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Fecal stomal incontinence is a problem that continues to defy surgical treatment. Previous attempts to create continent stomas using dynamic myoplasty have had limited success due to denervation atrophy of the muscle flap used in the creation of the sphincter and because of muscle fatigue resulting from continuous electrical stimulation. To address the problem of denervation atrophy, a stomal sphincter was designed using the most caudal segment of the rectus abdominis muscle, preserving its intercostal innervation as well as its vascular supply. The purpose of the present study was to determine whether this rectus abdominis muscle island flap sphincter design could maintain stomal continence acutely. In this experiment, six dogs were used to create eight rectus abdominis island flap stoma sphincters around a segment of distal ileum. Initially, the intraluminal stomal pressures generated by the sphincter using different stimulation frequencies were determined. The ability of this stomal sphincter to generate continence at different intraluminal bowel pressures was then assessed. In all cases, the rectus abdominis muscle sphincter generated peak pressures well above those needed to maintain stomal continence (60 mmHg). In addition, each sphincter was able to maintain stomal continence at all intraluminal bowel pressures tested.
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PMID:Dynamic rectus abdominis muscle sphincter for stoma continence: an acute functional study in a dog model. 1121 64

Fecal incontinence is a socially incapacitating condition with associated high treatment costs. The most common cause of fecal incontinence is trauma during childbirth followed by surgical interventions. After unsuccessful conventional treatment, muscle transposition is the next treatment option. Two local muscles are used for this purpose: the gluteus and the gracilis muscles. With both muscles, long-term muscle contractions are difficult to maintain due to muscle fatigue. The gracilis muscle, however, is technically much easier to transfer and most activities of daily living and even sports are still possible. Experimental studies have shown that electrical stimulation of skeletal muscles can transform fatigue-prone muscles into fatigue-resistant muscles. In 1986, we started to perform graciloplasty procedures with intramuscular electrodes connected to an electrical stimulator. To date, 200 patients have been treated in our institution using dynamic graciloplasty. All patients had severe incontinence without control of liquid or solid feces, most of them had previously received unsuccessful treatment using other techniques. The mean age was 48 years, the average time that patients had been incontinent was 12.4 years, and the cause of incontinence were trauma (n = 99), congenital (n = 28), pudendopathy (n = 58), and low motor neurological lesions (n = 15). Of these patients, 76% were considered to have successful outcomes. Patients whose cause of incontinence was trauma or pudendopathy tended to respond better to this treatment than patients with anal atresia.
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PMID:Dynamic graciloplasty for fecal incontinence. 1174 53

Nurses provide health services to an increasing number of older adults in acute care settings. Acute care nurses are committed to giving patients the highest quality care while recognizing the importance of delivering care in a cost-effective manner. In this study, a unit-based, nurse-centered geriatric program is evaluated. The program is designed to enhance the knowledge and skill of staff nurses in providing care to elderly patients. Both quantitative and qualitative methods are used to assess geriatric resource nurses' (GRNs) influence on quality and cost outcomes of the elderly participants. Patients age 65 years and older were randomly selected from two general medical units of a major academic tertiary care center in the southeastern United States. Data were collected during an 18-month period in 1996 and 1997. A total of 129 participants provided data for quantitative analysis. A subset of 34 participants (17 from the unit where GRNs were on staff and 17 from a control unit) was interviewed about their experience during hospitalization. This information was analyzed for common themes and trends using appropriate qualitative techniques. Demographic variables and common measures of illness severity and complexity showed comparable patient populations on the two units. However, results of quantitative analyses indicated significant differences between groups on admission for several of the health status measures. Participants on the unit without GRNs were found to have more problems with pain, incontinence, and mobility. Administrative measures showed the number of patients readmitted to the hospital within 31 days of discharge and the length of stay associated with this initial readmission were significantly lower on the unit with GRNs. The use of vest-type physical restraints was also less frequent on this unit. Elderly patients in both groups indicated they have special needs related to normal aging changes and chronic illnesses, resulting in higher levels of fragility and decreased energy reserves. They identified specific functional areas for which help was needed. These include assistance with bathing, eating, sleeping, mobility, and elimination. Fewer participants on the intervention unit reported decline in activities of daily living (ADL) function during hospitalization than did control participants. Participants in both groups stressed the importance of nurses' demonstrating understanding and caring when working with older individuals.
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PMID:Measuring quality of care with an inpatient elderly population. The geriatric resource nurse model. 1191 60

Improvements in preventive and rehabilitative care have transformed many cases of Human Immunodeficiency Virus (HIV) from being an absolute fatal disease to a chronic, expensive illness. As survival rates and life expectancy increase for people with HIV/AIDS, work plays a more central role in improving their quality of life [5]. Persons with HIV/AIDS face numerous physical challenges in maintaining employment. Signs and symptoms of HIV infection and related opportunistic infections include fatigue, muscle weakness, neuropathy and decreased sensation, bowel and bladder incontinence, persistent cough, weight loss, decreased range of motion and coordination, limited endurance, cardiac problems and vision loss. Occupational therapy practitioners must identify the unique impact they can make on a client's quality of life by addressing work-related issues faced by the HIV/AIDS population.
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PMID:HIV/AIDS and work: The implications for occupational therapy. 1244 56

We report on the clinical, morphologic, immunohistochemical, ultrastructural, and molecular cytogenetic features of a primitive neuroectodermal tumor (PNET) primarily arising in the urinary bladder. An 81-year-old man presented with lymphedema of the lower extremities, fatigue, and urge incontinence. Radiographically, a tumor filling the entire cavity of the urinary bladder and extending into the pelvic and retroperitoneal tissue was noted. Histology of tumor biopsies showed a highly cellular, focally necrotic small round-cell tumor with numerous mitoses and occasional rosette-like structures. The tumor cells displayed significant immunoreactivity for neuron-specific enolase (NSE) and the MIC2 gene product (CD99). Dense-core granules were detectable by electron microscopy. A molecular cytogenetic analysis using comparative genomic hybridization (CGH) revealed gains of the chromosomes 3p, 6, 8q, 12, 17q, and 21q. The patient died two weeks after diagnosis. To the best of our knowledge, this is the fifth reported case of a PNET of the urinary bladder, and the first that includes a molecular cytogenetic analysis based on CGH.
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PMID:Primitive neuroectodermal tumor (PNET) of the urinary bladder. 1470 42

In August 2002, 65 cases of Loa-associated neurological Serious Adverse Events were reported after ivermectin treatment. The first signs, occurring within the 12-24 hours following treatment, included fatigue, generalized arthralgia, and sometimes agitation, mutism, and incontinence. Disorders of consciousness, including coma, generally appeared between 24 and 72 hours, and showed a rapid variation with time. The most frequent objective neurological signs were extrapyramidal. The patients presented with haemorrhages of the conjunctiva and of the retina. Biological examinations showed a massive Loa microfilaruria, the passage of Loa microfilariae into the cerebrospinal fluid, haematuria, and an increase in the C-reactive protein, all of which have been correlated with the high intensity of the initial Loa microfilaraemia. Eosinophil counts decreased dramatically within the first 24 hours, and then rose again rapidly. Electroencephalograms suggested the existence of a diffuse pathological process within the first weeks; the abnormalities disappearing after 3-6 months. Death may occur when patients are not properly managed, i.e. in the absence of good nursing. However, some patients who recovered showed sequelae such as aphasia, episodic amnesia, or extrapyramidal signs. The main risk factor for these encephalopathies is the intensity of the initial Loa microfilaraemia. The disorders of consciousness may occur when there are >50,000 Loa microfilariae per ml. The possible roles of co-factors, such as Loa strains, genetic predisposition of individuals, co-infestations with other parasites, or alcohol consumption, seem to be minor but they should be considered. The mechanisms of the post-ivermectin Loa-related encephalopathies should be investigated to improve the management of patients developing the condition.
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PMID:Clinical picture, epidemiology and outcome of Loa-associated serious adverse events related to mass ivermectin treatment of onchocerciasis in Cameroon. 1497 61

Multiple sclerosis (MS) is a chronic disease affecting young adults. The presence of the sometimes-invisible symptoms (loss of vision, fatigue, incontinence) and the episodic nature and uncertainty of symptoms can create a constant sense of vigilance or support the use of denial. Indeed, family, friends, and even nursing support may be elusive, leaving one feeling lonely, frightened, and insecure. The purposes of this research were to investigate the lived experiences of people with MS and examine their needs from their perspectives. Two focus groups included 4 men diagnosed with MS from 2 to 15 years and 6 women diagnosed with MS from 1.5 to 15 years. Four themes were identified. The first theme resonated around feelings that "nobody listened." The second theme, symptom devastation, described the overwhelming presence of symptoms and the difficulty they caused. The third theme was "picking and choosing," or making choices to maintain some control. "Fight your own fight" with self-advocacy and taking charge was the final theme. Even though MS continuously caused challenges and changes interfering with goals, participants described creative solutions. They learned to deal with the denial, refocus their priorities, plan their activities, and choose carefully. They described a litany of being unheard, unimportant, and confused, which led to feelings of dejection, desperation, and depression. Their most poignant need was someone to listen and teach since they identified knowledge as power. The data gathered contribute to knowledge and understanding of people living with MS. Findings support nursing interventions that empower and teach self-management techniques.
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PMID:Focus groups: the lived experience of participants with multiple sclerosis. 1499 6

The current standard of care for soft tissue sarcoma (STS) is limb salvage surgery and adjuvant radiotherapy, with long-term survival rates of approximately 70%. However, the extensive surgical resection and subsequent reconstruction result in 50% of survivors living with chronic disability. Rehabilitation aims to optimize functional independence and quality of life, and is routinely offered to patients undergoing surgical treatment for STS. Unfortunately, there is a dearth of research related to rehabilitation in this area. We propose a model for assessing disability, for designing treatment interventions and for evaluating rehabilitative outcomes in STS. The World Health Organization's (WHO) international classification of functioning, disability, and health (ICF) is divided into three domains: 1) impairments (related to body structure and function), 2) activity limitations (related to usual self-care activities/activities of daily living), and 3) participation restrictions (related to social roles). A literature review of STS rehabilitation reveals that most studies have focused on disability assessment, with few papers describing or evaluating rehabilitation interventions commonly employed in STS. Clinicians are forced to extrapolate findings from other patient populations in order to evaluate the effectiveness of specific rehabilitation strategies (ie, those used for particular sequelae of STS, such as lymphedema or impaired exercise tolerance). There is strongest support for complex decongestive physiotherapy (targeting lymphedema) and aerobic exercise interventions (aimed at alleviating cancer-related fatigue and psychosocial sequelae). The most poorly researched topic is rehabilitation for genitourinary disability (both incontinence and sexual dysfunction). Most studies related to oncologic rehabilitation are restricted to the impairment level (eg, affecting range of motion, muscle strength) of the ICF, with only a small minority addressing activity limitations (eg, affecting activities of daily living) experienced by patients. A consideration of participation restrictions (eg, fulfillment of vocational roles) is almost wholly absent from the literature. Yet social role reintegration is of fundamental importance to patients. Further research is required in these two domains. The ICF provides a comprehensive framework for future research into rehabilitation interventions for STS.
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PMID:Rehabilitation and quality-of-life issues in patients with extremity soft tissue sarcoma. 1550 81

Although the expected mean age of women increased significantly in the 20th century, the time of menopause has not changed (age of 50-51 years). Women's life span in Hungary is 77.2 years, which means, that one third of their lives is lived in menopause. Aging and the consequent lack of estrogen means a more and more serious problem on social level as well. In Hungary there are approximately 1.8 million women above the age of 50. Only an insignificant part of them is treated, which is about 5%, compared to other European countries, where this ratio is between 5 and 25%. Menopause-related symptoms can be divided into the following groups: vasomotor symptoms (sweating, hot flashes, palpitation), decreased psychic and physical functions (fatigue, depression, panic disease, cognitive problems, decreased libido), cardiovascular diseases (ischaemic heart disease), endometrial atrophy, bone and articular alterations (osteoporosis) and urogenital symptoms (vaginal dryness, incontinence, cystitis). The most frequent symptom is hot flashes, which is characteristic of more than 60% of women in menopause. Osteoporosis after the cardiovascular diseases is the second most serious problem on public health level. Approximately 9% of the Hungarian population suffers from osteoporotic problems, which concretely means 600.000 women and 300.000 men. The most frequent fractures are the hip and vertebral fractures. In 1999, 15.100 hip and 51.000 peripheric fractures occurred in Hungary. The above mentioned symptoms, even separately, may decrease the quality of life, therefore their treatment and the knowledge of all of the therapeutic possibilities are essential.
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PMID:[Treatment of menopausal symptoms--review of the current literature]. 1678 43

A significant proportion of stroke survivors suffer from persistent and significant fatigue which is linked to reduced independence and case fatality. Despite its high prevalence and detrimental effects, studies of post-stroke fatigue (PSF) interventions are scarce. Only one randomised controlled trial of post-stroke fatigue treatment (i.e. fluoxetine) was identified, and though improving post-stroke emotional incontinence and depression in patients with fatigue this did not improve PSF itself. Despite there being no literature on its efficacy, patient and family education/counselling has been identified as an important rehabilitation intervention for the management of stroke-related fatigue, which has been found effective in other patient groups (i.e. cancer, multiple sclerosis, and those with traumatic brain injury). Factors contributing to the lack of evidence for PSF management are identified and it is concluded that there is a need to better differentiate those most likely to suffer PSF, to validate existing assessments of fatigue, and to evaluate the efficacy of fatigue management and treatment strategies in stroke survivors.
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PMID:Post stroke fatigue--where is the evidence to guide practice? 1797 87


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