Physical and rehabilitation medicine (PRM) care pathways: "spinal cord injury".

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. The patients after spinal cord injury are divided into five categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients.

Breath-ammonia testing of healthy subjects and patients with cirrhosis.

BACKGROUND: Hepatic encephalopathy (HE) is a serious neuropsychiatric complication in both acute and chronic liver disease. AIMS: To establish the utility of a portable noninvasive method to measure ammonia in the breath of healthy subjects and patients with HE. METHODS: The study included 106 subjects: 44 women and 62 men, 51 healthy and 55 cirrhotic. The breath ammonia was measured with an electrochemical sensor and expressed in parts/billion (ppb). RESULTS: The breath ammonia in healthy subjects had an average value of 151.4 ppb (95% confidence interval [CI]: 149.4-153.4) and the average value in cirrhotic patients was 169.9 ppb (95% CI: 163.5-176.2) (P < 0.0001). In cirrhotic patients with and without HE, the corresponding values were 184.1 ppb (95% CI: 167.7-200.6) and 162.9 ppb (95% CI: 158.8-167.0), respectively (P = 0.0011). Ammonia levels ≥ 165 ppb permitted a differentiation between healthy and cirrhotic subjects; the area under the receiver operating characteristic (ROC) curve for the ammonia-level values in cirrhotic versus control patients was 0.86 (95% CI: 0.79-0.93). In cirrhotic patients, ammonia levels ≥ 175 ppb permitted the distinction between patients with and without HE; the area under the ROC curve in cirrhotic patients with versus without HE was 0.83 (95% CI: 0.73-0.94). CONCLUSION: A portable sensor for measuring breath ammonia can be developed. If the results of the present study are confirmed, breath-ammonia determinations could produce a significant impact on the care of patients with cirrhosis and could even include the possibility of self-monitoring.

A new thermodynamic model describes the effects of ligand density and type, salt concentration and protein species in hydrophobic interaction chromatography.

A new thermodynamic model is derived that describes both loading and pulse-response behavior of proteins in hydrophobic interaction chromatography (HIC). The model describes adsorption in terms of protein and solvent activities, and water displacement from hydrophobic interfaces, and distinguishes contributions from ligand density, ligand type and protein species. Experimental isocratic response and loading data for a set of globular proteins on Sepharose resins of various ligand types and densities are described by the model with a limited number of parameters. The model is explicit in ligand density and may provide insight into the sensitivity of protein retention to ligand density in HIC as well as the limited reproducibility of HIC data.

Transcatheter closure of patent ductus venosus with the Amplatzer vascular plug in twin brothers.

We describe the transcatheter closure of a patent ductus venosus in twin brothers with an ill-defined systemic illness and respiratory failure using the Amplatzer vascular plug. To our knowledge, this is the first description of the use of the Amplatzer vascular plug for ductus venosus closure.

[Evolution of antibiotic resistance and serogroups of Streptococcus pneumoniae over the 1997-2003 period in Brittany]. / Evolution de la résistance aux antibiotiques et des sérogroupes de Streptococcus pneumoniae en Bretagne entre 1997 et 2003.

At this time, many antibiotics have decreased activity against Streptococcus pneumoniae, a major agent of infectious disease. In this study, we evaluated antibiotic susceptibility and serogroups of strains isolated from bacteraemia, meningitis and acute otitis media in adults and children over the 1997-2003 period in Brittany, France. In 2003, 62% of the isolates were not susceptible to penicillin and 11% were fully resistant. The prevalence of erythromycin resistance was 63%. Resistance rates were higher among isolates recovered from children than adults. Serogroups 19 and 14 were the most frequently isolated, especially the 19 one among children. The emergence of this serogroup might be a consequence of the use of heptavalent conjugate vaccine introduced in 2001 in France. Future surveillance after vaccination will be needed to detect emerging serogroups and resistance among S. pneumoniae.

[Tracheotomy in brain injured patients: which patients? Why? When? How?]. / Trachéotomie et traumatisme crânien grave: pour qui? Pourquoi? Quand? Comment?

The aim of this study is to determine, from the data available in the literature, the indications of tracheostomy in brain injured patients, the incidence and risk factors for complications and the follow-up required until decannulation. The incidence of tracheostomy is 10% in TBI and 50 to 70% in subpopulations with a Glasgow Coma Scale (GCS) below 9. Early complications are not specific. The most frequent late complication is laryngotracheal stenosis, which occurs in 15% and is more frequently observed in the most severe patients with major hypertonia. It is likely that tracheostomy, if needed, should be performed early and the prognosis as to whether it will be required, can be made at the end of the first week. The follow-up of these patients includes surveillance of multiresistant colonisations and systematic performance of fibroscopy before decannulation. Cuffless, small diameters, soft tracheostomy tubes, are preferred on the long-term unless the risk of aspiration remains high.

[Serious brain injury and public health, epidemiologic and financial considerations, comprehensive management and care]. / Santé publique et traumatismes crâniens graves. Aspects épidémiologiques et financiers, structures et filières de soins.

The management of persons with traumatic brain injury affects a large spectrum of interventions from acute phase to the hospital discharge and the return to community. The incidence of brain injuries on mortality and morbidity constitutes a serious problem in front of the Health Administration. The traffic accidents remain the main cause but the falls in elderly are increasing. In the both cases preventive measures can be efficiency. In France, each year, there are about 150,000 new cases, 8000 of them will be dead and 4000 with coma. It is likely that 30,000 persons are living to day with important sequela of a brain injury. The management requires various types of interventions, each of them with specific and specialized techniques. It is necessary to have an overview of the problem and to work together in a comprehensive network. So French Health Ministry has just published an official note to precise some directives and co-ordination of the different interventions.

[Gait orthosis in patients with complete thoracic paraplegia. Review of 43 patients]. / Place actuelle de la marche appareillée chez les patients paraplégiques complets de niveau thoracique. A propos d'une cohorte de 43 patients.

OBJECTIVE: To evaluate of the effective use of gait orthosis in patients with spinal cord injuries. PATIENTS AND METHODS: A total of 43 patients with complete paraplegia, level T3 to L1, who had a gait orthosis (hip-knee-ankle-foot orthosis, reciprocating gait orthosis, hybrid orthosis and functional electrical stimulation) answered a telephone questionnaire. RESULTS: Orthotic gait use was discontinued in 65% of patients who used the orthosis twice a week for 15 to 60 minutes. Two-thirds of the patients were able to fit the orthosis independently, 60% for standing and 25% for walking. The main reasons for discontinuing use were psychological reasons in 30% of patients, the lack of functional use and the necessity for human help or supervision. CONCLUSION: Presently available devices do not allow functional and independent use of gait orthoses. Their use is limited to physical training, and the only demonstrated physiological benefits are the effects of functional electrical stimulation on cardiovascular status. Prescription for gait orthosis appears justified only if requested by a motivated and well-informed patient or if it appears a useful step in the acceptation of the loss of the gait.

Congenital cardiomyopathy and pulmonary hypertension: another fatal variant of cytochrome-c oxidase deficiency.

Biventricular hypertrophy was noted at 24 weeks' gestation in a fetus with isolated cytochrome-c oxidase (COX) deficiency. Shock, caused by hypertrophic cardiomyopathy and severe pulmonary hypertension, led to the patient's death on day 6. His phenotype defines a new lethal variant of COX deficiency characterized by prenatal-onset cardiopulmonary pathophysiology.

[Pharmacological treatment of post-traumatic behavioural disorders]. / Traitement pharmacologique des troubles du comportement post-traumatiques.

OBJECTIVE: Literature review of the data concerning pharmacologic treatment of post-traumatic behavioural disorders. This review is limited to the treatment of agitation, excitation, mood lability, hostility and agressivity as defined by the NRS and excludes pharmacologic treatment of mental slowness, cognitive disorders and depression. METHODS: Medline interrogation using keywords Traumatic Brain Injury, Agitation, Agressivity, Behaviour, Pharmacology, Neuroleptics, Benzodiazepines, Carbamazepine, Valproate, Buspirone, SSRI, Propanolol, Methylphenidate and review of recent contents. The data finally includes 29 original studies. RESULTS: The overall level of evidence is quite low as the data mainly consist in open studies and case reports. These data and data from reviews or didactic articles suggest the efficiency of a variety of treatments. Mood-stabilizing antiepileptics, and specially carbamazepine constitute together with SSRI antidepressants the first choices. Some data suggest efficiency of buspirone, methylphenidate and atypic neuroleptics. Lithium requires close monitoring but is probably efficient. It is difficult to conclude concerning propanolol. CONCLUSION: The available data is in favour of the use of CBZ and SSRI antidepressants. Further studies are required. It is necessary to establish clear evidence of the efficiency of CBZ and assess the effects of methylphenidate, which is almost not prescribed in France.

[How can we define the modalities and clinical levels of coma to wakefulness?]. / Comment définir les modalités et les niveaux cliniques de passage du coma à l'éveil ?

OBJECTIVE: The starting point of the French conference of consensus concerning arousal after coma was to answer the following question: "How can we define the ways of going from coma to arousal and their clinical levels? MATERIALS AND METHOD: A team of readers have picked up in the literature one hundred and fifty papers, out of which fifty six have been analysed. RESULTS: From this analysis, three points emerged: The concepts of coma and arousal; The conditions of evolution from coma to arousal; Various groups of patients depending on their expressing arousal. One could not find any consensual model concerning the different ways of going from coma to arousal. The variability of the technics and the changing validity of all scores did not allow the conditions of arousal to reach a satisfactory level of proof. The Glasgow Coma Scale (GCS) is the recognised standard for severe wakefulness' impairment, but it is not sensitive enough while patients' arousing. The Glasgow Outcome Scale (GOS) takes into account the patients' situations far later and does not include situations such as Minimally Conscious States (MCS). That's why we face multiple scores, either ordinal, or categorial, all tending to evaluate the slow levels of arousal. CONCLUSION: Clinical findings concerning arousal are to be completed by non-clinical data. This would be greatly helpful to define appropriate management concerning individualized groups of patients. At this stage, another challenge for clinicians is to make the difference between emerging wakefulness and growing conscious activity.

Recurrent arch obstruction after repair of isolated coarctation of the aorta in neonates and young infants: is low weight a risk factor?

BACKGROUND: Repair of aortic coarctation is often delayed in small infants because of the belief that such patients are at risk of recurrent arch obstruction and that growth will decrease this risk. To determine whether low weight was a risk factor for recurrent arch obstruction, we reviewed our experience with coarctation repair via left thoracotomy in infants less than 3 months of age. METHODS: From 1990 to 1999, 103 patients less than 3 months of age underwent repair of aortic coarctation through a left thoracotomy. Median age was 18 days (1-90 days), with 45 patients less than 2 weeks. Median weight was 3.3 kg (1.0-6.4 kg) and 14 patients were less than 2 kg. The method of repair was resection and end-to-end anastomosis in 64 patients, subclavian flap angioplasty in 34, and patch augmentation of the arch in 5. Demographic, echocardiographic, and operative variables were analyzed for correlation with recurrent arch obstruction. RESULTS: One early and 1 late death occurred, both in patients who had complications but no evidence of recoarctation. At median follow-up of 24 months, reinterventions for recurrent arch obstruction were performed in 15 patients. The median time to reintervention was 5 months and was less than 1 year in 12 patients. Kaplan-Meier freedom from arch reintervention was 88% at 1 year (95% confidence intervals: 82%-94%) and 82% at 5 years (95% confidence intervals: 72%-92%). Factors associated with shorter duration to arch reintervention by univariable Cox regression included younger age (continuous, P =.01; <2 weeks, P =.005), smaller transverse arch (absolute diameter, P <.001; indexed to weight, P =.03; indexed to ascending aortic diameter, P =.02), and smaller ascending aorta (absolute diameter, P =.02). Smaller absolute transverse arch diameter and younger age were the only independent predictors of shorter time to arch reintervention by multivariable Cox regression analysis. Weight and type of repair did not correlate with risk of recoarctation. CONCLUSIONS: Low weight is not a risk factor for recurrent obstruction after repair of coarctation of the aorta in infants less than 3 months of age. Rather, risk of recoarctation is more a function of the anatomy of the arch. Thus, it is not indicated to delay repair in low weight infants with the goal of achieving growth.

[Post-traumatic endocrine deficits : analysis of a series of 93 severe traumatic brain injuries]. / Déficits endocriniens post-traumatiques : analyse d'une sériede 93 traumatismes crâniens graves.

OBJECTIVE: The aim of the study is to measure the incidence in severe traumatic brain injury of endocrine deficits with special consideration for hypotestosteronemia in male patients. PATIENTS AND METHODS: Retrospective analysis of a series of 115 TBIs consecutively admitted to our brain injury unit. Endocrine screening is routinely performed at admission and includes radioimmunological assays for T3, T4, TSH, testosterone or oestradiol and progesterone, FSH, LH and cortisol. Twenty-two records were incomplete and excluded from further analysis. The analysis relies on 93 records among which those of 75 males. RESULTS: One partial hypothyroidism of pituitary origin (low T3, T4 and TSH and no raise of TSH after stimulation by TRH) and one posthypophyseal deficit were found. The incidence of hypotestosteronemia is 28%. All are of central origin (low testosterone and low or normal LH). In one case the hypothalamic origin is demonstrated by the considerable increase of LH after injection of GnRH. We found no correlation between the occurrence of endocrine deficit and either the Glasgow Coma Scale or the existence of basal skull fracture. DISCUSSION - CONCLUSION: These results show that endocrine deficits are not exceptional in TBIs and that isolated hypotestosteronemia is frequent. These deficits are not necessarily all of functional origin, but further studies including longitudinal follow up are required to conclude on this point. Further studies addressing the opportunity of substitution in some patients should also be conducted.

Effectiveness of pharmacomechanical thrombolysis in infants and children.

Between March 1995 and February 2000, 10 children with major thromboses were treated with local pharmacomechanical thrombolysis. Clinical improvement was found in 8 patients: follow-up angiography showed complete thrombus resolution in 5 patients and subtotal resolution in 4.

Cardiovascular response to lower body negative pressure stimulation before, during, and after space flight.

BACKGROUND: It is well known that space travel cause post-flight orthostatic hypotension and it was assumed that autonomic cardiovascular control deteriorates in space. Lower body negative pressure (LBNP) was used to assess autonomic function of the cardiovascular system. METHODS: LBNP tests were performed on six crew-members before and on the first days post-flight in a series of three space missions. Additionally, two of the subjects performed LBNP tests in-flight. LBNP mimics fluid distribution of upright posture in a gravity independent way. It causes an artificial sequestration of blood, reduces preload, and filtrates plasma into the lower part of the body. Fluid distribution was assessed by bioelectrical impedance and anthropometric measurements. RESULTS: Heart rate, blood pressure, and total peripheral resistance increased significantly during LBNP experiments in-flight. The decrease in stroke volume, the increased pooling of blood, and the increased filtration of plasma into the lower limbs during LBNP indicated that a plasma volume reduction and a deficit of the interstitial volume of lower limbs rather than a change in cardiovascular control was responsible for the in-flight response. Post-flight LBNP showed no signs of cardiovascular deterioration. The still more pronounced haemodynamic changes during LBNP reflected the expected behaviour of cardiovascular control faced with less intravascular volume. In-flight, the status of an intra-and extravascular fluid deficit increases sympathetic activity, the release of vasoactive substances and consequently blood pressure. Post-flight, blood pressure decreases significantly below pre-flight values after restoration of volume deficits. CONCLUSION: We conclude that the cardiovascular changes in-flight are a consequence of a fluid deficit rather than a consequence of changes in autonomic signal processing.

Frequency of restenosis after balloon pulmonary arterioplasty and its causes.

Restenosis has been described after balloon pulmonary arterioplasty (BPA), but litte is known about its frequency, settings, and time course. We undertook this study to (1) determine the incidence of restenosis after BPA, and (2) identify its potential determinants. We reviewed clinical data and measured pulmonary artery diameters from angiograms of 134 dilations on 75 patients (median 2.1 years, range 0.3 to 32) who had BPA from January 1990 to June 1998. Successful BPA was defined as a > or = 50% increase in predilation diameter, whereas restenosis was said to occur if there was a > or = 50% loss in initial diameter gain. The success rate after BPA by angiographic criteria was 64% (95% confidence interval 56% to 73%). Seventy-four percent of BPAs were successful by published standard criteria (angiographic criteria or > or = 20% change in right ventricular/aortic pressure). Baseline demographic variables and predilation parameters were not predictive of initial dilation success. Restenosis occurred in 35% (95% confidence interval 22% to 49%) of successfully dilated vessels. Only weight at follow-up (p = 0.02) was associated with an increased likelihood of restenosis. Predilation parameters, technical aspects of dilation, or immediate results of BPA were not predictive of restenosis. We therefore conclude that restenosis is unpredictable and more common after BPA than previously recognized.

Arterial and venous contributions to near-infrared cerebral oximetry.

BACKGROUND: Cerebral oximetry is a noninvasive bedside technology using near-infrared light to monitor cerebral oxygen saturation (Sco2) in an uncertain mixture of arteries, capillaries, and veins. The present study used frequency domain near-infrared spectroscopy to determine the ratio of arterial and venous blood monitored by cerebral oximetry during normoxia, hypoxia, and hypocapnia. METHODS: Twenty anesthetized children aged < 8 yr with congenital heart disease of varying arterial oxygen saturation (Sao2) were studied during cardiac catheterization. Sco2, Sao2, and jugular bulb oxygen saturation (Sjo2) were measured by frequency domain near-infrared spectroscopy and blood oximetry at normocapnia room air, normocapnia 100% inspired O2, and hypocapnia room air. RESULTS: Among subject conditions, Sao2 ranged from 68% to 100%, Sjo2 from 27% to 96%, and Sco2 from 29% to 92%. Sco2 was significantly related to Sao2 (y = 0. 85 x -17, r = 0.47), Sjo2 (y = 0.77 x +13, r = 0.70), and the combination (Sco2 = 0.46 Sao2 + 0.56 Sjo2 - 17, R = 0.71). The arterial and venous contribution to cerebral oximetry was 16 +/- 21% and 84 +/- 21%, respectively (where Sco2 = alpha Sao2 + beta Sjo2 with alpha and beta being arterial and venous contributions). The contribution was similar among conditions but differed significantly among subjects (range, approximately 40:60 to approximately 0:100, arterial:venous). CONCLUSIONS: Cerebral oximetry monitors an arterial/venous ratio of 16:84, similar in normoxia, hypoxia, and hypocapnia. Because of biologic variation in cerebral arterial/venous ratios, use of a fixed ratio is not a good method to validate the technology.