Lower limb lymphedema and neurological complications after lymphadenectomy for gynecological cancer.

OBJECTIVE: Lymphadenectomy is a frequent procedure for surgical staging of gynecological malignancies. Nevertheless, minor complications, such as lower limb lymphedema (LLL) and neurological complications (NCs), after pelvic and aorto-caval lymphadenectomy still remain underinvestigated. The present study considers short-term and long-term incidence and risk factors for LLL and NC in patients with gynecological cancer who underwent lymphadenectomy. MATERIALS AND METHODS: In 2 different institutions, University of Turin and University of Lausanne, a total of 152 patients who received lymphadenectomy for endometrial, cervical, or ovarian cancer were retrospectively identified. During the follow-up, data about LLL and NC were collected by means of a questionnaire. Short-term and long-term incidence of LLL and NC was evaluated, and risk factors, such as age, body mass index, type of cancer, surgical approach, number and extension of the removed lymph nodes, presence of lymph node metastasis, and adjuvant treatments, were analyzed. RESULTS: Short-term incidence of LLL and NC after lymphadenectomy was high (36%) and predictive of long-term persistence. Between the analyzed risk factors, number of removed lymph nodes and adjuvant radiotherapy were significantly associated with an increased incidence of minor complications (P < 0.05). CONCLUSIONS: Lower limb lymphedema and NC are more frequent than expected. They are related to the radicality of lymphadenectomy and adjuvant radiotherapy. They affect the quality of life of the patients treated for gynecological cancer and their perceptions of healing. Minor complications are commonly persistent and need a prompt diagnosis and a specialized management to improve their prognosis.

Survey on current practices for neurological prognostication after cardiac arrest.

PURPOSE: To investigate current practices and timing of neurological prognostication in comatose cardiac arrest patients. METHODS: An anonymous questionnaire was distributed to the 8000 members of the European Society of Intensive Care Medicine during September and October 2012. The survey had 27 questions divided into three categories: background data, clinical data, decision-making and consequences. RESULTS: A total of 1025 respondents (13%) answered the survey with complete forms in more than 90%. Twenty per cent of respondents practiced outside of Europe. Overall, 22% answered that they had national recommendations, with the highest percentage in the Netherlands (>80%). Eighty-nine per cent used induced hypothermia (32-34 °C) for comatose cardiac arrest patients, while 11% did not. Twenty per cent had separate prognostication protocols for hypothermia patients. Seventy-nine per cent recognized that neurological examination alone is not enough to predict outcome and a similar number (76%) used additional methods. Intermittent electroencephalography (EEG), brain computed tomography (CT) scan and evoked potentials (EP) were considered most useful. Poor prognosis was defined as cerebral performance category (CPC) 3-5 (58%) or CPC 4-5 (39%) or other (3%). When prognosis was considered poor, 73% would actively withdraw intensive care while 20% would not and 7% were uncertain. CONCLUSION: National recommendations for neurological prognostication after cardiac arrest are uncommon and only one physician out of five uses a separate protocol for hypothermia treated patients. A neurological examination alone was considered insufficient to predict outcome in comatose patients and most respondents advocated a multimodal approach: EEG, brain CT and EP were considered most useful. Uncertainty regarding neurological prognostication and decisions on level of care was substantial.

Subjective perceptions as prognostic factors of time to fitness for work during a 4-year period after inpatient rehabilitation for orthopaedic trauma.

INTRODUCTION: Time to fitness for work (TFW) was measured as the number of days that were paid as compensation for work disability during the 4 years after discharge from the rehabilitation clinic in a population of patients hospitalised for rehabilitation after orthopaedic trauma. The aim of this study was to test whether some psychological variables can be used as potential early prognostic factors of TFW. MATERIAL AND METHODS: A Cox proportional hazards model was used to estimate the associations between predictive variables and TFW. Predictors were global health, pain at hospitalisation and pain decrease during the stay (all continuous and standardised by subtracting the mean and dividing by two standard deviations), perceived severity of the trauma and expectation of a positive evolution (both binary variables). RESULTS: Full data were available for 807 inpatients (660 men, 147 women). TFW was positively associated with better perceived health (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.13-1.19), pain decrease (HR 1.46, 95% CI 1.30-1.64) and expectation of a positive evolution (HR 1.50, 95% CI 1.32-1.70) and negatively associated with pain at hospitalisation (HR 0.67, 95% CI 0.59-0.76) and high perceived severity (HR 0.72, 95% CI 0.61-0.85). DISCUSSION: The present results provide some evidence that work disability during a four-year period after rehabilitation may be predicted by prerehabilitation perceptions of general health, pain, injury severity, as well as positive expectation of evolution.

Les déterminants de la prolongation des séjours en SSRG et les indicateurs du devenir des patients après leur sortie : Étude rétrospective au CHRU de Strasbourg [Determinants of prolonged stays in geriatric rehabilitation department and indicators of patient outcome after discharge: A retrospective study in Strasbourg university hospital]

Objectif. Analyser les déterminants de la prolongation des séjours hospitaliers en service de soins de suite et réadaptation gériatrique (SSRG) et identifier les indicateurs du devenir des patients après leur sortie. Méthode. Étude rétrospective au CHRU de Strasbourg de l'ensemble des séjours de durée supérieure à 90 jours entre le 1 janvier 2012 et le 30 septembre 2013. L'ensemble des données sociodémographiques, descriptives des séjours et de l'état de santé des patients ont été analysées. Les patients ont été suivis 9 mois après leur sortie. Les réhospitalisations, l'admission en institution et le décès ont été informés par un contact téléphonique auprès du médecin traitant ou de la famille. Résultats. Quarante-six séjours ont été analysés. Les patients étaient à 68,0 % des femmes. La moyenne d'âge était de 82,9 ± 5,8 ans. Quatre-vingt-dix-huit pour cent d'entre eux vivaient à domicile avant l'admission en milieu hospitalier. Les raisons justifiant la prolongation étaient d'ordre médical (60,8 %), psychique (45,6 %), social (65,2 %) et liées à la difficulté de trouver une solution d'aval (58,7 %). À la fin de leur séjour, 9 patients ont pu regagner leur domicile et 37 ont été admis directement en institution. Durant la période de suivi, 17 patients ont été réhospitalisés au moins une fois et 3 jusqu'à trois fois. Au 9e mois, 9 patients étaient décédés dans un délai moyen de 75 jours après la sortie du SSRG. Les résultats des analyses unifactorielles et multivariées ont permis d'identifier des indicateurs d'évolution défavorable (décès et/ou réhospitalisation). Aucune des variables sociodémographiques ou de syndrome gériatrique n'a été identifiée. Par contre un « motif d'hospitalisation pour une maladie infectieuse », ou pour « un trouble de la marche ou une chute », une « prolongation du séjour en SSRG pour raison médicale » et un « séjour prolongé en court séjour » étaient les facteurs identifiés. Conclusion. Dans la tendance actuelle à améliorer la rentabilité de l'utilisation des ressources de santé, ces résultats rappellent qu'il est important de maintenir un juste équilibre entre utilisation raisonnée des ressources et les besoins spécifiques des patients âgés.

Schizophrénies et troubles délirants tardifs à l'âge avancé

Persistent schizophrenias and delusional disorders are classified as primary psychiatric pathologies amongst the elderly. It is crucial to distinguish them from secondary psychotic disorders associated with physical illnesses, such as acute confusion and psychotic symptoms caused by dementia or other somatic pathologies. Employing the concept of a primary psychiatric disorder occurring in an elderly patient is not simple, and each term used to define the concept refers back to an array of various criteria in clinical, psychological, biological, neurological, and cognitive fields. What about very late-onset schizophrenia, occurring after the age of 60 years, for instance? Is this a primary psychiatric illness occurring very late or a secondary pathology caused by brain disease, particularly a degenerative one? Studies reveal controversial results and it is still being debated as to whether the disease has neurodevelopmental or neurodegenerative causes. Due to the variable symptoms and psychiatric, somatic, and cognitive comorbidities associated with psychosis in elderly patients, patient healthcare must not be limited to prescribing an antipsychotic. Once it has been determined whether the psychosis is secondary or primary (old-agerelated schizophrenia, late-onset or very late-onset schizophrenia, or late-onset delusional disorder), an aetiological or symptomatic treatment must follow, including a psychotherapeutic approach, close surveillance of the drug treatment and its potential side-effects, rehabilitation steps through community-based care, and psychoeducational support for the family and other professionals in charge of the patient. Our article's aim has been restricted to summarising our understanding regarding late-onset schizophrenias and delusional disorders amongst the elderly.

Serious games for rehabilitation using head-mounted display and haptic devices

In the health domain, the field of rehabilitation suffers from a lack specialized staff while hospital costs only increase. Worse, almost no tools are dedicated to motivate patients or help the personnel to carry out monitoring of therapeutic exercises. This paper demonstrates the high potential that can bring the virtual reality with a platform of serious games for the rehabilitation of the legs involving a head-mounted display and haptic robot devices. We first introduce SG principles and the current context regarding rehabilitation interventions followed by the description of an original haptic device called Lambda Health System. The architecture of the model is then detailed, including communication specifications showing that lag is imperceptible for user (60Hz). Finally, four serious games for rehabilitation using haptic robots and/or HMD were tested by 33 health specialists.

Harmonization of training and assessment of medical specialists in physical and rehabilitation medicine across Europe - The contribution of the UEMS Board of Physical and Rehabilitation Medicine

Background.- The main goals of the European Board of Physical and Rehabili-tation Medicine (EBPRM), founded in 1991 as the third speciality board of theUnion of European Medical Specialists (UEMS), are to harmonize pre-graduate,post-graduate and continuous medical education in physical and rehabilitationmedicine (PRM) all over Europe. The harmonization of curricula of the medi-cal specialities and the assessment of medical specialists has become one of thepriorities of the UEMS and its working groups to which the EBPRM contributes.Action.- The EBPRM will continue to promote a specific minimal undergraduatecurriculum on PRM including issues like disability, participation and handicapto be taught all over Europe as a basis for general medical practice. The EBPRMwill also expand the existing EBPRM postgraduate curriculum into a detailedcatalogue of learning objectives. This catalogue will serve as a tool to boostharmonization of the national curricula across Europe as well as to structurethe content of the MCQ examination. It would be a big step forward towardsharmonization of European PRM specialist training if an important number ofcountries would use the certifying MCQ examination of the Board as a part ofthe national assessments for PRM specialists.

Continuing Medical Education Self-Assessment Questions Vol. 50, No. 2 - April 2014. Focal vibration in neurorehabilitation.

During the last decade, many studies have been carried out to understand the effects of focal vibratory stimuli at various levels of the central nervous system and to study pathophysiological mechanisms of neurological disorders as well as the therapeutic effects of focal vibration in neurorehabilitation. This review aimed to describe the effects of focal vibratory stimuli in neurorehabilitation including the neurological diseases or disorders like stroke, spinal cord injury, multiple sclerosis, Parkinson's' disease and dystonia. In conclusion, focal vibration stimulation is well tolerated, effective and easy to use, and it could be used to reduce spasticity, to promote motor activity and motor learning within a functional activity, even in gait training, independent from etiology of neurological pathology. Further studies are needed in the future well- designed trials with bigger sample size to determine the most effective frequency, amplitude and duration of vibration application in the neurorehabilitation.

Educational resources offered by the European Board of Physical and Rehabilitation Medicine (EBPRM)

Background .- Physical and Rehabilitation Medicine (PRM) is a very demanding medical speciality. To ensure high standard of research and care in PRM all across Europe, it is crucial to attract gifted trainees and offer them high quality education. At undergraduate level, many medical schools in Europe omit to offer teaching on disabled persons and on basic PRM knowledge. Thus PRM is hardly known to medical students. For postgraduate trainees access to evidence-based knowledge as well as teaching of research methodology specific to PRM, rehabilitation methodology, disability management and team building also need to be strengthened to increase the visibility of PRM. Action .- To address these issues the EBPRM proposes presently a specific undergraduate curriculum in PRM including the issues of disability, participation and handicap as a basis for general medical practice and postgraduate rehabilitation training. For PRM trainees many educational documents are now available on the EBPRM website. A growing number of educational sessions for PRM trainees take place during international and national PRM Congresses which can be accessed at low cost. Educational papers published regularly in European rehabilitation journals and European PRM Schools are offered free or at very low cost to trainees.

Care related pain in rehabilitation after orthopedic trauma: An exploratory study with qualitative data.

OBJECTIVE: Care related pain (CRP) is generally under-estimated and rarely studied in rehabilitation as well as in general medecine. Beliefs about pain influence psychological distress, adjustment to pain and physical disability. In this sense, perceptions of CRP could limit recovery. This exploratory study aims to understand patients' and caregivers' subjective perceptions and beliefs about CRP. PATIENTS AND METHODS: Questionnaires about CRP were submitted to members of the interdisciplinary team of a rehabilitation hospital and to patients with musculoskeletal complaints (cross-sectional design). Twenty patients were also individually interviewed (qualitative data). Four topics were addressed: frequency of CRP, situations and procedures causing CRP, beliefs about CRP and means used to deal with CRP. RESULTS: Seventy-five caregivers and 50 patients replied to the questionnaire. CRP is a very common experience in rehabilitation and it is recognized by both groups. Generally, the situations causing CRP reflect the specificity of rehabilitation (mobilization...) and are similarly perceived by patients and caregivers, with patients considering them as more painful. Beliefs about CRP are clearly different from those usually associated with pain. Both groups point out the utilitarian and the inevitable character of CRP. They differ on that, that patients had a more positive view about CRP. They associate it more often with progress and see it as acceptable at least until a certain limit. They are also able to perceive the richness of means used by physiotherapists to help them coping with CRP. CONCLUSION: Our data may suggest new keys to motivate patient to be active in rehabilitation for example in choosing carefully arguments or words which may fit theirs' beliefs about CRP, or in using various means to manage CRP. Promoting the use of relational competences with chronic pain patients and of a patient-centred approach may also be a concern in training caregivers.