Biomedical subjects
Publications and source records attributed to M Azaria.
A case report is used as an example of how the will of a patient convinced an entire rehabilitation team to alter its assessment of the patient's ambulatory potential. The question of dual dynamics is discussed in the light of the realities of the honest desire and motivation to walk and regain independence.
A 58-year-old woman presented at a disability assessment tribunal with a severely deformed left forearm. She had broken the arm 25 years previously and the infected open fracture had not healed. There were no sensory or motor functions in the hand, which the patient kept constantly hidden in her garments. The question of an amputation was raised and the advantages of modern prosthetics with respect to cosmesis and function failed to convince the patient that she might benefit from such surgery. One questions why a patient should want to retain this cumbersome, obviously embarrassing, burden and whether the question of surgery should have been raised.
OBJECTIVES: To assess the usage of carbon fibre orthoses in assisting post-polio syndrome patients who reported advancing weakness and difficulty in maintaining their independent ambulatory status. DESIGN AND INTERVENTIONS: Carbon fibre orthoses that are 30% lighter than metal braces were constructed. SUBJECTS: Thirty patients who complained of difficulty in maintaining their ambulation using long-leg braces were provided with lightweight orthoses. RESULTS: Seventy per cent of the patients reported satisfaction with their braces. There were, however, problems in construction and use. CONCLUSIONS: Ambulation can be preserved in some patients who report advancing weakness because of post-polio syndrome.
The use of silicone inner sockets, with or without the incorporation of shuttle locks, has greatly improved the function of artificial limbs. They cushion and protect the stump and provide a means for prosthetic suspension, allowing more comfortable use, especially in patients with ischaemic stumps. They also allow greater movement at the proximal joint.
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Overstimulation of sympathetic nervous system activity is related to atherosclerotic cardiovascular disease risk, but the role of parasympathetic activity in this association is not clear. This study evaluated sympathetic and parasympathetic function by spectral analysis of heart rate variability and plasma levels of norepinephrine (NE) epinephrine (EPI), dihydroxyphenylglycol (DHPG), dihydroxyphenylalanine (DOPA) and dihydroxyphenylacetic acid (DOPAC). It also examined the interrelationships among these parameters and established atherosclerotic cardiovascular disease risk factors in 53 men (mean age 59.5 years). During supine rest, low-frequency power correlated positively with high-frequency power (r = 0.58, p < 0.001), plasma NE correlated with plasma DHPG (r = 0.41, p < 0.001) and plasma DOPA with DOPAC (r = 0.47, p < 0.001) but neither low- nor high-frequency power was correlated with plasma levels of any catechol. Among risk factors, plasma NE correlated with fasting insulin and mean arterial blood pressure, and urine NE correlated with body mass index. Both low- and high-frequency power correlated positively with insulin levels. Orthostasis decreased high-frequency power and increased low-frequency power and plasma NE levels. During the oral glucose tolerance test, both high- and low-frequency power increased, plasma NE levels were unchanged, and plasma EPI levels decreased [88.5 +/- 18 (SEM) versus 52.5 +/- 12 pM, p = 0.001]. The results suggest that orthostasis decreases and the oral glucose tolerance test increases parasympathetic outflows, whereas both stimuli increase sympathetic outflows. Among all atherosclerotic cardiovascular disease risk factors, hyperinsulinaemia showed the strongest association with autonomic nervous system activity, especially parasympathetic activity. Estimates of sympathetic responses obtained from power spectral analysis of heart rate variability agree poorly with those from plasma levels of catechols, possibly because of a parasympathetic contribution to low-frequency power and independence of sympathoneural outflows to the arm and heart.
This study examined plasma insulin response to oral glucose load and autonomic nervous system activity in male lower limb amputees (n = 52) aged 50-65 years, compared to matched controls (n = 53). The groups had similar body mass index, blood pressure and plasma lipid levels. The amputees had higher mean fasting plasma insulin levels (18.4 +/- 9.7 (SD) versus 13.7 +/- 5.1 mU/l, p = 0.005) and during an oral glucose tolerance test (OGTT) (1 h levels 88.1 +/- 45.3 versus 62.1 +/- 42.7, p = 0.016) with similar plasma glucose levels, indicating insulin resistance. At baseline with the subjects supine, there were no group differences in low- or high-frequency power of heart rate variability or in plasma levels of norepinephrine (NE) or epinephrine (EPI). In response to orthostasis, the groups had similarly increased plasma NE levels. During the OGTT, amputees had significantly larger increments in low-frequency power than did controls (2.2 +/- 1.3 versus 1.6 +/- 0.9 (beats/min)2 respectively, p < 0.01) and plasma NE levels increased significantly in amputees (1595 +/- 849 versus 1941 +/- 986 pM, p = 0.0008) but not in controls. At 1 h after glucose administration, plasma EPI levels were decreased significantly from baseline in both groups; at both 1 and 2 h after glucose administration, plasma EPI levels were higher in the amputees than controls. Amputees appear to have a combination of enhanced sympathoneural responsiveness and attenuated suppression of adrenomedullary secretion during glucose challenge. As catecholamines antagonize insulin effects, one possible explanation for insulin resistance in amputees is hyperglycaemia-induced sympathoneural activation and a failure of hyperglycaemia to decrease adrenomedullary secretion.
Pulmonary embolism is a major complication after spinal cord injury and difficult to diagnose in any patient. Supraventricular tachycardia (SVT) is an unusual presentation for pulmonary embolism (PE). This article documents the records of a 60-year-old patient who was undergoing comprehensive rehabilitation after traumatic spinal cord injury and multitrauma. His treatment programme was interrupted by a PE with SVT as the only presenting symptom. This article outlines the clinical approach to the diagnosis of pulmonary embolism. A high index of suspicion of PE should always be kept in mind when SVT occurs in a spinal cord injured patient.
Three patients with paraplegia following corrective surgery for idiopathic scoliosis, using the Cotrel-Dubousset (CD) instrumentation, were admitted to our department over a period of 22 months. They were operated on by three different surgeons and they were the first serious neurological complications in these surgeons' careers. The monitoring method was the "wake-up" test, applied at the end of the correction maneuver with the instrument. One patient presented paraplegia at the "wake-up" test and the other two were paraplegic shortly after ceasing anesthesia. Electrophysiological spinal cord monitoring during surgery may reduce the risks of complications.
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Twelve patients with reflex sympathetic dystrophy were referred to a comprehensive orthopaedic rehabilitation center after failure of conservative management. Ten underwent amputation of the affected limb and, although functional improvement occurred in the patients undergoing lower limb amputation, psychosocial dysfunction persisted. All the patients required psychological support. In cases of post-Sudeck amputation, early orthopaedic diagnosis and referral to a comprehensive treatment center are recommended. In the 12 cases described here, apart from the obvious limb pathology, severe psychological inadequacies were found to be present.
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We have had the opportunity to treat and follow up two young males with cauda equina syndromes after recurrent resection of intraspinal lipomas. This condition is relatively rare. The patients underwent myelographies, operations, long periods of hospitalisation, and rehabilitation. The syndromes included low back pain, arachnoiditis, and recurrence of the lipoma after several years and multiple operations. These are the problems that we were faced with: (1) Although the tumor is benign it is impossible to resect it completely. (2) There are complications which interfere with rehabilitation, including pain, arachnoiditis, and neurological deterioration. (3) Long term prognosis might be grave and the patient and family should know this. (4) Physiotherapy and sports: should these patients perform strenuous exercise or not?