. Cutaneous vasomotion alters, with a prevalence of closing periods of the pre-capillary sphincters, limiting capillary hypertension and resulting in capillary haemoconcentration. This phenomenon promotes drainage of fluids from the interstitial spaces and prevents hypoxic damage to the endothelium. In severe CVI this defence mechanism is overwhelmed, vasomotion declines and arteriolar vasoparalysis occurs. The capillary bed is filled and the intracapillary pressure increases. Reduced microcircula-tory perfusion flow velocity favours capillary plugging by white cells. Leucocyte activation damages the endothelium through the release of proteolytic enzymes, oxygen metabolites and lipid oxidation products. Increased permeability of the endothelium allows passage of fibrinogen and results in a perivascular fibrin cuff. Initially this protects the capillary but later blocks oxygen exchange. These events lead to capillary thrombosis with destruction of capillaries with tissue ischaemia and trophic lesions.

Conclusions:

The result of venous hypertension in the large veins of the lower limb is damage to the microcirculation of the skin. This leads to lipodermato-sclerosis and eventually ulceration in some patients.

Recurrent varicose veins following surgical treatment: our experience with five years follow-up

OBJECTIVE

To report the 5 year outcome of varicose veins surgery and to establish the factors determining recurrence.

STUDY DESIGN

Prospective observational study.

MATERIALS AND METHODS

This study reports the outcome in 1326 patients treated in a day surgery centre of an institutional referral centre. Patients were investigated clinically and by colour flow duplex scanning before operation. Treatments used included flush ligation of the sapheno-femoral junction (SFJ) and the sapheno-popliteal junction (SPJ). Incompetence of the great saphenous vein (GSV) and small saphenous vein (SSV) were managed by stripping of these veins. Perforating vein ligation and hook phlebectomy were also used. Patients were evaluated 3 weeks and 5 years following treatment by clinical examination and duplex ultrasonography.

RESULTS

412 patients were excluded from the study because they failed to attend for follow-up or did not wear elastic stockings post-operatively. No residual saphenous truncal reflux was found at the initial assessment 3 weeks following surgery. After 5 years, recurrence of varicose veins occurred in 332 patients out of 1326 (25 %). Recurrences arose at the sapheno-femoral junction in 109 out of 862 patients (13%), at the sapheno-popliteal junction in 39 out of 132 patients (30%), in both saphenous regions 38 out of 107 patients (36%) and in 146 out of 225 subjects (65 %) with secondary varicose veins.

CONCLUSION

Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography. The likelihood of recurrence increased in the presence of SSV reflux, perforating vein incompetence and post-thrombotic deep vein incompetence.

[Thrombophilia and pregnancy]

The risk of venous thromboembolism (VTE) increases up to 5-10-fold during pregnancy and VTE represents the first cause of maternal mortality. The annual incidence of VTE is 0.97 per 1000 women during pregnancy and 7.19 per 1000 in the puerperium. The risk is higher in carriers of inherited thrombophilia. Prophylaxis of VTE during pregnancy in thrombophilic women, is still controversial, whereas there is agreement on the used of LMWH or oral anticoagulants during puerperium. LMWH is suggested during pregnancy in antithrombin deficient women, compound heterozygotes for prothrombin G20210A and factor V Leiden, and homozygotes for these conditions, with no prior VTE. In heterozygotes for F V Leiden or prothrombin G20210A with no prior VTE surveillance is preferred during pregnancy and LMWH or OA during puerperium. For patients with APLAs and no prior VTE or fetal loss, one of the following approaches is suggested: prophylactic LMWH and/or low-dose aspirin, mini dose heparin, surveillance (7 degrees ACCP). Patients with APLAs and a history of thrombosis should receive therapeutic-dose LMWH or UH plus low-dose aspirin during pregnancy and long term OA postpartum. In women with prior VTE and inherited thrombophilia, prophylactic or intermediate-dose LMWH is recommended during pregnancy plus post-partum OA. Intermediate-dose LMWH during pregnancy is suggested in antithrombin-deficient women, compound heterozygotes for prothrombin G20210A and factor V Leiden, and homozygotes for these conditions.