Psychological status and role of caregivers in the neuro-rehabilitation of patients with severe Acquired Brain Injury (ABI).

OBJECTIVE: To investigate the relationships between (a) the psychological status of the caregiver, (b) the specific features of caregiving as perceived by the cognitive therapist in neuro-rehabilitation, (c) the caregivers' subjective approach to neuro-rehabilitation, and (d) the functional outcome of the patient. METHODS: Twenty-four patients with severe acquired brain injury and their 24 caregivers participated in this observational study. Caregivers underwent a psychological assessment examining emotional distress, burden and family strain; their subjective approach to neuro-rehabilitation has been evaluated by two specific answers. The patients' cognitive therapists responded to an ad-hoc questionnaire, namely the "Caregiving Impact on Neuro-Rehabilitation Scale" (CINRS), evaluating the features (i.e., amount and quality) of caregiving. Finally, the functional outcome of the patient was assessed through standardized scales of disability and cognitive functioning. RESULTS: The caregivers' psychological well-being was associated to the features of caregiving, to the subjective approach to neuro-rehabilitation, and to the functional recovery of their loved ones. A better caregivers' approach to neuro-rehabilitation was also associated to an overall positive impact of caregiving in neuro-rehabilitation and to a better functional outcome of the patients. CONCLUSIONS: We posited a virtuous circle involving caregivers within the neuro-rehabilitation process, according to which the caregivers' psychological well-being could be strictly associated to a better level of caregiving and to a better functional outcome of the patients that, in turn, could positively influence the caregivers' psychological well-being. Although preliminary, these results suggest a specific psycho-educational intervention, aimed at improving the caregivers' psychological well-being and at facilitating their caring of the loved one.

Spontaneous plasma exchange by gravity.

Lysagth et al have reported a semplified model of spontaneous plasmapheresis by placing between an A-V shunt a conventional plasmafilter. On the basis of this experience we tried to make a further semplification of this apparatus using a single venous puncture, obtaining by gravity sufficient transmembrane pressure for plasma separation. By alternatively lowering and elevating the system, plasma is separated from the blood and packed red cells are reinfused after a new pass through the filter with FFP or plasma substitutes.

Restoration of ultrafiltration capacity of peritoneal membrane in patients on CAPD.

Among 55 uremic patients who entered our CAPD program, 7 of them showed a reduction or loss of the ultrafiltration capacity (UF) of the peritoneal membrane (PM). They have been treated with high dose of Furosemide (F) to force residual urine output. Four appeared "responders" to drug administration with a significant increase in urine volume, Na excretion and, within a week period gained their dry body weight (BW). In the remaining 3 patients drug therapy resulted ineffective, and fluid removal was obtained by hemofiltration (HF). In both groups we noted an increase in the UF capacity of PM when their dry BW was obtained either by pharmacological or technical approach. These results support the assumption that the over-hydration status of the PM plays a major role in maintaining the UF process.

Cold as cardiovascular stabilizing factor in hemodialysis: hemodynamic evaluation.

Vascular instability represents the most frequent intradialytic complication of uremic patients. Catecholamine impairment, changes in plasma sodium or osmolality and, more recently, temperature (T) of dialysate have been proposed to explain this phenomenon. In order to evaluate the role of T in hemodynamic stability, we studied the effect of cooling dialysate in 5 patients (3 m, 2 f), who often experienced hypotension during dialytic sessions. Dialysate T was lowered, leading to a body T decrease of 1.5 degrees C, measured by a thermistor in the pulmonary artery. Ultrafiltration was kept constant during both "warm" (W) and "cold" (C) hemodialysis (HD). Systemic and pulmonary hemodynamic parameters were studied by thermodilution technique. The evaluation was performed in the same patients during W-HD and C-HD with the same dialysate composition. MAP showed a significant reduction during the first hour under both dialysis conditions. Subsequently a further decrease of MAP was observed in W-HD, while it remained stable in C-HD. CI and SI demonstrated similar trends, whereas HR showed no major changes. TPRI appeared significantly higher during C-HD compared to W-HD, with no clinical symptoms of hypotension. Similarly pulmonary parameters resulted in a better cardiovascular stability during C-HD. Our hemodynamic study confirms the important role played by T on intradialytic vascular stability and may explain the better control observed during hemofiltration compared to standard W-HD.

A new technique of continuous ambulatory peritoneal dialysis (CAPD): double-bag system for freedom to the patient and significant reduction of peritonitis.

A new technical approach has been described for the treatment of patients on CAPD. The new approach is based on the use of a two-bag system and closed connection by a connector to the Tenckhoff catheter. After each dialyzate exchange the patient discards the entire system and is completely bag-free, unlike the Oreopoulos CAPD technique. Using this new procedure we have markedly reduced the incidence of peritonitis and we have made the patient free from carrying an uncomfortable burden during the interval of solution exchange.

Continuous ambulatory peritoneal dialysis without wearing a bag: complete freedom of patient and significant reduction of peritonitis.

Despite the great impact of continuous ambulatory peritoneal dialysis (CAPD) as an effective modality of treatment for uraemic patients, two limiting factors remain: the high incidence of peritonitis and the need for patients continuously to carry a bag. We have designed a new closed system with two bags connected to the permanent Tenckhoff catheter. Two clamps alternately allow outflow and inflow of peritoneal dialysate. When the exchange manoeuvre is finished the patient frees the whole system from the needle and discards it. Since December 1978, 24 patients have been treated with this technique. The results are similar to the Toronto series with a marked reduction in the incidence of peritonitis (22.5 pt/months).