[Peripheral neuropathic pain relieved by somatosensory rehabilitation]

The femoral neuralgia is a rather frequent and invalidating clinical disorder. It takes on many clinical forms because of the anatomical variations of the cutaneous branches of saphenous and femoral nerves. The neuroplasticity of the somato-sensory system has now been determined which allows for a better understanding of the techniques of somatosensory rehabilitation. The authors precisely explain the various stages necessary in the care of patients suffering from femoral neuralgia. The various strategies of somatosensory rehabilitation are mentioned. The authors also present a brief review of the pharmacological treatments of peripheral neuropathic pain. Lastly, the result of the somatosensory rehabilitation of femoral neuralgia (NNT = 1.8) is documented on the basis of a prospective study done on 59 patients.

An initial investigation of the reliability of the Rivermead Extended ADL index in patients presenting with neurological impairment

The objective of this study was to establish the reliability and sensitivity of both postal and interviewer-administrated versions of the Rivermead Extended Activities of Daily Living (READL) index, which assesses six domestic activities and six community activities. Sixty patients with stable neurological impairment were recruited. In one group (n = 40), every patient was assessed face-to-face using the READL, the Barthel index (BI) and the short orientation memory and concentration test (SOMC). One week later, the READL was repeated by the same person, in the same place. In the second group (n = 20), all the patients were first sent a postal form of the READL and were then seen face-to-face for assessment as in group 1. To be included patients had to score at least 18/28 points on the SOMC. Scores were compared using scatterplots, Bland and Altman plots and correlation coefficients, and difference scores were calculated. Sensitivity was established comparing groups of patients expected to differ in their activities. Repeated assessment score, both face-to-face and by post, showed significant correlation (Pearson coefficient = 0.97 and 0.88, respectively). Most scores were within four points of each other, with no systematic bias, although patients tended to rate themselves more independent. Both methods were able to detect differences in the level of activities as predicted between more and less dependent groups (t-test: p < 0.00001 and p = 0.00087). The READL index appears to be a reliable and sensitive measure, with some evidence for validity, but further research is needed.

Validity and reliability comparison of 4 mobility measures in patients presenting with neurologic impairment

OBJECTIVE

To establish the reliability and validity of 4 mobility measures in neurologically impaired adults undergoing rehabilitation.

DESIGN

Repeated assessment of same patients.

SETTING

Two specialized neurologic centers in England.

PATIENTS

Forty-six patients with neurologic disabilities selected from inpatient and outpatient rehabilitation centers who were able to stand and walk at least 10 meters, with some aid if needed.

INTERVENTIONS

Patients were assessed twice, at an interval of 7 days, by the same person at the same location. Validity and reliability of each measure were compared by means of scatterplots, Bland-Altman method, and correlation coefficients. Validity was also established by comparing groups of patients expected to differ in mobility.

MAIN OUTCOME MEASURES

The Rivermead Mobility Index (RMI) standard version and a version with 4 levels of answer, the 10-meter timed walk, and the 2-minute walk test.

RESULTS

The measures showed significant intercorrelation, suggesting that all were valid mobility measures. Each was reasonably reliable, with no evidence of systematic bias. The revised RMI was less sensitive to differences. The distance covered in the 2-minute walk test was significantly decreased for patients using aids (p <.0005) and those with impaired leg sensation (p =.02).

CONCLUSIONS

All 4 measures tested (2 RMI versions, 1-meter timed walk, 2-minute walk test) showed similar validity and reliability, and the 4-level RMI version failed to show an increased ability to detect differences. All measures showed more disability in patients using aids and those with sensory impairment.

The effect of magnesium oral therapy on spasticity in a patient with multiple sclerosis

The effects of magnesium glycerophosphate oral therapy on spasticity was studied in a 35-year-old woman with severe spastic paraplegia resulting from multiple sclerosis (MS). We found a significant improvement in the spasticity after only 1 week from the onset of the treatment on the modified Ashworth scale, an improvement in the range of motion and in the measures of angles at resting position in lower limbs. No side-effects were reported and there was no weakness in the arms during the treatment.

Outbreak of Salmonella braenderup gastroenteritis due to contaminated meat pies: clinical and molecular epidemiology

OBJECTIVES

To determine the epidemiologic, clinical and molecular characteristics of an outbreak of severe gastroenteritis due to the ingestion of meat pies highly contaminated with Salmonella braenderup.

METHODS

In October 1993, we observed an outbreak of Salmonella braenderup gastroenteritis that occurred in the Lausanne area, Canton de Vaud, Switzerland. Cultures of suspected food products, of samples at the incriminated food factory and from workers, as well as a case-control study, were used to determine the source of the epidemics. Ribotyping of representative Salmonella braenderup strains was performed to define the molecular epidemiology. The clinical characteristics of this infection were determined by using a standardized interview performed during and 6 months after the outbreak in 156 of 215 identified patients.

RESULTS

The outbreak resulted from the ingestion of pies, heavily contaminated (> 106 CFU/g) with a strain of Salmonella braenderup. The contamination was due to mishandling and recycling of jelly poured on top of the products. According to its ribotype and plasmid characteristics, this strain had not been isolated previously in Switzerland. Ten of the 24 workers of the incriminated food factory were shedding the epidemic strain in their stools, and one of them reported gastroenteritis 3 weeks before the beginning of the outbreak. The estimated attack rate in the exposed population was 7.5%. The median incubation time was 18 h. Among 127 adult patients studied, 98% had diarrhea, 95% abdominal pain, 74% fever > or = 38.5 degrees C, 69% nausea and 35% vomiting. One patient developed prosthetic valve endocarditis, and one reactive arthritis. Long-term complications were not identified, although 12 patients complained of irritable bowel syndrome and 24 of unusual asthenia lasting for more than 6 weeks after infection. Children had more severe signs and symptoms compared to adults, and six of 29 needed hospitalization.

CONCLUSIONS

This study showed that ingestion of food highly contaminated with Salmonella braenderup resulted in severe but typical gastroenteritis and indicated mishandling of food during manufacture as the cause of this outbreak.

Clinical features and analysis of the duration of colonisation during an outbreak of Salmonella braenderup gastroenteritis

During an outbreak of acute Salmonella braenderup gastroenteritis we performed a standardised interview encompassing questions on clinical symptoms in 156 (127 adults and 29 children) of 215 identified patients. Sequential stool cultures were obtained for up to five months in these 156 cases. We restricted the analysis to the 122 patients with at least 3 or more available cultures. They were treated with a fluoroquinolone, trimethoprim-sulfamethoxazole, or not treated with antibiotics, according to the decision of the practitioners. For this reason, a randomised double blind study was not possible. Minimum inhibitory concentrations (MIC) of the prescribed drugs were measured for representative isolates before and after treatment. The most frequent symptoms were diarrhoea (98%) and abdominal pain (96%). Vomiting occurred in 43% of cases. Children were more severely ill. Seven weeks after acute gastroenteritis, stool cultures were still positive for salmonella in 71% of the 22 children and 30% of the 100 adults examined (p < 0.002). This rate decreased progressively in both groups to 5 and 3% respectively at 20 weeks (n.s.). Among adults, no significant difference in enteric carriage over time could be demonstrated between untreated patients and those treated with either a fluoroquinolone or trimethoprim-sulfamethoxazole. MIC for salmonella isolates remained unchanged after treatment. In a cohort of patients infected with a single strain of salmonella, fluoroquinolone therapy of acute gastroenteritis failed to influence the duration of enteric carriage, despite continuing susceptibility of the strain. In children, the rate of clearance of Salmonella braenderup from stool was statistically lower until the tenth week after the acute disease, but there was no further difference after 5 months.

The bridge between administrative and clinical information system

On one side, physicians are asked to record administrative information, such as activity measurement, case-mix of their specialty, billing, for statistical, legal or reimbursement purposes; and on the other side, they need to gather detailed information about their own patients in terms of clinical evolution, for the day-to-day care of the patients or for clinical research purposes. Many other actors are also involved with these processes, both on the administrative side, such as registration officers, administrators and on the clinical side, nurses and other care providers. Applications have been developed within hospital information systems for capturing and disseminating information according to these specific actors and dedicated purposes. But more and more appears the need to integrate these data for insuring the coherence of information and avoiding redundancy of data capture. How to conciliate these objectives? We describe the Geneva's approach for integrating the administrative and the clinical systems.

Happy birthday DIOGENE: a hospital information system born 20 years ago

Since its birth in 1978, DIOGENE, the Hospital Information System of Geneva University Hospital has been constantly evolving, with a major change in 1995, when migrating from a centralized to an open distributed architecture. Since a few years, the hospital had to face health policy revolution with both economical constraints and opening of the healthcare network. The Hospital Information System DIOGENE plays a significant role by integrating four axes of knowledge medico-economical context for better understanding and influencing resources consumption the whole set of patient reports and documents (reports, encoded summaries, clinical findings, images, lab data, etc.) patient-dependent knowledge, in a vision integrating time and space external knowledge bases such as Medline (patient-independent knowledge) integration of these patient-dependent and -independent knowledges in a Case-Based Reasoning format, providing on the physician desktop all relevant information for helping him to take the most appropriate adequate decision.

Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof

OBJECTIVE

To review the risk factors and the radiological appearance of insufficiency fractures of the sacrum and acetabular roof.

DESIGN AND PATIENTS

Twenty patients with sacral and acetabular roof insufficiency fractures were reviewed retrospectively. There were 16 women (80%) and 4 males (age range 48-86 years, excluding an 8-year-old boy). Thirteen patients had a known tumour, and nine had received pelvic irradiation. All patients, except one who was asymptomatic, presented with low back or hip pain. In patients with a known tumor, metastases were suspected. Plain radiography (20), bone scintigrams (16), MR examinations (20), and bone densitometry (14) were performed. Nine patients also each had a CT scan.

RESULTS AND CONCLUSIONS

In three cases the CT scan performed 10-25 days after onset of symptoms was interpreted as normal. MR examination performed a few days after the CT scan showed in each of these three patients a fracture line with a band of edema. Scintigraphy was very sensitive, but the H-shaped pattern of sacral uptake, specific for an insufficiency fracture, was detected in only three of 16 cases. The earliest MR sign was medullary edema, seen as early as 18 days after the onset of symptoms. On spin echo (SE) T1-weighted images (T1WI), the hypointense signal of edema could mask a fracture line. On SE T2WI the fracture line could be detected within the hyperintense edema (10 of 17 patients with examinations including SE T2WI). However, in four patients a fracture of the sacrum was not seen on T2WI, these having been obtained in the axial plane. For this reason, intravenous gadolinium was injected, revealing a fracture line in 12 of 14 examinations, or fat suppression sequences were performed, revealing a fracture line in five of five cases. The total number of fractures detected was 17 [15 fractures of the sacrum (bilateral in 10 cases) and two of the acetabular roof]. At a later stage, the edema resolved and the fracture was clearly seen. The two cases of fracture of the acetabular roof were easily recognized at MRI, particularly in the sagittal plane.

Discrepancies between HMPAO and ECD SPECT imaging in brain tumors

Among several brain radiopharmaceuticals for SPECT imaging, 99mTc complexes of HMPAO and ECD are the most widely used. They are considered to be equal in their capacity to reflect regional cerebral blood flow; but discrepancies between HMPAO and ECD brain uptake have been reported in stroke patients. This paper reports our observations regarding discrepancies between HMPAO and ECD SPECT in 14 of 23 patients with suspected brain tumors or presumed metabolic cerebral abnormalities. We obtained similar conflicting results, namely focal HMPAO hyperactivities and isoactive ECD SPECT. The majority of these discrepancies were found in patients with brain tumors (10 of 13 patients), while only 4 of the 10 remaining patients with nontumoral process showed similar discrepant results. The physiopathology behind these observations is discussed here, and it is likely to be related to the specific response to cellular metabolic disorders rather than to perfusion disturbances.

[Vaccination in elderly patients in rehabilitation: a missed opportunity?]

BACKGROUND

Immunization against influenza is recommended for elderly persons in Switzerland, but no national guidelines are currently available regarding immunization of the elderly against pneumococcus and tetanus. In addition, almost no data are available regarding immunization rates of the elderly in the general population. In this study we explored the immunization status for influenza, tetanus and pneumococcus of a selected elderly population admitted to a Swiss rehabilitation facility.

POPULATION AND METHODS

The study population (n = 145) were patients admitted to a rehab facility during 3 consecutive winter months. Data on demographics, immunization, previous functional status (BADL, IADL), cognitive (MMSE) and affective status (GDS) were collected upon admission.

RESULTS

Subjects' mean age was 79.4 years, 32.4% were male, 42.8% had BADLs dependencies and 81.9% IADLs dependencies. Most patients had normal MMSE and GDS scores. Vaccination rates were 39.3% for influenza, 12.4% for tetanus and only 2.1% for pneumococcus. In univariate analyses, people immunized against influenza were older than those who were not (p = 0.01). This relationship remained in multivariate analyses, controlling for gender, functional, cognitive and affective status. Subjects aged 80 and over were 2.5 times (95% CI 1.2-5.5, p = 0.02) more likely to be immunized against influenza, but were less likely to be immunized against tetanus (OR 0.3, 95% CI 0.1-0.9, p = 0.04). Functional status was not significantly associated with any vaccination status.

CONCLUSIONS

Immunization rate for influenza in this selected population is similar to those described in US surveys. The positive association between older age and flu vaccination is surprising and needs further investigation. These results also indicate a need to educate patients and physicians in order to increase vaccination use, especially against pneumococcus.

Third-body irradiation as an effective palliative treatment for painful multiple bone metastases resistant to chemo- or hormonal treatment

Fifty-three patients had 54 third-body areas irradiated for breast and prostate bone metastases using the third-body irradiation technique during a period of 6 years. These patients were previously treated with chemotherapy, hormonal therapy and limited field irradiation. Seventy percent responded completely and 24% partially. This modality is safe and effective for pain relief.

[The hepatitis B vaccination campaign carried out from 1982 to 1984 using the Hevac B Pasteur vaccine among 6162 employees of Vaud hospitals]

6162 Swiss hospital employees were vaccinated against hepatitis B from 1982-1984 with Hevac B Pasteur vaccine. Vaccination was offered free of charge to 8471 employees, 72% of whom accepted a series of three injections and 50% a booster about 15 months later. Side effects, all benign, brief and rapidly resolved, were observed after 4% of injections in 7% of patients. Side effects after each of the three injections were noted in 0.7% of subjects. These figures are below those of other authors. -Concentrations of protective anti-HBs antibodies produced by the vaccination were measured by sampling of subjects. Four years after the beginning of the vaccinations the subjects had an average concentration of 87 mU/ml without booster and 595 mU/ml with booster. On average these concentrations are higher in employees more heavily exposed to hepatitis B than in the others. They are also higher in vaccines than in subjects immunized after natural infection, in whom they were 138 mU/ml. Production of anti-HBs antibodies was observed in 94% of subjects vaccinated.-In conclusion, the preparation used proved effective and well tolerated. This observation should help to foster more general use of vaccination campaigns in exposed populations.