Tag Archives: pressure ulcer

Feb 28 2015
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Journal Reviews

Rehab Journal Review: February 2015

BMJ, 24 February 2015

“Irrational drug prescribing, kickbacks for referrals, and unnecessary investigations & surgical procedures” – testimonies from 78 doctors on the malaise afflicting India’s private healthcare system are part of a book written by Dr Arun Gadre. This commentary in BMJ titled “India’s private healthcare sector treats patients as revenue generators” gives an indication to the extent, intensity and the near-inevitability of these practices. Clichéd, but Shankar-KamalHassan were spot on in describing why it would be difficult to stem the rot. Dishonesty is so omnipresent, that we as a society have stooped low enough to accept it as a virtue. The state, the big brother who’s supposed to watch over, itself is the perpetrator. How else to explain government medical colleges juggling teaching faculty and movable infrastructure in the name of “deputation” to falsely get through MCI inspections. Coming back… the author of this article does suggest ” the only solution for India would be accountable social regulation of the private medical sector and the movement towards a combination of social insurance and a tax based system for universal healthcare”. Amen.

Annals of Internal Medicine, February 2015

Nutritional advice to patients with pressure ulcers have more similarities to MS Dhoni’s decisions on-field than James Watt’s energy calculations. Impromptu, I-believe-in-my-logic decisions that wouldn’t count as science. This blinded randomized trial “A Nutritional formula enriched with Arginine, Zinc and Antioxidants for the healing of pressure ulcers” tries to make sense of the issue. 200 patients recruited from 7 centers. Great effort. But I can’t understand why they chose to end the study at 8 weeks, instead of waiting until complete healing of ulcers, which is what matters. For what it’s worth, supplementation did seem to help. Needs work though. #thesisalert

NEJM, 11 February 2015

Acute stroke management with thrombolysis is a mixed bag. Recent systematic reviews could not make up their mind on the specifics or on whether benefits clearly outweighed the risks. This new RCT on “Rapid Endovascular Treatment of Ischmic Stroke” takes sides. In fact, the study had to be halted midway since the treatment was found to be definitely more beneficial than controls. The abstract conclusion, for a change, is well-worded, describing clearly the population to which the results could be extrapolated, and is grounded in facts “Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality.”

JAMA, 27 Jan 2015

I’ve known healthcare professionals and patients who have blind immense faith on topical antimicrobials Povidone Iodine (Betadine) and Chlorhexidine, so much so that I won’t be surprised if they add a bit of the conspicuously colored fluid to their food. I wonder if this article “Chlorhexidine bathing and health care-associated infections” would make at least a dent in their belief. “…daily bathing with chlorhexidine DID NOT REDUCE the incidence of health care–associated infections including central line associated blood stream infections, catheter associated urinary tract infections, ventilator-associated pneumonia, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine”

From the mainstream media

“My Own Life” is a #NYT article by Oliver Sacks, the neurologist author of the unmistakably titled book “The man who mistook his wife for a hat“. He says he has metastatic malignancy, and ponders aloud on the life he has lived. “I cannot pretend I am without fear. But my predominant feeling is one of gratitude. I have loved and been loved; I have been given much and I have given something in return; I have read and traveled and thought and written…Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure”. Sounds like words of a man who has made peace with life.

19sacks-superJumbo

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Liked in twitter: Ben Goldacre at his usual irreverant best

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Dec 05 2013
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Journal Reviews

Rehab Journal Review: November 2013

After a few roller coaster weeks of curricular, co-curricular and extra-curricular activities, here is the delayed follow-up act.

Spinal cord, Volume 51, Issue 8, August 2013

596 A few years ago, a couple of junior consultants in our department submitted a study proposal to the institutional review board- an RCT to study whether anticoagulants offered clinically appreciable benefits as against no treatment in persons with acute/post-acute spinal cord injury. Our proposal was shot down by the IRB, saying it was unethical to have a placebo/no-treatment group. Seems it probably might not have been unethical. Heparin for venous thromboembolism prophylaxis in acute SCI, a review article from China (Open access in Spinal Cord is a rarity) reports a few such studies with no-treatment groups. After you wade through the typos in page 601, the authors conclude that “in acute SCI, low dose unfractionated heparin (LDUH) have no thromboprophylaxis effect compared to placebo or no treatment (0/4 studies). LMWH reduce bleeding risk, but cannot prophylaxis thromboembolism compared with LDUH (8/9 studies). [Tinzaparine is the exception here (Green D 1994), but I don’t remember ever discussing that name for clinical use. Anyone??] Because no good quality studies existed in this setting, well-designed RCTs are urgently needed.”

The related clinical dilemma expressed by this BMJ article in July 2013 adds to the intrigue in situations warranting therapeutic anticoagulation. “Combination of large increase in incidence, reduced case fatality (in-hospital deaths among people with a diagnosis of pulmonary embolism), and a minimal decrease in mortality (deaths from pulmonary embolism in the population) suggests that many of the extra emboli being detected are not clinically important. Harms from overdiagnosis—Substantial increase in complications from anticoagulation. Anxiety and inconvenience for patients following diagnosis and treatment”. So, are there clots that we don’t need to treat? “Without prospectively observing untreated patients, it is impossible to be certain which emboli are not clinically important”.

Now, I’m keen to revive the rejected study proposal.

642 Assisted Reproductive Techniques in SCI is a retrospective cohort analysis of 32 patients, reported from Israel. The authors claim testicular aspiration success rates of almost 90%. Primary testicular failure and elevated FSH levels are reported to be associated with poor pregnancy outcomes. “Clinical pregnancy rate was 32/106 (30.2%) per cycle, and 19/32 (59.3%) per couple.” Not bad, just that most of our patients cannot afford one cycle of IVF.

645 Compliance with clean intermittent catheterization in spinal cord injury patients from Turkey. This is a retrospective review of medical notes of 164 patients in 10 years. At discharge, 63% on CIC, 10% indwelling catheter, 15% reflex voiding. Compliance with CIC at followup (54months±28) was 58%. Of those who stopped, 74% started reflex voiding. Commonest cause for stopping CIC was urinary tract infections. All these numbers do not mean much since no data is provided on clinical end points related to long term urological health.

Spinal Cord Volume 51, Number 9, September 2013

694 Gluteal blood flow and oxygenation during electrical stimulation-induced muscle activation pressure relieving movements in wheelchair users with a spinal cord injury. The learning point is not in the results but in the notion that electrical stimulation can potentially reduce pressures over the ischial tuberosity. Could this be a viable alternative to those not capable of doing pressure-relief measures?

715 Studies on telehealth in general are yet to come out with anything substantial to justify resources spent. A pilot study of a telehealth intervention for persons with spinal cord dysfunction doesn’t break the trend. Though the authors report that women who listened to telephonic health education instructions had 100% ulcer healing, it must be noted that only stage 1 and 2 ulcers were included. Other interventions were neither controlled for, nor data collected. Hence, no clinically meaningful interpretations can be made.

Archives of PMR, Volume 94, No. 8, August 2013

Functional benefits (emerging evidence do not support them) versus Complications (common in clinical practice) of partial foot amputations is the subject of this article from the editor’s desk. They looked at outcomes of ankle power generation and energy expenditure during gait, as well as Quality Of Life. They conclude “Despite high rates of complications experienced by persons with partial foot amputation, …is still preferred to transtibial amputation… we should adopt practices that minimize the likelihood of ulceration and secondary amputation…”. There might be some truth in this, going by what we see in our diabetic foot clinic (We don’t have actual numbers).

1473 Meta-Analysis of Botulinum Toxin A Detrusor Injections in the Treatment of Neurogenic Detrusor Overactivity After Spinal Cord Injury. The topic of the study seemed very relevant to our practice, and I was keen to look at the results. One look at the forest plots and the diamonds seemed impressively in favor of BTX-A. Into the text then. The study selection flowchart says that of the 269 potentially relevant studies, 14 studies met inclusion criteria. Good so far. “Only one study was a randomized controlled trial”. Dud. 12 of those studies had no control group. The conclusion still inexplicably states “BTX-A injections into the detrusor muscle were associated with significant beneficial treatment effects”. The abstract too makes no mention of the fact that 12 of 14 studies reported only pre-post data and were not RCTs. The one RCT included in the meta-analysis would have sufficed to make interpretations, but the authors chose (and Archives colluded) to unnecessarily beef up the thin evidence. Read the conflict of interest section and you might understand why. Gullible readers could be tricked to believe this is level I stuff.

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Top among the few things I came to know about the past couple of months that made me pause and reflect on lines of the road taken and not taken:

1. a book written by a friend from schooldays

2. a tamil movie being produced by my namesake batch-mate from MBBS days.

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Oct 15 2013
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Journal Reviews

Rehab Journal Review: October 2013

Blame it on procrastination. This initiative has had a stuttering course from idea to action. Though inspired by a family physician who took no vacation in 15 years of weekly journal reviewing, I can’t assure even a second month. These musings are an expression of a self-learning process in interpreting scientific research, and the reader is encouraged to take these with a generous pinch of salt. Articles that find a mention here are those that are likely to be relevant to practice of rehabilitation medicine as I understand at my current workplace. Non-mention does not mean to undermine clinical significance otherwise, but would imply just my ignorance. Any tinge of irreverence in these passages might not be entirely unintended. What is written about here would be constrained by the availability of full texts, electronic or hardcopy (The paywalls, grrr). Hence, I’m starting with just the dated Archives of PM&R, Volume 94, No 6, June 2013. Do send in no-holds-barred feedbacks to make the learning more purposeful and mutual.

Conflicts of interest: Nothing to do with the industry. I’m likely to be biased in favor of evidence based healthcare, and against clinical studies that do not have clinically relevant hard endpoints as outcome measures.

A recently concluded MD thesis in our department studied the efficacy of an indigenously designed peroneal nerve stimulator (PNS) in gait of persons with stroke. This study from the Case Western Reserve University was done to see if there is any motor relearning with such PNS compared to usual care (AFO when necessary). The stimulator they used was a commercial product with a pressure-sensing foot-switch to detect heel rise at pre-swing (we had used a hand-operated manual switch). Better technology didn’t prove to be too beneficial though; the authors have been honest with the results in concluding “there was no motor relearning in either … groups”. More importantly, at 6 months, usual care fared as well as the stimulator in terms of functional mobility and quality of life. PNS will have to wait.

Taiwanese authors aren’t far behind in honest conclusions in their study on mirror therapy in chronic stroke. They conclude “application of mirror therapy…may not translate into daily functions in the population with chronic stroke”.

It takes just two hours to instill confidence in use of manual wheelchair among older adults who are completely inexperienced previously, as this paper reports. Let’s remember to find those 2 hours for each of our KAFO dependent functional-walkers too; will come handy sometime, somewhere.

This could have been easily dismissed as just an observational study, but the authors conclude “Long-stay home care patients who receive rehabilitation at home have improved outcomes and lower utilization of costly health services. Our findings suggest that investment in PT and OT services for relatively short periods may provide savings to the health care system over the longer term.” Encouraging words for anyone keen on population rehabilitation (a derivative of the term population medicine advocated by Muir Gray).

Robotics might be the next big thing in rehabilitation, but in this before-after clinical intervention study, there is nothing for anyone as of now, probably except for the uber-rich interested to try out some toys. I am a fan of Tony Stark’s excursions in his gizmo suit, in case you doubted that I’m an anti-technologist.

Didn’t know about wearable laser Doppler flowmetry probes; that’s the only thing to know from this study. Could someone suggest how to put these probes to better use, design a good study and come out with a clinically useful prediction model for pressure ulcer incidence.

Glad to find friend and former colleague Apurba Barman’s name in the list of reviewers acknowledged in this edition of Archives of PMR (the links would not lead to full-texts if your institution does not pay for online editions of the linked journals, please see the print edition instead. The paywalls *!@#$*)

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