Preventing Harm During Treatment of Acute Kidney Injury: What Do We Really Know?

Acute kidney injury (AKI) affects approximately 5% of all hospitalized patients, and its incidence continues to increase. The treatment of AKI involves tremendous financial costs, estimated to exceed $10 billion in the United States annually. Although our understanding of the pathophysiology of AKI has progressed at a tremendous pace, mortality remains high at 50% to 80%, with no improvement during the past several decades. More questions than answers currently exist regarding the optimal dialysis dose, optimal modality, and optimal timing of the initiation of renal replacement therapy in the setting of AKI, making it particularly difficult for the practicing clinician to both optimize treatment and practice cost-effective medicine. This article will review current evidence and concerns regarding these issues and identify areas of future research.     

Colonic Transit Time After Spinal Cord Injury: Any Clinical Significance?

Abstract

Background: Both bowel dysfunction and increases in colonic transit time (CTT) are frequently observed in individuals with spinal cord injury; however, it is unknown whether there is an association between chronic intestinal problems and changes in CTTs. The current study investigates a possible relationship between the main intestinal symptoms of SCI patients and CTT values.

Methods: The following clinical variables and symptoms were investigated and collected in 30 individuals with SCI: total time for bowel care, abdominal pain, abdominal gas, success of rectal emptying, fecal incontinence, and decrease in quality of life. Total and segmental CTTs (right colon, left colon, and rectosigmoid colon) were assessed using radiopaque markers. The effects of the sociodemographic variables and the clinical symptoms on the different CTTs (total and segmental) were analyzed.

Results: The assessed clinical conditions were observed in the following percentages of subjects: abdominal gas symptoms (70%), fecal incontinence (56%), abdominal pain (63%), total time for bowel care > 1 hour (11%), difficult rectal emptying (66%), and decrease in quality of life (36%). We also observed an increase in total CTT in 47% of subjects; increases in segmental CTT were found in the right colon in 23%, in the left colon (60%), and in the rectosigmoid segment (23%). Statistical analyses failed to show a significant difference in mean CTT values between the group of symptomatic patients (1 or more symptoms) and the group of asymptomatic patients. No significant difference could be detected in the incidence of each intestinal symptom between the group of participants with normal CTT values and those with abnormal CTT values. For each of the clinical data assessed separately, a significantly longer CTT (left colon) was associated with the lack of abdominal pain (P < .03) and the presence of fecal incontinence (P < .01 ); successful rectal emptying was associated with significantly shorter total (P < .02) and segmental CTTs for the left colon (P < .01 J and rectosigmoid colon (P < .05).

Conclusions: Besides an association between shorter CTT and successful rectal emptying, there was little relationship between CTTs and intestinal symptoms in this study of patients with SCI.     

Physiologic Basis Of Digital–Rectal Stimulation For Bowel Evacuation In Patients With Spinal Cord Injury: Identification Of An Anorectal Excitatory Reflex

Abstract

Background and purpose: Although advances in rehabilitation practices, pharmacology, and surgery offer new bowel program alternatives, digital-rectal stimulation is still utilized to facilitate defecation in patients with spinal cord injury (SCI) . We speculated that defecation induced by such a technique is mediated through a reflex mechanism.

Methods: The study comprised 18 healthy volunteers (10 men, 8 women, mean age 36.6 ± 9.7 years) and 9 patients with SCI (6 men, 3 women, mean age 35 .1 ± 11 .2 years). The anal canal was dilated by a balloon inflated in 2-ml increments to 10 ml, and rectal pressure response was then recorded. The test was repeated after separate block of the external and internal anal sphincters and after individual anesthetization of the anal canal and rectum.

Results: In normal subjects, the rectal pressure rose significantly (p<0.01) with 2-ml inflation. Increases in anal dilatation effected further rectal pressure elevations (p < 0.001 ), although there were no significant differences among the 4-, 6-, and 10-ml distensions (p > 0.05). The rectal pressure rise occurred with external, but not with internal, sphincter paralysis. In the subjects with paraplegia, there was no rectal pressure response to the 2- and 4-ml anal dilatations, while the 6-, 8-, and 10-ml distensions effected significant pressure increases (p<0.001, p<0.001, p<0.001, respectively) that did not differ significantly among the 3 distending volumes. Internal sphincter inhibition,in contrast to the external sphincter, produced no rectal pressure response. In both normal subjects and subjects with paraplegia, the rectal pressure response did not occur after individual anesthetization of the rectum and anal canal.

Conclusions: Anal dilatation induces rectal contraction through stimulation of mechanoreceptors, possibly in the internal sphincter.Rectal contraction upon anal dilatation suggests a reflex relationship that was absent onindividual anesthetization of the possible2arms of the reflex arc: anal canal and rectum.This relationship, which we term the "anorectal excitatory reflex ," appears to be evoked on digital anal dilatation. The reflexmight be of diagnostic significance in defecationdisorders and has the potential to be used as an investigative tool.     

Treatment of Erectile Dysfunction: What Should We Do Next?

Abstract Because sildenafil (Viagra) is scheduled to be clinically available in the near future, urologists in Japan must prepare for changes in the treatment of erectile dysfunction. The drug will surely influence our current clinical style of diagnosis and treatment of the dysfunction. We herein discuss this issue, referring to favorable and unfavorable effects that will be brought about by the drug. We also propose several future studies that we should do, including those on testosterone replacement therapy. We present results of our experiment using testosterone replacement therapy in aged rats and speculate about the mechanism by which the hormone replacement works in the sex center of the brain. E-pub: 29 August 2000     

Fatal Spinal Cord Injury of the 20th President Of The United States: Day–By-–Day Review Of His Clinical Course,With Comments

Abstract

Background: This article presents the medical history of the 20th president of the United States, James A. Garfield, with an emphasis on hisspinal cord injury (SC I). Numerous references debate the care he received from the medical and surgical perspectives, but little has been written about the essential aspect of his gunshot wound-namely, the darnage to his spinal cord. President Garfield was shot in the lumbar spine and was bedridden until he died 80 days following his injury. This article contrasts state-of-the-art care in 1881 to today’s standards of care for SCI.

Method: Literature review. Arecord of daily reports of the president’s condition was analyzed. Comparisons were made between the president’s care and what is now available.

Findings: Although the president had access tothebest physicians, the chronicle of his course underscores the deficiencies in basic medical care, the controversies concerning surgical intervention, and the problems inherent in the care of a prominent patient. Press releases did not overtly address spinal cord trauma and its complications so as to avoid conveying the president’s degree of incapacity. Garfield ’s SCI was documented on autopsy. The bullet entered the 1Oth intercostal space, 3 112 inches to the right of the spinous processes, fracturing the 11th and 12th vertebrae and nicking the Tl 2-L 1 disc. The bullet then passed through the right side of the body of L 1 and exited the vertebra anteriorly and to the left and lodged behind the pancreas, where it was found encased by a firm cyst.

Conclusion: Deficiencies in general medical care and surgical technique at the time contributed to the president’s demise. This case was marked by controversies that still are debated today-for example, whether the bullet should have been removed surgically. Examination of available evidence suggests that with today’s advances in medical, surgical, and SCI medicine, a person with this type of injury would likely survive and be a candidate for rehabilitation.     

Vocational Rehabilitation in Spinal Cord Injury: What Vocational Service Activities Are Associated with Employment Program Outcome?

Background:

Designing effective vocational programs for persons with spinal cord injury (SCI) is essential for improving return to work outcome following injury. The relationship between specific vocational services and positive employment outcome has not been empirically studied.

Objective:

To examine the association of specific vocational service activities as predictors of employment.

Method:

Secondary analysis of a randomized, controlled trial of evidence-based supported employment (EBSE) with 12-month follow-up data among 81 Veteran participants with SCI.

Results:

Primary activities recorded were vocational counseling (23.9%) and vocational case management (23.8%). As expected, job development and employment supports were the most time-consuming activities per appointment. Though the amount of time spent in weekly appointments did not differ by employment outcome, participants obtaining competitive employment averaged significantly more individual activities per appointment. Further, for these participants, job development or placement and employment follow-along or supports were more likely to occur and vocational counseling was less likely to occur. Community-based employment services, including job development or placement and employment follow-along or supports as part of a supported employment model, were associated with competitive employment outcomes. Office-based vocational counseling services, which are common to general models of vocational rehabilitation, were associated with a lack of employment.

Conclusions:

Vocational services that actively engage Veterans with SCI in job seeking and acquisition and that provide on-the-job support are more likely to lead to employment than general vocational counseling that involves only job preparation.     

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Evidence: What Is It,Where Do We Find It,and How Do We Use It?

The purpose of this paper is to review the history and rationale for evidence-based medicine (EBM). The development of EBM is briefly described, together with the pros and cons of evidence-based research, review techniques, and resources. The current status of EBM with regard to the treatment of overactive bladder (OAB) is also discussed. In short, EBM can be defined as the conscientious, explicit and judicious use of current best evidence to make decisions about the care of individual patients. The four main steps are: (1) formulate a clear question from a patient’s problem, (2) search the literature for relevant clinical articles, (3) evaluate and critically appraise existing evidence for its validity and usefulness, and (4) implement useful findings in clinical practice. The power of the evidence-based approach can be enhanced by the development of techniques such as systematic review and meta-analysis. However, although EBM allows us to use current best evidence to make decisions about patient care, the evidence gained from systematic review and meta-analysis only applies to an “average patient” and is not readily adaptable to issues such as etiology, diagnosis and prognosis.     

Renal Replacement Therapy in Acute Kidney Injury: Intermittent Versus Continuous? How Much Is Enough?

Approximately 4% of all critically ill patients will require renal replacement therapy (RRT). Despite its potential reversibility, acute kidney injury has a significant impact on morbidity and mortality. Numerous studies have addressed the questions of modality choice and dose of RRT in the intensive care unit setting. There is no clear evidence that one renal replacement modality is superior to another. Two multicenter trials focusing on dialysis dose will probably be published in the next year, either confirming or invalidating the benefit of higher effluent rates. Another key aspect in the treatment of acute kidney injury is the consequence of RRT on long-term renal function. Although cohort studies have shown that continuous RRT shortens dialysis-dependence compared with intermittent hemodialysis, randomized trials and meta-analyses do not support these findings. Several unanswered questions, such as the timing of initiation and cessation of RRT, the modification of dialysis parameters over the course of acute kidney injury and the influence of fluid status need to be addressed in future trials in order to improve outcomes related to this condition.     

Nonoperative Treatment of Neuro-Osteoarthropathy of the Foot: Do We Need New Criteria?

The worst manifestation of neuro-osteoarthropathy of the pain-insensitive foot is the Charcot foot with its devastating osteoarticular destructions and irreversible deformities. New diagnostic tools such as MRI have revealed that mechanical injury and overuse is the origin of the condition. Traditionally, only feet with bone and joint damage apparent on plain radiographs (fracture and dislocation injuries) have undergone nonoperative treatment with off-loading and immobilization; however, treating painless, seemingly asymptomatic nonfracture injuries (bone bruise or bone marrow edema) with off-loading and immobilization has proven highly effective in preventing the Charcot foot. Whether pharmaceutical treatment has a role in terms of prevention or healing of osteoarticular destructions remains to be demonstrated.     

Participation and Life Satisfaction in Aged People with Spinal Cord Injury: Does Age at Onset Make a Difference?

Background:

Few studies have reported on outcomes in samples of elderly people with SCI and the impact of the age at onset of SCI is unclear.

Objective:

To study levels of participation and life satisfaction in individuals with SCI aged 65 years or older and to analyze differences in participation and life satisfaction scores between individuals injured before or after 50 years of age.

Methods:

This cross-sectional survey included 128 individuals with SCI who were at least 65 years old. Age at onset was dichotomized as <50 or ≥50 years of age. Participation was measured with the Frequency scale of the Utrecht Scale for Evaluation-Participation, and life satisfaction was measured with 5 items of the World Health Organization Quality of Life abbreviated form.

Results:

Participants who were injured before 50 years of age showed similar levels of functional status and numbers of secondary health conditions but higher participation and life satisfaction scores compared to participants injured at older age. In the multiple regression analysis of participation, lower current age, higher education, and having paraplegia were significant independent determinants of increased participation (explained variance, 25.7%). In the regression analysis of life satisfaction, lower age at onset and higher education were significant independent determinants of higher life satisfaction (explained variance, 15.3%).

Conclusion:

Lower age at onset was associated with better participation and life satisfaction. This study did not reveal indications for worsening participation or life satisfaction due to an accelerated aging effect in this sample of persons with SCI.Key words: aged, aging, quality of life, rehabilitation outcome, spinal cord injuriesAging in the population of individuals with spinal cord injury (SCI) has 2 aspects: the average age at onset of SCI is increasing and people with SCI live on average longer than half a century ago. Age at onset of traumatic SCI has risen from 28.7 years in the 1970s to 40 years in the United States during the 2005-2009 period.¹ In other countries, a bimodal distribution of age at onset of traumatic SCI has emerged in recent years.² In the Netherlands, the median age at first admission to the acute hospital after traumatic SCI has increased to 62 years in 2010.³ People who are older at injury are more often victims of falls and have nontraumatic, incomplete, and cervical SCI more often than individuals who are injured at a younger age.³-⁵ They are more vulnerable than younger people and are at greater risk of death shortly after the onset of SCI.⁶ If they survive the acute phase, they are less often referred to specialized rehabilitation hospitals.³ If referred to a specialized center, elderly people with SCI may gain a similar rate of functional improvement⁷; but because older patients generally have lower functional scores at admission, they also show worse rehabilitation outcomes compared to people who are injured at a younger age.^4,8–10The life expectancy of the population with SCI has grown over the last 50 to 60 years.¹¹ Many people with a new SCI can expect to live another 30 to 40 years or more. However, this life expectancy has not grown in recent decades and is still clearly below that of the general population.¹¹ People with SCI are at risk of “accelerated aging” due to an inactive lifestyle and a greater risk of obesity, chronic inflammation, pressure ulcers, and pulmonary infections.^1,12Participation and quality of life in aged persons with SCI are influenced by a complex interaction of many factors associated with current chronologic age, age at injury, duration of injury, and age cohort effects. It has been suggested that increasing age and being of older age at onset of SCI are independently associated with worse outcomes and that longer time after SCI is associated with better adjustment, whereas the impact of age cohort effects on adjustment is unknown.^1,13–15 However, research into the impact of these health-related changes on participation and life satisfaction of aged people living with SCI is sparse, and associations with aging are often studied in samples that are well below retirement age.¹⁵Only 2 longitudinal projects in aging people with SCI are available. Krause and Bozard¹⁶ described 35-year longitudinal data of 64 individuals with SCI (mean age, 61.5 years; mean time since SCI, 41.4 years). The participants rated their overall adjustment significantly higher at follow-up than they did at the first assessment 35 years before (8.4 and 7.6 on a 0–10 scale, respectively). The participants, however, showed decreases in satisfaction with social life and participation indicators (visits with others, outings).¹⁶ Charlifue and Gerhart¹⁷ found in a large sample of people with long-standing SCI (mean age, 59 years; time since onset of SCI, 36 years at follow-up) a small but significant decline in community reintegration over a period of 10 years. Life satisfaction, however, remained stable over this time period.¹⁷It is still unclear how people aging with SCI differ from people who acquire SCI in later life.¹⁸ Given the same age, the accelerated aging hypothesis predicts that people injured at a younger age will be worse off. However, the reverse – higher age at injury is an independent predictor of worse functional outcomes – has also been shown.¹⁰ We therefore used data from earlier research with the following objectives: (a) to describe the levels of participation and life satisfaction in individuals with SCI aged 65 years or older, and (b) to analyze differences in participation and life satisfaction between individuals injured before 50 years of age or at or after 50 years of age.