Carcinoid tumor mistaken for persistent neurogenic bowel symptoms in a patient with paraplegia: a case report.

Neurogenic bowel in spinal cord injury (SCI) can present with constipation and diarrhea as ongoing problems. Usually, these manifestations are adequately controlled with modification in the bowel program. When these symptoms persist, other causes should be considered. This case report describes a jejunal carcinoid tumor with colonic extension that was diagnosed in a paraplegic patient with persistent constipation and diarrhea. A 39-year-old man sustained a T1 paraplegia with neurogenic bowel and bladder dysfunction from a gunshot wound. His bowels were initially managed adequately with digital disimpaction. Over the next 8 years, he had intermittent constipation that was managed with the addition of various suppositories. He then developed progressively worsening constipation, and other gastrointestinal (GI) symptoms. Although his symptoms initially resolved with medical management, the constipation worsened. Upper endoscopy revealed a submucosal bulge in the duodenal bulb. A month later, gallstones were found on renal ultrasound performed to evaluate recurrent urinary tract infections. He underwent cholecystectomy, but his GI symptoms persisted over the next several months. Repeat upper endoscopy subsequently revealed an ulcerated tumor at the duodenojejunal flexure. An upper-GI scan with small bowel follow through showed a proximal jejunal mass. The patient underwent laparotomy with resection of the mass. Final pathologic diagnosis was malignant carcinoid tumor. This case shows the importance of entertaining other clinical entities in patients with SCI when constipation and diarrhea persist despite adequate management.

Heterotopic ossification as a complication of toxic epidermal necrolysis.

The development of heterotopic ossification (HO) as a complication of toxic epidermal necrolysis (TEN) has not been previously reported. TEN, also known as Lyell's syndrome, is a rare but serious skin disorder that typically occurs after the administration of drugs, especially sulfonamides, barbiturates, phenytoin, and nonsteroidal anti-inflammatory agents. TEN is characterized by the development of large fluid-filled bullae with separation of large sheets of skin. Complications of TEN can include extensive denudation of skin with dehydration and electrolyte abnormalities, gastrointestinal hemorrhage, acute tubular necrosis, secondary infection of denuded skin, pneumonia, bacterial conjunctivitis, keratitis, and septic infarcts of internal organs. We report a case of HO in a patient with TEN after treatment with trimethoprim-sulfamethoxazole. A 49-year-old man developed an erythematous rash, bullae, fever, and extensive skin loss consistent with a diagnosis of TEN. He was intubated for complications of TEN (pneumonia) and maintained on bed rest for several weeks. In addition, he developed HO that resulted in multiple joint contractures. He was treated with aggressive range of motion by physical therapy, surgical resection of the HO followed by radiation to both elbows, right hip, and right knee. Postoperative outpatient rehabilitation enabled improved function in his mobility and activities of daily living. HO is known to occur after spinal cord and brain injuries and burns. It has not been reported to occur after TEN. Our experience with this case suggests that HO may merit inclusion into the list of complications of TEN.

Inpatient rehabilitation: the correlation between functional gains and appropriateness of admissions.

All admissions to an acute rehabilitation unit were later critiqued by the rehabilitation team to determine appropriateness of admissions. The physiatrist alone evaluated the patient for admission. From the team which worked with the patient, a physical therapist, occupational therapist and a nurse were asked to evaluate the appropriateness of the admission; a decision on appropriateness had to be supported by at least two of these three. The team scored patients with the Functional Independence Measure (FIM) on admission, weekly, and at discharge. In a six-month period there were 60 appropriate admissions and ten inappropriate admissions. The average length of stay was 38.3 days for appropriate and 17.3 days for inappropriate admissions. The appropriate gorup had an average initial FIM score of 40.6 and discharge score of 66.6. The inappropriate group started with high FIM scores, with an average of 61.0, and did not significantly improve their scores. Their average discharge score was 70.0. The rate of progress (efficiency ratio), in points per day, was 0.81 for the appropriate and 0.36 for the inappropriate group. Thus, there is a strong positive correlation between the rate of progress and appropriateness as assessed at discharge by the multidisciplinary team [corrected].

Inpatient rehabilitation: physiatric and nurse practitioner admission assessment of stroke patients and their rehabilitation outcomes.

The purpose of this study was to compare outcomes in stroke patients with two different methods of admission to an inpatient unit. Patients' outcomes were studied for 3 years. Admission screening was performed either by a physiatrist (group I, n = 93) or by a nurse practitioner (group II, n = 100). All admission decisions were made solely by the physiatrist. The outcome measures used were appropriateness of admission, discharge to home versus nursing home and functional gains measured on the Functional Independence Measure. The average length of stay was 28 days for group 1 patients and 29 days for group II. Ninety-seven per cent of group I and 94% of group II patients were considered appropriate for admission. The difference is not statistically significant (Z = 1.02). Ninety-six per cent of patients in each group were discharged home. Ninety-six per cent of group I and 89% of group II patients met the functional goals. Group I fared better than group II, and the difference between the groups (Z = 1.85) is statistically significant at p < 0.04.

Predicting discharge functional status and rehabilitation efficiency from preadmission functional assessments.

Various indicators have been used to predict functional change and outcome in stroke rehabilitation. One previous study indicated that functional assessments performed prior to rehabilitation admission correlated well with functional status at discharge and also were indicative of rehabilitation efficiency scores. The present study attempted to replicate these findings in a study of 14 additional stroke patients admitted to an inpatient unit; data collection on additional patients is ongoing. Patients' weekly Functional Independence Measure (FIM) scores were assessed, together with their preadmission FIM score (PFM) and other clinical data. As in the previous study, PFM scores correlated well with functional ratings made by the team following admission (r = 0.78), and with discharge FIM scores (r = 0.68). Patients with PFM scores of 30 or less had much lower rehabilitation efficiency ratios (0.62) than those with PFM scores greater than 30 (0.97). Finally, in a multiple regression equation with discharge functional status as the dependent variable, PFM scores accounted for almost as much of the variance (47%) as FIM scores obtained during the first week of admission (63%). Overall, the results obtained were remarkably consistent with the previous study cited. The current results imply that the use of preadmission functional ratings may be a valid and useful way to predict functional change and efficiency of inpatient rehabilitation admission.

Shoulder pain in stroke patients and its effects on rehabilitation.

The purpose of this study was to examine whether prompt diagnosis and management of shoulder pain is beneficial in decreasing pain and increasing range of motion and functional recovery. Among 116 stroke patients receiving outpatient rehabilitation, 48 had shoulder pain. Twenty-eight of the patients with shoulder pain received occupational therapy and physiatric management. Five of the 28 patients had specific diagnoses. Etiology of the pain in the remaining 23 patients (Group 1) was not known, and these patients were treated with nonsteroidal antiinflammatory drugs (NSAIDs). The remaining 20 (Group 2) received only occupational therapy and were used as the control group. Pain relief, range of motion (ROM) in flexion, and abduction and functional recovery were compared in the two groups. Results show that a significantly higher percentage of Group 1 was found to have pain relief; 91% versus 15% with p < 0.00001 for the difference. A significant number of patients improved ROM for flexion and abduction in Group 1 versus Group 2 (p < 0.006 and p < 0.055 for the difference for flexion and abduction, respectively). Functional recovery was highly significant for Group 1,100% compared to 55% for Group 2, with p < 0.0001 for the difference. These results emphasize the importance of management of shoulder pain with NSAIDs along with ROM exercises for successful rehabilitation of hemiplegic patients.

Multiple sclerosis masquerading as a mass lesion.

Six patients presenting with new neurological deficits underwent magnetic resonance imaging (MRI) that displayed mass lesions leading to diagnoses of tumor or abscess. Biopsy revealed demyelinating lesions.