Differences in Glucose Metabolism Among Women With Spinal Cord Injury May Not Be Fully Explained by Variations in Body Composition.

OBJECTIVE: To investigate the differences in glucose metabolism among women with paraplegic, and tetraplegic spinal cord injury (SCI) in comparison to their able-bodied (AB) counterparts after adjusting for differences in body composition. DESIGN: Cross-sectional study. After an overnight fast, each participant consumed a 75-g glucose solution for oral glucose tolerance test (OGTT). Blood glucose, insulin, and C-peptide concentrations were analyzed before and 30, 60, 90, and 120 minutes after ingesting glucose solution. Insulin sensitivity index (ISI) was estimated using the Matsuda index. Percentage fat mass (%FM) and total body lean mass (TBLM) were estimated using data from dual-energy x-ray absorptiometry. Visceral fat (VF) was quantified using computed tomography. Outcome measures were compared among groups using analysis of covariance with %FM (or VF) and TBLM as covariates. SETTING: Research university. PARTICIPANTS: Women (N=42) with SCI (tetraplegia: n=8; paraplegia: n=14) and their race-, body mass index-, and age-matched AB counterparts (n=20). INTERVENTIONS: Not applicable. RESULTS: At fasting, there was no difference in glucose homeostasis (glucose, insulin, C-peptide concentrations) among 3 groups of women. In contrast, glucose, insulin, and C-peptide concentrations at minute 120 during OGTT were higher in women with tetraplegia versus women with paraplegia and AB women (P<.05, adjusted for TBLM and %FM). In addition, women with tetraplegia had lower ISI (P<.05, adjusted for TBLM and %FM) versus AB women. These differences remained after adjusting for VF and TBLM. CONCLUSION: Our study confirms that impaired glucose metabolism among women with tetraplegia may not be fully explained by changes in their body composition. Future studies exploring additional factors involved in glucose metabolism are warranted.

Normalization of disrupted clock gene expression in males with tetraplegia: a crossover randomized placebo-controlled trial of melatonin supplementation.

STUDY DESIGN: Crossover double blind, randomized placebo-controlled trial. OBJECTIVES: Circadian oscillators are located both in the brain and in peripheral organs. Melatonin, the main brain-derived hormone governing circadian variations, is highly associated with daylight patterns. However, in subjects with tetraplegia the melatonin levels are blunted. Here we studied peripheral oscillators in peripheral blood mononuclear cells (PBMCs) in males with tetraplegia by examining how exogenous melatonin may influence the expression of clock gene mRNAs. SETTING: Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway. METHODS: Six males with tetraplegia received 2 mg of melatonin or placebo 4 days before the study period. We also included six able-bodied men sleeping or kept awake during the night. Plasma samples were collected four times during a 24-h period. The mRNA expression levels of the clock genes PER1, PER2, BMAL1, and REV-ERBα were quantified in PBMCs using quantitative RT-PCR. RESULTS: The mRNA expression levels of PER-1 and -2 and REV-ERBα were increased at 04:00 h compared with the able-bodied controls (p < 0.05). Melatonin supplementation changed mRNA peak-time toward the time of supplementation. CONCLUSIONS: Several peripheral clock genes displayed distorted expression levels in tetraplegia. Supplementation with melatonin changed the mRNA expression levels of these genes toward those observed among able-bodied. SPONSORSHIP: Financial support was provided from the Throne Holst Foundation, Sunnaas Rehabilitation hospital and the University of Ferrara (FAR2016).

Vitamin D deficiency in Swiss elite wheelchair athletes.

STUDY DESIGN: This is a retrospective analysis of total serum 25-hydroxyvitamin D (25[OH]D) in Swiss elite wheelchair athletes. OBJECTIVES: The aim was to investigate the occurrence of vitamin D deficiency in Swiss elite wheelchair athletes over the whole year and to detect differences between winter and summer months, and between indoor and outdoor athletes. SETTING: This study was conducted in Switzerland. METHODS: A total of 164 blood samples from 72 Swiss elite wheelchair athletes (mean±s.d.: age 32±13 years) were analyzed for total serum 25[OH]D. All participants were members of the national team in their discipline. The following disciplines have been included: rugby, athletics, cycling, tennis, ski alpine, curling and basketball. According to general guidelines, insufficient vitamin D status was defined between 50 and 75 nmol l-1, deficiency below 50 nmol l-1 and severe deficiency below 27.5 nmol l-1. RESULTS: In all, 73.2% of all samples showed an insufficiency/deficiency in vitamin D status. Total serum 25[OH]D was significantly higher during summer compared with winter months (69.5±21.4 nmol l-1 vs 51.5±21.9 nmol l-1; P<0.001). Indoor sports showed a higher amount of vitamin D insufficiency/deficiency (80.9%) than outdoor sports (70.1%), with a significantly higher 25[OH]D concentration in outdoor sports (P=0.042). CONCLUSION: A high percentage of vitamin D deficiency was found among Swiss elite wheelchair athletes. Conclusively, we recommend supplementation with vitamin D-especially during winter-to prevent a deficiency and an impairment of performance.

Brain-derived neurotrophic factor concentrations in tetraplegic athletes.

STUDY DESIGN: A prospective cohort with acute tetraplegia. OBJECTIVE: The purpose of this study was to investigate acute changes in serum brain-derived neurotrophic factor (BDNF) concentrations in tetraplegic spinal cord-injured (SCI) athletes during a typical training session of wheelchair rugby. SETTINGS: German Sport University Cologne, Cologne, Germany. METHODS: Eleven male SCI (AIS A and B) athletes completed a 90-min training session: The warm-up period included continuous pushing, submaximal increasing sprints and agility drills. The main training section comprised ball handling, passing drills, scrimmage activity and tactical practice. At the end of the training session, the athletes did moderate continuous pushing as a short cool-down. Venous blood samples were taken at rest before exercise, after the warm-up period and immediately following the first part of the main training section. Serum was pipetted after 30 min of blood sample resting and a subsequent centrifugation. BDNF concentrations were measured using an enzyme immunoassay ELISA kit. RESULTS: Heart rate (P < 0.01) and lactate (P = 0.04 and P < 0.01) concentration differed significantly in warm-up and main training part in comparison with basal values at rest. At rest, BDNF concentrations were 33.2 ± 21.6 ng ml(-1), after warm up 31.9 ± 18.9 ng ml(-1) and after the training session 29.9 ± 11 ng ml(-1), without significant differences (P > 0.05). CONCLUSIONS: A typical wheelchair rugby training session does not affect basal serum BDNF concentration in elite SCI athletes. In comparison with concentrations previously reported in healthy subjects, the current values at rest were slightly higher or rather at the upper limit.

Circadian rhythms of hemostatic factors in tetraplegia: a double-blind, randomized, placebo-controlled cross-over study of melatonin.

STUDY DESIGN: This is a double-blind, randomized, placebo-controlled cross-over study of melatonin in complete tetraplegia. OBJECTIVES: Tetraplegic patients have an increased risk of venous thrombosis despite prophylaxis, blunted variations in melatonin and altered circadian variation of several hemostatic markers. To examine whether melatonin could modify the regulation of hemostasis, we measured plasma melatonin and several markers of hemostasis in tetraplegic subjects with or without melatonin supplement. SETTING: The study was conducted in the Section for Spinal Cord Injury, Sunnaas Hospital, Nesoddtangen, Norway. METHODS: Six subjects with long-standing complete tetraplegia were included in this cross-over study with 2 mg of melatonin or placebo given 4 days before sampling. We also included six able-bodied men without any intervention. Plasma samples were then collected frequently during a 24-h awake/sleep cycle. The plasma concentrations of melatonin and the various markers were analyzed using linear mixed models. RESULTS: The 24-h profiles of prothrombin fragment 1+2 and von Willebrand factor, but not D-dimer, activated FVII, tissue factor pathway inhibitor and plasminogen activator inhibitor type 1, differed (P<0.05) between tetraplegic patients and able-bodied subjects. The absolute plasma concentration of activated FVII was higher (P<0.05) among the able-bodied compared with the tetraplegic groups. Supplementation of melatonin had no impact on these findings. CONCLUSIONS: We found differences in circadian variation of several hemostatic markers between able-bodied and tetraplegics. These differences were apparently unrelated to fluctuations in the melatonin concentrations, suggesting little or no role of melatonin in the regulation of hemostasis in tetraplegia. SPONSORSHIP: Financial support was provided from the Throne Holst Foundation.

Low-dose baclofen therapy raised plasma insulin-like growth factor-1 concentrations, but not into the normal range in a predictable and sustained manner in men with chronic spinal cord injury.

OBJECTIVE: To evaluate, whether once-daily oral baclofen administration increases and/or sustains plasma insulin-like growth factor-1 (IGF-1) concentration in 11 men with chronic spinal cord injury (SCI) and IGF-1 deficiency (i.e. <250 ng/ml). DESIGN: Prospective, open-label, dose titration study. Baclofen was administered at 20 mg/day for 8 weeks; then increased to 40 mg/day for another 8 weeks. Plasma IGF-1 and self-reported side effects were measured at baseline and every other week for the duration of the study. RESULTS: The subjects were 43 ± 12 years old, had duration of injury of 20 ± 12 years; eight subjects had a complete motor injury, and eight had paraplegia. Nine of 11 subjects completed the 20 mg/day treatment and 5 subjects completed the 40 mg/day treatment. Plasma IGF-1 levels improved with each baclofen dose; however, only one subject increased from baseline and remained above the targeted physiological range of 250 ng/ml throughout treatment. A significant increase in IGF-1concentration was observed between baseline and week 2 (154 ± 63 vs. 217 ± 69 ng/ml; P < 0.05), weeks 8 and 10 (188 ± 95 vs. 228 ± 93 ng/ml; P < 0.05), and weeks 8 and 16 (188 ± 95 vs. 259 ± 92 ng/ml; P < 0.05). No serious side effects were observed at 20 mg/day; the 40 mg/day dose was less well tolerated. CONCLUSION: Baclofen was not effective at sustaining plasma IGF-1 concentrations in the physiological range in men with chronic SCI.

Cerebrovascular reactivity and dynamic autoregulation in tetraplegia.

Humans with spinal cord injury have impaired cardiovascular function proportional to the level and completeness of the lesion. The effect on cerebrovascular function is unclear, especially for high-level lesions. The purpose of this study was to evaluate the integrity of dynamic cerebral autoregulation (CA) and the cerebrovascular reactivity in chronic tetraplegia (Tetra). After baseline, steady-state hypercapnia (5% CO(2)) and hypocapnia (controlled hyperventilation) were used to assess cerebrovascular reactivity in 6 men with Tetra (C5-C7 lesion) and 14 men without [able-bodied (AB)]. Middle cerebral artery blood flow velocity (MCAv), cerebral oxygenation, arterial blood pressure (BP), heart rate (HR), cardiac output (Q; model flow), partial pressure of end-tidal CO(2) (Pet(CO(2))), and plasma catecholamines were measured. Dynamic CA was assessed by transfer function analysis of spontaneous fluctuations in BP and MCAv. MCAv pulsatility index (MCAv PI) was calculated as (MCAv(systolic) - MCAv(diastolic))/MCAv(mean) and standardized by dividing by mean arterial pressure (MAP). Resting BP, total peripheral resistance, and catecholamines were lower in Tetra (P < 0.05), and standardized MCAv PI was approximately 36% higher in Tetra (P = 0.003). Resting MCAv, cerebral oxygenation, HR, and Pet(CO(2)) were similar between groups (P > 0.05). Although phase and transfer function gain relationships in dynamic CA were maintained with Tetra (P > 0.05), coherence in the very low-frequency range (0.02-0.07 Hz) was approximately 21% lower in Tetra (P = 0.006). Full (hypo- and hypercapnic) cerebrovascular reactivity to CO(2) was unchanged with Tetra (P > 0.05). During hypercapnia, standardized MCAv PI reactivity was enhanced by approximately 78% in Tetra (P = 0.016). Despite impaired cardiovascular function, chronic Tetra involves subtle changes in dynamic CA and cerebrovascular reactivity to CO(2). Changes are evident in coherence at baseline and MCAv PI during baseline and hypercapnic states in chronic Tetra, which may be indicative of cerebrovascular adaptation.

Prospective analysis of lipid profiles in persons with a spinal cord injury during and 1 year after inpatient rehabilitation.

OBJECTIVES: To investigate the course of lipid profiles during and 1 year after inpatient rehabilitation of persons with spinal cord injury, and to determine which personal, lesion, and lifestyle characteristics influence the changes in lipid profiles over time and among subjects. DESIGN: Multilevel regression analysis of measurement points during and after rehabilitation. SETTING: Eight rehabilitation centers in The Netherlands. PARTICIPANTS: People with complete and incomplete paraplegia and tetraplegia (N=180). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), and the TC/HDL ratio. RESULTS: We found a significant decrease in TG and TC/HDL during inpatient rehabilitation and a significant increase in HDL during and after inpatient rehabilitation. TC and LDL, however, showed unfavorable increases after clinical discharge. The changes in HDL and LDL over time differed between lesion groups. An increase in the body mass index (BMI) led to an unfavorable change in all lipid profiles. Older participants showed higher TC, LDL, and HDL concentrations. Women and participants who consumed some alcohol, or who were more active 1 year after discharge, had more favorable HDL levels. CONCLUSIONS: Lipid profiles improved during inpatient rehabilitation but deteriorated somewhat after clinical discharge. Controlling one's BMI seems important in diminishing the risk for unfavorable lipid profiles.

Glucagon response to hypoglycemia in sympathectomized man.

Hypoglycemia stimulates immunoreactive glucagon (IRG) secretion and increases the activity of the sympathetic nervous system. To ascertain if the augmented alpha cell activity evoked by glucopenia is mediated by the adrenergic nervous system, the glucagon response to insulin-induced hypoglycemia of five subjects with neurologically complete cervical transections resulting from trauma, thereby disrupting their hypothalamic sympathetic outflow, was compared to six healthy volunteers. In addition to clinical neurological evaluation, completeness of sympathectomy was verified by failure to raise plasma norepinephrine levels during hypoglycemia compared to the two- and threefold increase observed in controls. Total IRG response (IRG area above basal 0-90 min) and peak IRG levels achieved were the same in the quadriplegics and the controls. Although the glucagon rise tended to be slower, and the peak levels attained occurred later in the quadriplegic patients than in the controls, this response was appropriate for their sugar decline, which was slower and reached the nadir later than in the control subjects. These observations that the glucagon release during insulin-induced hypoglycemia is normal in subjects whose hypothalamic sympathetic outflow has been interrupted provide strong evidence that the sympathetic nervous system does not mediate the glucagon response to hypoglycemia.

Clinical significance of abnormal electrocardiographic findings in individuals aging with spinal injury and abnormal lipid profiles.

BACKGROUND: Cardiovascular risk factors are common in individuals with chronic spinal cord injury (SCI), and their prevalence increases with age. The actual prevalence of overt cardiovascular disease (CVD) in this population has not been well established. METHODS: Electrocardiograms (ECGs) were examined for abnormalities in 43 individuals with abnormal lipid profiles being followed in the outpatient SCI clinic of our institution. The mean age of the study population of predominantly men was 43 +/- 9.9 years and the mean duration of injury 16.6 +/- 8 years. RESULTS: ECG abnormalities were common and present in 60.5% of participants. ST-T wave abnormalities were the most commonly observed (35%). Evidence of previous myocardial infarction was present in 7% of all individuals and in 12% of those with ECG abnormalities. The only clinical parameter differentiating the group with normal vs abnormal ECG was the duration of injury (19.5 +/- 8 y vs 12 +/- 5 y; P = 0.0026). Analysis of variance showed that injury duration was the sole predictor of abnormal ECG with 68% accuracy (P = 0.006). Among those with ECG abnormalities, although no significant differences were detected between those with and without evidence of previous myocardial infarction, mean total cholesterol and low-density lipoprotein were higher, and mean high-density lipoprotein was lower. Mean age and injury duration were greater in those with evidence of previous myocardial infarction. CONCLUSION: Although age is an important risk factor for CVD in the population of individuals without disabilities, injury duration is at least as important as age in those with SCI. Our findings support the recommendation that individuals with SCI and abnormal lipids should be screened for CVD regardless of age.

Spinal Cord Injury Level Influences Acute Plasma Caffeine Responses.

PURPOSE: This study aimed to investigate the absorption curve and acute effects of caffeine at rest in individuals with no spinal cord injury (SCI), paraplegia (PARA), and tetraplegia (TETRA). METHODS: Twenty-four healthy males (eight able-bodied [AB], eight PARA, and eight TETRA) consumed 3 mg·kg caffeine anhydrous (CAF) in a fasted state. Plasma caffeine [CAF], glucose, lactate, free fatty acid, and catecholamine concentrations were measured during a 150-min rest period. RESULTS: Peak [CAF] was greater in TETRA (21.5 µM) compared with AB (12.2 µM) and PARA (15.1 µM), and mean peak [CAF] occurred at 70, 80, and 80 min, respectively. Moderate and large effect sizes were revealed for TETRA compared with PARA and AB (-0.55 and -1.14, respectively) for the total area under the [CAF] versus time curve. Large interindividual responses were apparent in SCI groups. The change in plasma catecholamine concentrations after CAF did not reach significance (P > 0.05); however, both adrenaline and noradrenaline concentrations were lowest in TETRA. Significant increases in free fatty acid were seen over time (P < 0.0005), but there was no significant influence of SCI level. Blood lactate concentration reduced over time (P = 0.022), whereas blood glucose concentration decreased modestly (P = 0.695), and no difference between groups was seen (P > 0.05). CONCLUSION: The level of SCI influenced the caffeine absorption curve, and there was large interindividual variation within and between groups. Individual curves should be considered when using caffeine as an ergogenic aid in athletes with an SCI. The results indicate TETRA should trial low doses in training and PARA may consider consuming caffeine greater than 60 min before exercise performance. The study also supports caffeine's direct effect on adipose tissue, which is not secondary to catecholamine release.

Differences in circadian variations of tissue factor pathway inhibitor type 1 between able-bodied and spinal cord injured.

INTRODUCTION: Tissue factor pathway inhibitor type 1 (TFPI) is the physiological inhibitor of the tissue factor pathway of coagulation. TFPI is produced by endothelial cells, and most intravascular TFPI is composed of full-length TFPI associated with the endothelium. Circulating TFPI is mainly truncated and lipoprotein-associated, but a small fraction circulates in a free full-length form. Although hormonal state influences the plasma variation of TFPI between individuals, other factors like temporal variation may be important. Hence, in the current study we aimed at exploring the intra-individual variation with focus on the possible circadian variations of TFPI. MATERIALS AND METHODS: TFPI free and total antigen from 8 able-bodied and 6 tetraplegic men were measured at 12 time points during a 24 h period. RESULTS: TFPI free antigen in the able-bodied exhibited circadian variation with the highest levels (approximately 20% above mean) from 12:00 to 18:00 h and the lowest levels (approximately 15% below mean) at 09:00 and 02:00 h. In contrast, TFPI free antigen in the tetraplegic group showed no circadian variation. TFPI total antigen exhibited circadian variation in neither group, but mean TFPI total antigen was lower in the tetraplegic group compared with the able-bodied (80 versus 110 ng/mL, respectively). Notably, even if TFPI total antigen in both groups did not vary according to any specific circadian rhythm, the intra-individual variation was higher than the assay variation. CONCLUSION: TFPI free antigen exhibited circadian variations in able-bodied, but not in tetraplegic subjects and the able-bodied had higher levels of TFPI total antigen than the tetraplegic group.

Rapidly Resolving Weakness Related to Hypokalemia in Patients Infected With Dengue Virus.

OBJECTIVES: Dengue is a mosquito-borne disease caused by arbovirus and well known for its typical fever with thrombocytopenia syndrome. Acute hypokalemic quadriparesis is a rare presentation of dengue with uncertain pathogenesis. We aim to describe the clinical and biochemical characteristics of rapidly resolving weakness related to hypokalemia in patients infected with dengue virus. METHODS: A retrospective review of the records of patients with diagnosis of dengue-associated hypokalemic weakness was performed. Demography, clinical, biochemical characteristics, and outcome of the patients were recorded during acute phase of illness. RESULTS: Our study cohort comprised 12 patients and all were males from urban dwelling. The median age was 34.5 years (range, 18-50). Presentation was acute onset rapidly worsening pure motor quadriparesis preceded by short lasting febrile episode. Weakness ranged from 2/5 to 4/5 on Medical Research Council (MRC) scale with generalized hyporeflexia or areflexia. The baseline serum potassium was mean ± SD (2.7 ± 0.48 mmol/L). All patients showed elevation of liver transaminases and elevated creatine phosphokinase level. Weakness improved in 24-72 hours in all patients with correction of serum potassium. CONCLUSIONS: Dengue-associated acute hypokalemic paralysis is an underrecognized entity having favorable outcome. It should be suspected in patients presenting as acute pure motor quadriparesis after febrile illness in dengue endemic areas.

Effect of acute aminophylline administration on diaphragm function in high cervical tetraplegia: a case report.

Theophylline has been shown to have beneficial effects on phrenic nerve and diaphragm activation. This case report involves a C5-C6 chronic tetraplegic patient with acute respiratory failure and ventilator dependence. IV aminophylline was administered in increasing doses (2 mg/kg, 4 mg/kg, and 6 mg/kg) over the course of 1 day. Diaphragm surface electromyography (sEMG), measures of respiration (tidal volume, minute ventilation, and frequency), and serum theophylline levels were captured. Diaphragm sEMG activity increased by a maximum of 50% at therapeutic levels. The rapid shallow breathing index dropped from 112 to 86. The subject was successfully weaned from ventilatory support. We conclude that administration of aminophylline facilitated weaning from ventilatory support in this tetraplegic patient.

Appearance of a novel prostacyclin receptor antibody and duration of spinal cord injury.

BACKGROUND: Cardiovascular disease (CVD) appears to be accelerated in individuals with chronic spinal cord injury (SCI). Previously, we have identified a novel circulating antibody (IgG) in persons with SCI that specifically blocks the high-affinity prostacyclin (PGI2) receptors on the platelet surface without affecting the low-affinity PGI2 receptors. OBJECTIVE: In this study, the relationship between the time course after SCI to the development of IgG to the high-affinity PGI2 receptor was determined. METHODS: Blood samples were collected 1, 3, 5, 10, and > 10 (15 +/- 4) years after SCI (n = 36). Plasma samples (50 microg) were analyzed by polyacrylamide gel electrophoresis (PAGE) followed by densitometry. RESULTS: The optical density (OD) of the IgG (molecular weight 47,000) at 1 year after SCI was significantly higher than control (1.65 +/- 0.08 vs 1.33 +/- 0.04; P < 0.01). This anti-receptor IgG appears to increase for 5 years and then plateau. At 5 years, 6-10 years, and > 10 years of injury, the OD was 1.83 +/- 0.09, 1.83 +/- 0.10, and 1.87 +/- 0.08, respectively. With an increase in this specific IgG, there was a concomitant decrease in the binding of prostacyclin to its high-affinity receptors on SCI platelets, (non-SCI vs 1, 3, and 5 years after injury; n1 = 172 +/- 25 vs 153 +/- 15, 107 +/- 25, and 40 +/- 4 sites/platelet, respectively; P < 0.001), with no significant change in receptor affinity. CONCLUSIONS: The level of the high-affinity PGI2-receptor antibody determined in individuals with SCI was associated with the duration and not with the level of injury. Platelets from subjects with SCI had a reduction in numbers of high-affinity receptors.

Reduced peak, but no diurnal variation, in thrombin generation upon melatonin supplementation in tetraplegia. A randomised, placebo-controlled study.

Tetraplegic patients have increased risk of venous thrombosis despite anti-thrombotic prophylaxis. Moreover, they have blunted plasma variations in melatonin and altered diurnal variation of several haemostatic markers, compared with able-bodied. However, whether healthy individuals and tetraplegic patients, with or without melatonin, display abnormalities in thrombin generation during a 24-hour (h) cycle, is unknown. We therefore used the Calibrated Automated Thrombogram (CAT) assay to examine diurnal variations and the possible role of melatonin in thrombin generation. Six men with long-standing complete tetraplegia were included in a randomised placebo-controlled cross-over study with melatonin supplementation (2 mg, 4 consecutive nights), whereas six healthy, able-bodied men served as controls. Ten plasma samples were collected frequently during a 24-h awake/sleep cycle. No significant diurnal variation of any of the measured CAT indices was detected in the three study groups. Whereas endogenous thrombin potential (ETP) was independent (p > 0.05) of whether the tetraplegic men received melatonin or placebo, melatonin decreased (p = 0.005) peak values in tetraplegia compared with those given placebo. Able-bodied men had lower (p = 0.019) ETP and Lag-Time (p = 0.018) compared with tetraplegics receiving placebo. Neither the Time-to-Peak nor the Start-Tail was affected (p > 0.05) by melatonin in tetraplegia. In conclusion, indices of thrombin generation are not subjected to diurnal variation in healthy able-bodied or tetraplegia, but peak thrombin generation is reduced in tetraplegic men receiving oral melatonin.

Glucocorticoid-induced myopathy in the intensive care unit.

Glucocorticoids (GC) are used for intensive care unit (ICU) patients on several indications. We present a patient who was admitted to the ICU due to severe respiratory failure caused by bronchospasm requiring mechanical ventilation and treated with methylprednisolone 240 mg/day in addition to antibiotics and bronchiolytics. When the sedation was lifted on day 10, the patient was awake but quadriplegic. Blood samples revealed elevated muscle enzymes, electromyography showed myopathy, and a muscle biopsy was performed. Glucocorticoid-induced myopathy was suspected, GC treatment was tapered, and muscle strength gradually returned. The patient made full recovery from the quadriplegia a few months later.