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Biomedical subjects

S A Yablon

Publications and source records attributed to S A Yablon.

18 recordsLinked to original sources
PubMed2001

Conceptual dilemmas in evaluating individuals with severely impaired consciousness.

States of severely impaired consciousness (SIC) are characterized by cognitive and motor limitations. This case report describes a 45-year-old female with impaired consciousness who began to 'walk'. She initially presented to the hospital unresponsive and was subsequently diagnosed with metabolic encephalopathy due to severe hypoglycaemia. Traditional indices of consciousness indicated a low level of responsiveness; however, during physical therapy, she displayed reciprocal walking movements when lifted to a standing position by two therapists. Despite her ability to walk increased distances during and after neurorehabilitation, she was unable to consistently demonstrate responses indicative of higher levels of consciousness. This case illustrates the challenge of rating patients with limited behavioural repertoire using established measures of impaired consciousness.

Brain Diseases, Metabolic↗
PubMed2001

Hypodipsic hypernatremia and diabetes insipidus following anterior communicating artery aneurysm clipping: diagnostic and therapeutic challenges in the amnestic rehabilitation patient.

Hypodipsic hypernatremia (HH) represents a pathological increase in serum sodium due to a lack of thirst and defect in hypothalamic osmoreceptors. While 15% of patients with HH have a vascular aetiology, few cases have been described. Moreover, the presence of such abnormalities in the amnestic patient can have particularly threatening implications, as HH tends to recur unless the patient complies with a regimen of water intake. This study reports the case of a 46-year-old male admitted for rehabilitation of functional deficits following subarachnoid haemorrhage (SAH), with clipping of an anterior communicating artery (ACoA) aneurysm. Clinical examination was remarkable for profound short-term memory loss and inability to retain new information. Blood chemistry on admission showed a serum sodium level of 160 mEq/L, increasing to 167 mEq/L the following day. The patient denied thirst, and showed no clinical signs of dehydration. Neuroendocrine evaluation revealed diabetes insipidus (DI) and HH. Treatment initially included DDAVP and intravenous hydration, later supplemented with chlorpropramide. Stabilization of serum sodium and osmolality did not ensue until the treatment regimen included hydrochlorothiazide and supervision of enforced fluid intake. Endocrine abnormalities may be encountered among patients with vascular lesions adjacent to the hypothalamus. Rehabilitation interventions include establishing a structured medication regimen with fluid administration in the amnestic patient with hypothalamic dysfunction.

Amnesia, Anterograde↗
PubMed2001

Botulinum neurotoxin intramuscular chemodenervation. Role in the management of spastic hypertonia and related motor disorders.

There is a range of interventions available in the management of spastic hypertonia among patients with central nervous system injury. Many of these treatment options can be used concurrently with great effectiveness. Although manifestations of spastic hypertonia vary from patient to patient, they usually are not limited to one site. Nevertheless, problematic spastic muscle overactivity may be localized to one or more specific extremities, and these may be referred to as examples of focal dysfunctional spasticity. Botulinum neurotoxin (BTX) intramuscular chemodenervation procedures are an important therapeutic technique in focal spasticity management. Magnitude and duration of response varies with successful selection and localization of targeted muscles, spasticity severity, BTX dosage, and chosen functional goals. In focal dysfunctional spasticity and related motor disorders, BTX injections have demonstrated efficacy and safety when performed by clinicians familiar with the agent, regional anatomy, the specific condition, and patient being treated.

Anti-Dyskinesia Agents↗
PubMed1999

Antiepileptic drugs.

Antiepileptics are a very important class of medications, and the number of these drugs available for clinical use has increased dramatically in the last decade. The pharmacology and indications for use in a variety of physiatric patient groups are comprehensively and systematically reviewed.

Anticonvulsants↗
PubMed1997

Incidence and sequelae of symptomatic venous thromboembolic disease among patients with traumatic brain injury.

Venous thromboembolism (VTE) is a potentially life-threatening complication among patients with traumatic brain injury (TBI). However, few reports describe the incidence of this important disease. We reviewed the incidence of symptomatic VTE among 124 consecutive admissions with TBI to a free-standing rehabilitation hospital over an 18-month period. Four patients manifested evidence of VTE within 2 months of injury: two with leg swelling, one with an oedematous arm, and one with respiratory distress. None of the patients with suspected VTE received prophylactic anticoagulant therapy. Diagnosis of VTE was confirmed with venograph in two of the four patients. Although VTE is frequently asymptomatic, the incidence of symptomatic VTE (1.6%) among this series of rehabilitation inpatients with TBI still appears surprisingly low. These results have implications regarding the utility of non-invasive diagnostic screening of asymptomatic VTE and routine anticoagulant prophylaxis of high-risk patients with TBI.

Activities of Daily Living↗
PubMed1997

A clinical overview of treatment decisions in the management of spasticity.

Spasticity from an upper motor neuron syndrome may cause a variety of symptoms that interfere with function. Decisions regarding spasticity treatment are influenced by the chronicity, severity, and distribution of the spasticity; the locus of injury; the presence and severity of co-morbidities; the availability of support; and the goals of treatment. Not all spasticity can or even should be treated; tone reduction is indicated only if spasticity interferes with some level of function, positioning, care, or comfort. Treatment goals should be well outlined before treatment begins. Botulinum toxin may be used to treat focal spasticity as part of an overall treatment plan.

Adult↗
PubMed1996

Subacute methylphenidate treatment for moderate to moderately severe traumatic brain injury: a preliminary double-blind placebo-controlled study.

OBJECTIVE: To determine the effect of subacute administration of methylphenidate on recovery from moderate to moderately severe closed head injury. DESIGN: Double-blind placebo-controlled with random assignment. Patients were enrolled when their Galveston Orientation and Amnesia Test score was at least 65. Drug/placebo treatment began the day following baseline cognitive assessment and continued for 30 consecutive days. Follow-up evaluations were conducted at 30 and 90 days after baseline, after discontinuation of drug/placebo. SETTING: A level I trauma center. PATIENTS: Twenty-three patients ranging in age from 16 to 64 years. Head injury severity ranged from moderately severe (Glasgow Coma Score [GCS] < or = 8, no intracranial pressure monitor) to "complicated mild" (GCS from 13 to 15 with positive computed tomography brain scan). Thirty-day follow-up was based on 12 patients, whereas 90-day evaluation was based on 9 patients, with complicated mild head injuries excluded from the analyses. INTERVENTIONS: Methylphenidate administered twice daily at a dose of .30 mg/kg; placebo administered according to the same schedule in identical pill form. MAIN OUTCOME MEASURES: The Disability Rating Scale (DRS) and tests of attention, memory, and vigilance. RESULTS: The methylphenidate group was significantly better at 30 days on the DRS (p < .02), and on tests of attention (p < .03) and motor performance (p, .05). No significant differences were noted between groups at 90 days. CONCLUSIONS: Subacute administration of methylphenidate after moderately severe head injury appeared to enhance the rate but not the ultimate level of recovery as measured by the DRS and tests of vigilance. Problems with possible selection bias and small sample size limit generalization of results.

Adolescent↗
PubMed1996

Botulinum toxin in severe upper extremity spasticity among patients with traumatic brain injury: an open-labeled trial.

We studied the effect of botulinum toxin A (BTXA) among patients with traumatic brain injury (TBI) and severe spasticity unresponsive to conservative management. Twenty-one consecutive adult patients with severe spasticity involving the wrist and finger flexor musculature were treated with BTXA injection (20 to 40 units per muscle) under EMG guidance. After injection, patients received passive range of motion (ROM) exercise, with modalities and casting as clinically indicated. Outcome measures, including wrist ROM and the modified Ashworth Scale (MAS), were assessed 2 to 4 weeks after injection. Among the respective acute and chronic groups, mean ROM improved 42.9 (p = 0.001) and 36.2 degrees (p < 0.001). Mean MAS rating improved 1.5 (p = 0.01) and 1.47 (p = 0.002) points. There were no significant adverse effects. BTXA, in conjunction with conventional modalities, significantly improves spasticity and ROM in the distal upper extremity musculature of patients with TBI.

Adult↗
PubMed1996

Akathisia resulting from traumatic brain injury.

Restlessness and agitation are commonly reported early sequelae of traumatic brain injury (TBI). Severe restlessness (akathisia) is also observed in psychiatric patients as a result of the use of dopamine receptor blocking agents. A recent case study described akathisia in a patient with bilateral orbitofrontal lesions following TBI. We report a case of unusually marked motor restlessness (akathisia) following TBI in a 17-year-old woman. When admitted for rehabilitation she was alert but agitated, severely restless, and mute. She constantly paced her room and the hospital unit, repeatedly retracing the same route. MRI scan revealed large, well-delineated bifrontal contusions. During baseline evaluation prior to anticipated psychopharmacological intervention her restlessness began to resolve rapidly. She became verbal and oriented within expected limits without medication. This case lends support to the observation that akathisia is related to lesions of the prefrontal cortex.

Activities of Daily Living↗
PubMed1993

Effect of transdermal clonidine on spinal spasticity. A case series.

Clonidine, a centrally acting alpha 2 receptor adrenergic agonist, has been successfully used as adjunctive therapy in patients with spinal cord injury with problematic spasticity not adequately controlled by recognized spasmolytic agents. A transdermal system providing approximately constant and continuous systemic delivery of clonidine has been recently introduced to enhance patient compliance. However, experience with transdermal clonidine in the management of spasticity is limited. Three cases are presented of patients with spasticity as the result of cervical spinal cord injury, inadequately managed by oral baclofen, in whom transdermal clonidine was administered. Significant improvement in spastic hypertonia was observed in all three cases. Transdermally delivered clonidine was well tolerated, with reported side effects limited to dryness of the mouth.

Administration, Cutaneous↗
PubMed1993

Clostridium difficile-related disease: evaluation and prevalence among inpatients with diarrhea in two freestanding rehabilitation hospitals.

Clostridium difficile has been associated with diarrhea in hospitalized patients receiving antibiotic therapy, and may be nosocomially acquired. Rehabilitation hospital inpatients may require frequent antibiotic intervention and are thus at risk, though few reports of epidemics at such centers have been published. This study describes the evaluation and prevalence of C difficile-related disease, among rehabilitation hospital inpatients. A retrospective review was conducted of all diarrhea evaluations performed among inpatients in two freestanding rehabilitation hospitals over a two-year period. A total of 303 laboratory tests were performed among the 115 patients evaluated. C difficile was determined to be the etiologic agent of diarrhea in 25% of patients undergoing enteric evaluation, and in 39% of patients specifically assayed for C difficile toxin B. Giardiasis was detected in one patient, and no evidence of Salmonella, Shigella, Campylobacter, or Yersinia infection was found. The estimated prevalences for diarrhea and C difficile-related disease were 3.7% and 1.1%, respectively. Thus, C difficile is an important cause of diarrhea among rehabilitation hospital inpatients, though its true prevalence may be underestimated due to inadequate diagnostic evaluation. Enteric bacterial pathogens such as Campylobacter, Salmonella, Shigella, Yersinia, and Giardia are insignificant causes of diarrhea among these patients. Elimination of routine testing for these pathogens would reduce costs without compromising diagnostic utility. Diagnostic evaluation should include C difficile toxin assay, and if positive, appropriate therapy instituted.

Adolescent↗
PubMed1993

Posttraumatic seizures.

Posttraumatic seizures (PTS) are an important complication of head injury, and their management is frequently a central pharmacologic consideration in patients recovering from these injuries. A comprehensive review of the literature regarding posttraumatic seizures over the past 50 years is presented, addressing incidence, natural history, and characteristics predictive of their appearance. Treatment issues regarding anticonvulsant prophylaxis and symptomatic management are also discussed. Emphasis is directed towards addressing issues related to prophylaxis of PTS in the adult patient with severe head injury, particularly those encountered in the rehabilitation setting.

Anticonvulsants↗
PubMed1992

Electrodiagnostic characteristics of Wegener's granulomatosis-associated peripheral neuropathy.

Wegener's granulomatosis is a multisystem disease distinguished by a triad of necrotizing granulomatous vasculitis involving the upper and lower respiratory tracts, glomerulonephritis and systemic, small vessel vasculitis. The latter can cause neurologic manifestations when the vasa nervorum are affected. A 53-yr-old male presented with a 3-mo history of chronic nasal congestion, arthralgias, pruritic maculopapular eruption, epistaxis and lower extremity weakness. Subsequent lung and chest wall biopsies confirmed diagnosis of Wegener's granulomatosis. Summary of electrodiagnostic data obtained on initial presentation and comparison with later study indicated a sensorimotor polyneuropathy with wide-spread axonal involvement noted particularly in the distal lower extremity musculature. Electrodiagnostic documentation of rapid progression proved useful in directing alteration of immunosuppressive therapy, with favorable clinical and functional outcome. We believe this is the second case presented of a patient with documented Wegener's granulomatosis and overt clinical evidence of poly-neuropathy in whom both electroneurographic and electromyographic studies are described. Electrodiagnostic results are presented with discussion of pertinent literature.

Electrodiagnosis↗
PubMed1992

Diarrhea in hospitalized patients.

Clostridium difficle has been associated with diarrhea in hospitalized patients receiving antibiotic therapy and may be nosocomially acquired. Rehabilitation hospital inpatients may require frequent antibiotic intervention and are thus at risk, although few reports of epidemics at such centers have been published. This study describes the impact of C. difficle-related disease among rehabilitation hospital inpatients. A retrospective review was conducted of all inpatients evaluated for diarrhea in two freestanding rehabilitation hospitals over a 13-month period. Clostridium difficle was determined to be the etiologic agent of diarrhea in 36% of the 33 patients, and no other etiologies were identified. Four patients were transferred to acute care because of the severity of symptoms. A total of 120 altered or canceled therapy sessions were observed to occur during the rehabilitative hospital course among studied patients, of which 90% (108) occurred during periods when patients were documented to have been symptomatic for diarrhea. Diarrhea and C. difficile-related disease thus appear to exert an important and adverse impact on the hospital course of these patients, both in terms of medical complications and therapy attendance. Physicians should therefore possess a heightened index of suspicion for C. difficile infection when evaluating patients with diarrhea in this setting. Diagnostic evaluation of rehabilitation hospital inpatients with diarrhea should include C. difficile toxin assay. If the results of the toxin assay are positive, appropriate therapy, including initiation of oral vancomycin or metronidazole and avoidance of antimotility drugs, should be instituted promptly to minimize risk of potential sequelae.

Adult↗
PubMed1991

Resident interest in physical medicine and rehabilitation fellowships. Results of a survey.

Physiatry, one of the six medical specialties that does not currently offer added or special qualification certification examinations, does not have accredited fellowships in potential subspecialty areas. These issues are currently being debated by the leadership organizations within physical medicine and rehabilitation such as the Association of Academic Physiatrists, the American Academy of Physical Medicine and Rehabilitation, the Physical Medicine and Rehabilitation Residency Review Committee and the American Board of Physical Medicine and Rehabilitation. Recent events, such as the establishment of funding agencies with an interest in medical rehabilitation research training, suggest that physiatric fellowships may become more available. A survey was conducted to determine whether physiatric residents desire postresidency training and, if interested, what type of additional training they would seek. This information could be used in formulating policies regarding the establishment, accreditation and certification of subspecialty fellowships within physical medicine and rehabilitation. Of 968 physiatric residents currently in training, 525 (54%) responded to a 22-question survey assessing resident interest regarding fellowship training, the different subspecialty areas, salary expectations, fellowship duration, preferred amount of time devoted to clinical v research work, mentorship, double boarding, accreditation, certification and a section for general comments. The results of the survey indicate considerable interest in fellowship training, which diminishes as residents approach graduation. Residents favored clinically oriented fellowships of 1-yr duration, which should be accredited and certified. Sports medicine was identified as the area of greatest subspecialty interest.

Attitude of Health Personnel↗
PubMedDate not supplied

Postoperative transcutaneous oxygen measurement in the prediction of delayed wound healing and prosthetic fitting among amputees during rehabilitation. A pilot study.

Postoperative assessment of amputation wound healing remains largely subjective in nature, being based on the physician's clinical judgement. These considerations significantly impact on the rehabilitation course, as premature prosthetic fitting may result in wound breakdown. Alternatively, delayed healing may result in prolonged hospital length of stay. Few attempts have been made to correlate objective parameters of limb perfusion with amputation wound healing or prosthetic fitting outcome during the rehabilitation phase of treatment. A pilot study was conducted, in which the transcutaneous oxygen monitor, a noninvasive device measuring transcutaneous partial pressure of oxygen (tcpO2), was applied to the stumps of 11 consecutive above-or below-knee amputees admitted for rehabilitation after amputation. All patients were tested within 1 wk of admission and 45 days of amputation. The treatment team was blinded as to the test results. A direct correlation was observed between wound healing outcome and tcpO2 results (Fisher's exact test [FET], P = 0.03), and no patient with a tcpO2 of < or 15 mm Hg healed during their rehabilitation stay (FET, P = 0.006). TcpO2 of < or = 15 mm Hg was significantly correlated with prolonged length of stay (Point Biserial Correlation Coefficient [rpbi], = -0.835; P = 0.01), delayed prosthetic fitting (rpbi = 0.742; p = 0.01), and poorer wound healing at admission (rpbi = 0.932; P = 0.001). Postoperative tcpO2 measurement may have use in objectively identifying patients at greater risk of delayed wound healing and prosthetic fitting, although further study is warranted.

Aged↗
PubMedDate not supplied

Potential role of serum prolactin measurement in the diagnosis of late posttraumatic seizures. A case report.

Posttraumatic seizures are an important medical complication after traumatic brain injury. However, the diverse clinical presentation of posttraumatic seizures, combined with the cognitive and behavior deficits frequently seen in this patient population, can make the diagnosis of posttraumatic seizures particularly challenging. Electroencephalography and imaging studies are often abnormal and nonspecific. It has been reported that serum prolactin levels frequently rise after epileptic seizures. This case report describes the use of prolactin measurement to confirm two suspected posttraumatic seizure episodes in a 42-yr-old male with severe traumatic brain injury. Each episode lasted less than 1 min and involved conspicuously altered postural tone and respiratory pattern, followed by a change in verbal and motor responsiveness. No rhythmic extremity movements were observed. Diagnostic evaluation included electroencephalography and imaging studies, which demonstrated nonspecific abnormalities. Serum prolactin levels obtained within 20 to 40 min were markedly elevated and two to three times greater than the baseline level. The use of prolactin levels in the diagnosis of posttraumatic seizures is reviewed, accompanied by discussion of pertinent aspects of normal and abnormal states of prolactin secretion and regulation.

Adult↗