Relationship Between CT Head Findings and Long-term Recovery in Children with Complicated Mild Traumatic Brain Injury.

PRIMARY OBJECTIVE: Complicated mild traumatic brain injury (C-mTBI) refers to CT positive patients with clinically mild TBI. This study investigates the association between CT head findings at time of injury and recovery of paediatric patients with C-mTBI. RESEARCH DESIGN: Retrospective survey and chart review. METHODS: For paediatric patients with C-mTBI (N = 77), CT findings associated with corresponding degree and lengths of recovery from C-mTBI using logistic regression analysis. RESULTS: There was a trend that the odds of incomplete recovery at the time of survey was higher for older children than for younger children (OR = 1.14, 95% CI = 0.98-1.32, p = 0.072). There was a trend that the odds of incomplete recovery (OR = 6.26, 95% CI = 0.97-40.57, p = 0.054) and longer duration for recovery (OR = 8.14, 95% CI = 0.78-84.46, p = 0.079) was higher for children with multiple haemorrhagic contusions than those with single haemorrhagic contusion. No other imaging patterns predicted degree or length of recovery with statistical significance (p > 0.05). CONCLUSIONS: Other than the presence of multiple haemorrhagic contusions, no other pattern of imaging abnormality in paediatric C-mTBI appears to be associated with degree or length of recovery. Further studies with larger cohorts are encouraged.

Gabapentin and Tricyclics in the Treatment of Post-Concussive Headache, a Retrospective Cohort Study.

OBJECTIVE: To examine the association of commonly prescribed post-concussive medications, namely gabapentin and tricyclic antidepressants (TCAs), with symptom reduction after concussion. BACKGROUND: Concussion is a common diagnosis in modern medicine. Many providers use medication to target the residual symptoms of a concussion, with little evidence supporting their efficacy. DESIGN: Retrospective study with longitudinal analysis using mixed-effects and piecewise regression analyses of 277 patients presenting to an academic sports medicine clinic, all of whom were clinically diagnosed with a concussion. Main outcomes were patient-reported headache score (quantitative variable; 0-6) and combined symptom score (quantitative variable; 0-132) from the Post-Concussion Symptom Scale (PCSS). METHODS: Patients self-reported their symptom scores on the PCSS at the time of each clinic visit. Gabapentin or TCAs were prescribed to some patients during their follow-ups for headache treatment, based on physician judgment. Patients were classified into 3 groups: (1) no medication; (2) gabapentin; or (3) TCAs. Follow-up data were evaluated over 1 year. A mixed-effects and piecewise regression analysis were performed to assess long- and short-term effects of medication status. RESULTS: The mixed-effects analysis showed a significant decrease in both headache and symptom scores over time in each medication group and in those not receiving medication (P ≤ .014 for all scenarios, B = -0.005 and -0.08, respectively). Although patients in the 2 medication groups showed significantly higher headache and symptom scores (P < .001), neither medication had a significant effect on longitudinal improvements in the outcome scores. The piecewise regression, however, showed short-term improvements with gabapentin (1.3 points, P = .004) and more sustained improvements with TCAs (3.5 points, P = .006). CONCLUSIONS: Patients recover from a concussion with time, regardless of medication. Gabapentin and TCAs appear to have immediate effects on improving symptom burden, but long-term outcomes show similar improvement compared to those who are not prescribed medication. More rigorous prospective studies are required to better elucidate their efficacy.

Phosphate signaling through alternate conformations of the PstSCAB phosphate transporter.

BACKGROUND: Phosphate is an essential compound for life. Escherichia coli employs a signal transduction pathway that controls the expression of genes that are required for the high-affinity acquisition of phosphate and the utilization of alternate sources of phosphorous. These genes are only expressed when environmental phosphate is limiting. The seven genes for this signaling pathway encode the two-component regulatory proteins PhoB and PhoR, as well as the high-affinity phosphate transporter PstSCAB and an auxiliary protein called PhoU. As the sensor kinase PhoR has no periplasmic sensory domain, the mechanism by which these cells sense environmental phosphate is not known. This paper explores the hypothesis that it is the alternating conformations of the PstSCAB transporter which are formed as part of the normal phosphate transport cycle that signal phosphate sufficiency or phosphate limitation. RESULTS: We tested two variants of PstB that are predicted to lock the protein in either of two conformations for their signaling output. We observed that the pstBQ160K mutant, predicted to reside in an inward-facing, open conformation signaled phosphate sufficiency whereas the pstBE179Q mutant, predicted to reside in an outward-facing, closed conformation signaled phosphate starvation. Neither mutant showed phosphate transport. CONCLUSIONS: These results support the hypothesis that the alternating conformations of the PstSCAB transporter are sensed by PhoR and PhoU. This sensory mechanism thus controls the alternate autokinase and phospho-PhoB phosphatase activities of PhoR, which ultimately control the signaling state of the response regulator PhoB.

Reliability of the balance error scoring system in a population with protracted recovery from mild traumatic brain injury.

OBJECTIVE: This study aimed to identify the Balance Error Scoring System's (BESS) intraclass reliability in a cohort of patients with prolonged symptoms using variance component analysis and intraclass correlation coefficient (ICC). SETTING: Outpatient sports medicine/concussion clinic. PARTICIPANTS: A total of 241 paediatric and 102 adult patients with symptoms lasting longer than 10 days. INTERVENTIONS: BESS testing. DESIGN: Retrospective review. MAIN OUTCOME MEASURES: Percent variance for each BESS component and intraclass reliability. A five-component model (including all components except for firm double-leg) and a four- component model (including all components except for firm and foam doubleleg) were also performed to compare ICC values. RESULTS: The largest source of variance came from stance (41.1%). The BESS components firm single (25.5%) and foam tandem (27.5%) stances accounted for the largest percentages of variance, while firm double (1.1%) and foam double (6.9%) accounted for the smallest percentages. The ICC for all patients was 0.800, and increased both if the firm double stance was excluded, or if both double-leg stances were excluded. CONCLUSION: BESS reliability appears to be high in a concussed cohort, regardless of age. Removing the two double-leg stance portions increases the ICC of the test without failing to identify balance deficits.

Reliability Testing of the Balance Error Scoring System in Children Between the Ages of 5 and 14.

OBJECTIVE: Pediatric concussion is an extensive public health concern with a complex clinical presentation. Balance assessment has been well-studied in the adult population, but has been limited in children. We aimed to assess the reliability and minimum detectable change (MDC) of the Balance Error Scoring System (BESS) in healthy children. DESIGN: This prospective observational study included 373 healthy children aged 5 to 14. Interrater reliability was assessed by having 4 assessors review videos of 50 random subjects distributed evenly by age and sex across the entire cohort. Intrarater reliability was performed by having assessors review videos of other assessors' live evaluations. Test-retest reliability was obtained by comparing BESS scores as recorded live at the 2 separate time points by the same rater. SETTING: Local elementary and junior high schools. PARTICIPANTS: Three hundred and seventy three healthy children between the ages of 5 and 14. INTERVENTIONS: The BESS was performed on all children. MAIN OUTCOME MEASURES: Intraclass Correlation Coefficients (ICCs) and MDC Scores. RESULTS: The overall interrater ICC was determined to be 0.93 [95% confidence interval (CI), 0.79-0.97] and intrarater ICC was 0.96 (95% CI, 0.95-0.97) with individual intrarater ICCs ranging between 0.69 and 0.99. The test-retest reliability was 0.90 (95% CI, 0.88-0.92). The MDCs were 9.6, 4.6, and 7.3 points at the 95% CIs for interrater, intrarater, and test-retest comparisons, respectively. No learning effect was seen. CONCLUSIONS: The BESS demonstrates excellent reliability in the pediatric population without evidence of a learning effect.

A Normative Dataset of the Balance Error Scoring System in Children Aged Between 5 and 14.

OBJECTIVE: Pediatric head injuries occur commonly and are being reported in increasing numbers. Balance testing is a key component in the evaluation of suspected concussion, and the balance error scoring system (BESS) is likely the most well-known and widely used measure. To date, normative BESS scores for adults have been reported but not for children. DESIGN: Normative data for BESS scores and modified BESS scores were created in a cohort of healthy children. Potential variables were analyzed as predictors of BESS performance. SETTING: Local elementary and junior high schools. PARTICIPANTS: A total of 373 healthy children between the ages of 5 and 14. INTERVENTIONS: The BESS was performed on all children. ASSESSMENT OF RISK FACTORS: Gender, body mass index percentile, previous concussions, athletic participation, age, and the parental opinion of child's balance ability were examined as factors associated with the BESS score. MAIN OUTCOME MEASURES: BESS scores. RESULTS: Normative data are reported, stratified by age groups of 5 to 7 years, 8 to 10 years, and 11 to 14 years of age, for both BESS and modified BESS. Median BESS scores are 23 for children aged 5 to 7, 18 for children aged 8 to 10, and 16 for children aged 11 to 14. Median modified BESS scores are 8 for children age 5 to 7, 5 for children age 8 to 10, and 4 for children age 11 to 14. Increasing age and positive parental opinion regarding their child's balance ability were independently correlated with decreasing BESS scores (P < 0.01). CONCLUSIONS: The normative data on BESS scores for healthy children reported here provide age-stratified reference values for suspected balance alterations.

Evidence for the Validation of a Single Item Recovery Question (SIRQ) in Children With Mild and Complicated Mild Traumatic Brain Injury.

BACKGROUND: Recovery from a brain injury occurs in varying degrees. The objective of this study was to investigate the concurrent validity of a parent-reported 10-point scale for degree of recovery, Single Item Recovery Question (SIRQ), in children with mild traumatic brain injury (mTBI) or complicated mTBI (C-mTBI) compared with validated assessments of symptom burden (Post-Concussion Symptom Inventory Parent form-PCSI-P) and quality of life (Pediatric Quality of Life Inventory [PedsQL]). METHODS: A survey was sent to parents of children aged five to 18 years who presented to pediatric level I trauma center with mTBI or C-mTBI. Data included parent-reported postinjury recovery and functioning of children. Pearson correlation coefficients (r) were calculated to measure the associations of the SIRQ with the PCSI-P and the PedsQL. Hierarchical linear regression models were used to examine if covariates would increase the predictive value of the SIRQ to the PCSI-P and the PedsQL total scores. RESULTS: Of 285 responses (175 mTBI and 110 C-mTBI) analyzed, Pearson correlation coefficients for the SIRQ to the PCSI-P (r = -0.65, P < 0.001) and PedsQL total and subscale scores were all significant (P < 0.001) with mostly large-sized effects (r ≥ 0.500), regardless of mTBI classification. Covariates, including mTBI classification, age, gender, and years since injury, resulted in minimum changes in the predictive value of the SIRQ to the PCSI-P and the PedsQL total scores. CONCLUSIONS: The findings demonstrate preliminary evidence for the concurrent validity of the SIRQ in pediatric mTBI and C-mTBI.

Sport participation among children with complicated mild traumatic brain injury.

BACKGROUND: Complicated mild traumatic brain injury (C-mTBI) represents mTBI with positive trauma-related radiographic findings, such as hematoma. It is estimated that 7.5% of all pediatric mTBIs meet these criteria. There is a paucity of research on return to sports in children with C-mTBI. OBJECTIVE: To examine children with C-mTBI, mTBI with skull fracture (mTBI-SF) only and mTBI in relation to sport participation and factors associated with repeated injury. DESIGN: Cross-sectional survey. SETTING: Level I pediatric trauma center. PARTICIPANTS: Parents of children who were 5-18 years of age at the time of injury who sustained C-mTBI or mTBI from 2010 to 2013. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sports participation characteristics before and after injury in children with C-mTBI and mTBI as a function of degree and length of recovery. Repeat mTBI after the index injury was also examined. RESULTS: Of 247 children who participated in sports preinjury (27.5% with C-mTBI and 9.7% with mTBI-SF), 95.1% returned to sports. There was no significant difference by mTBI type regarding participation in any sports (p = .811) nor with high-risk sports (p = .128). C-mTBI but not mTBI-SF (versus mTBI) was associated with lower odds of sustaining a repeat mTBI (odds ratio = 0.30, p = .045). Waiting longer (>3 months compared to <1 month) to return to contact sports was associated with lower odds of sustaining a repeat mTBI (odds ratio = 0.23, p < .05). CONCLUSIONS: Children with C-mTBI and mTBI-SF resume similar sports as children with mTBI. Those with C-mTBI and those who take longer to return to play may have lower risk of repeat mTBIs. Prospective research is needed to inform the development of evidence-based guidelines for children with C-mTBI and mTBI-SF.

Outcomes after minimally invasive and surgical management of suprascapular nerve entrapment: A systematic review.

Background: The prevalence of suprascapular neuropathy is higher than previously estimated. Recent literature highlights a myriad of treatment options for patients ranging from conservative treatment and minimally invasive options to surgical management. However, there are no comprehensive review articles comparing these treatment modalities. Objective: The purpose of this review article is to summarize the current state of knowledge on suprascapular nerve entrapment and to compare minimally invasive treatments to surgical treatments. Methods: The literature search was performed in Mendeley. Search fields were varied redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by 3 authors until an agreement was reached. Results: Recent studies have further elucidated the pathoanatomy and described several risk factors for entrapment ranging. Four studies met our inclusion criteria regarding peripheral nerve stimulation with good pain and clinical outcomes. Two studies met our inclusion criteria regarding pulsed radiofrequency and showed promising pain and clinical outcomes. One study met our inclusion criteria regarding transcutaneous electrical nerve stimulation and showed good results that were equivalent to pulsed radiofrequency. Surgical treatment has shifted to become nearly all arthroscopic and surgical outcomes remain higher than minimally invasive treatments. Conclusions: Many recently elucidated anatomical factors predispose to entrapment. A history of overhead sports or known rotator cuff disease can heighten a clinician's suspicion. Entrapment at the suprascapular notch is more common overall, yet young athletes may be predisposed to isolated spinoglenoid notch entrapment. Pulsed radiofrequency, peripheral nerve stimulation, and transcutaneous electrical nerve stimulation may be effective in treating patients with suprascapular nerve entrapment. Arthroscopic treatment remains the gold-standard in patients with refractory entrapment symptoms.

Sensory Phenotypes for Balance Dysfunction After Mild Traumatic Brain Injury.

BACKGROUND AND OBJECTIVES: Recent team-based models of care use symptom subtypes to guide treatments for individuals with chronic effects of mild traumatic brain injury (mTBI). However, these subtypes, or phenotypes, may be too broad, particularly for balance (e.g., 'vestibular subtype'). To gain insight into mTBI-related imbalance we 1) explored whether a dominant sensory phenotype (e.g., vestibular impaired) exists in the chronic mTBI population, 2) determined the clinical characteristics, symptomatic clusters, functional measures, and injury mechanisms that associate with sensory phenotypes for balance control in this population, and 3) compared the presentations of sensory phenotypes between individuals with and without previous mTBI. METHODS: A secondary analysis was conducted on the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium. Sensory ratios were calculated from the Sensory Organization Test, and individuals were categorized into one of eight possible sensory phenotypes. Demographic, clinical, and injury characteristics were compared across phenotypes. Symptoms, cognition, and physical function were compared across phenotypes, groups, and their interaction. RESULTS: Data from 758 Service Members and Veterans with mTBI and 172 with no lifetime history of mTBI were included. Abnormal visual, vestibular, and proprioception ratios were observed in 29%, 36%, and 38% of people with mTBI, respectively, with 32% exhibiting more than one abnormal sensory ratio. Within the mTBI group, global outcomes (p<0.001), self-reported symptom severity (p<0.027), and nearly all physical and cognitive functioning tests (p<0.027) differed across sensory phenotypes. Individuals with mTBI generally reported worse symptoms than their non-mTBI counterparts within the same phenotype (p=0.026), but participants with mTBI in the Vestibular-Deficient phenotype reported lower symptom burdens than their non-mTBI counterparts [e.g., mean(SD) Dizziness Handicap Inventory = 4.9(8.1) for mTBI vs. 12.8(12.4) for non-mTBI, group*phenotype interaction p<0.001]. Physical and cognitive functioning did not differ between groups after accounting for phenotype. DISCUSSION: Individuals with mTBI exhibit a variety of chronic balance deficits involving heterogeneous sensory integration problems. While imbalance when relying on vestibular information is common, it is inaccurate to label all mTBI-related balance dysfunction under the 'vestibular' umbrella. Future work should consider specific classification of balance deficits, including specific sensory phenotypes for balance control.

Hyperhidrosis of the residual limb: a narrative review of the measurement and treatment of excess perspiration affecting individuals with amputation.

BACKGROUND: Hyperhidrosis (HH) is a relatively common disorder involving excessive sweating, typically of the palms or axilla. HH can also frequently occur after limb amputation, where the remaining residual limb excessively perspires, leading to an increased risk of dermatological disorders and functional limitations, such as the inability to comfortably or safely wear a prosthesis. Although many treatments have been proposed to treat HH within the dermatology community, they are not widely known by healthcare providers typically involved in caring for individuals with acquired limb loss. OBJECTIVES: To appraise the current state of quantitative and qualitative assessment of HH within the residual limb and examine existing and future treatment strategies for this problem. STUDY DESIGN: Narrative Literature Review. METHODS: A literature review focused on the assessment and treatment of excessive sweating of residual limbs. RESULTS: There is currently no objective or subjective standard to assess or diagnose HH of the residual limb. Conventional therapies for HH do not always translate to the population of individuals with limb loss. Emerging modalities for treating HH show promise toward a permanent resolution of excess perspiration but require additional studies within people with amputation. CONCLUSIONS: Further research is needed to quantify standard values to objectively and subjectively assess and diagnose hyperhidrosis of the residual limb. New and developing treatments for hyperhidrosis require additional studies to assess efficacy and safety in the residual limb.

Novice vs expert inter-rater reliability of the balance error scoring system in children between the ages of 5 and 14.

BACKGROUND: The Balance Error Scoring System (BESS) is a tool to measure balance, however, no studies have shown its reliability between novice and expert raters. RESEARCH QUESTION: What is the inter-rater reliability of BESS measurements when performed by novice raters compared to experts, and does completion of a focused, online training module increase the inter-rater reliability among novice raters? METHODS: In this reliability study, 5 novice volunteers were asked to independently rate BESS tests from 50 random prerecorded BESS videos of normal healthy subjects aged 5-14. Novice raters regraded the same 50 videos after receiving a formal training. The novices' scores before and after the formal training were compared to one another and then the scores were compared to 4 expert scores. Intraclass correlation (ICC) with 95 % confidence intervals or percent agreements were calculated and compared across groups. RESULTS: For the total BESS score, novice raters showed good reliability (ICC 0.845) which did not change with a formal training (ICC 0.846). Expert raters showed excellent reliability (ICC 0.929). Poor to moderate reliability was noted in the foam stance-single leg in the untrained novice and trained novice group (ICCs 0.452 and 0.64 L respectively). SIGNIFICANCE: BESS testing by novice raters with only written instruction and no formal training yields good inter-rater reliability. In contrast, BESS testing by expert raters yields excellent reliability. A focused training for novice raters conferred a small improvement in the reliability of the scoring of the single leg stance on foam condition but not a significant difference to the overall BESS score. While novices demonstrated promising reliability for overall BESS scores, optimizing clinical research using the BESS with expert raters show the highest reliability.

Factors Associated With Degree and Length of Recovery in Children With Mild and Complicated Mild Traumatic Brain Injury.

BACKGROUND: A complicated mild traumatic brain injury (C-mTBI) is an mTBI with some form of intracranial abnormality identified radiographically. The lack of knowledge in recovery patterns and no clear guidelines on return to activity in children with C-mTBI provide unique challenges to physicians. OBJECTIVE: To examine recovery patterns among three cohorts: mTBI, mTBI with skull fracture only (mTBI-SF), and C-mTBI via a cross-sectional survey. METHODS: Caregivers of children with mTBI (from hospital database queries 2010-2013) were mailed a questionnaire on preinjury health, postinjury recovery, and activity patterns before and after injury. We examined degree (0-10 with 10 being complete recovery) and length (in months) of recovery in children with mTBI, and associations of potential risk factors to these variables. RESULTS: Of the 1777 surveyed, a total of 285 complete responses were analyzed for this study. Data included 175 (61.4%) children with mTBI, 33 (11.6%) children with mTBI-SF, and 77 (27.0%) children with C-mTBI. Older age and C-mTBI (vs mTBI) were significantly associated with a lower degree and longer period of recovery (P < .05). Predicted probabilities of complete recovery for children with mTBI, those with mTBI-SF, and those with C-mTBI were 65.5%, 52.7%, and 40.0%, respectively. Predicted probabilities of not yet completely recovered after more than a year since injury for these groups were 11.3%, 24.4%, and 37.6%, respectively. CONCLUSION: These results demonstrate significant differences in children with different forms of mTBI, and argue for further investigation of treatment plans individualized for each form of mTBI.

Complicated Mild Traumatic Brain Injury at a Level I Pediatric Trauma Center: Burden of Care and Imaging Findings.

OBJECTIVE: The aims of this study were: (1) to characterize mild traumatic brain injury (mTBI), mTBI with skull fracture, and complicated mTBI in school-aged children seen at a Level I pediatric trauma center and (2) to examine the nature of imaging findings seen in children with mTBI with skull fracture and those with complicated mTBI. METHODS: A total of 1777 pediatric patients (male: 1193 or 67.1%; age = 11.1 ± 3.5 years) sustaining mTBI who presented to the Emergency Department or directly to the trauma service in the years 2010 to 2013 were identified and classified into mTBI (n = 1,319 or 74.2%), mTBI with skull fracture (n = 127 or 7.2%), and complicated mTBI (n = 331 or 18.6%). Patient characteristics and imaging findings were analyzed using descriptive statistics, Pearson's χ2 test, Fisher's exact test, and logistic regression analysis. RESULTS: In children with complicated mTBI, subdural hematoma (36.9%) was the most common finding. Of the 331 children with complicated mTBI, 241 (72.8%) had multiple findings compared with one (0.8%) of 127 children having mTBI with skull fracture (Fisher's exact P < 0.001), with logistic regression analysis revealing younger age as a potential risk factor (P < 0.01). Children sustaining a depressed or complex skull fracture were nearly twice as likely as those with simple, linear skull fracture to have intracranial abnormality. CONCLUSIONS: Multiple radiographic findings in children sustaining mTBI with skull fracture or complicated mTBI are prevalent (72.8%), with younger age as a potential risk factor.

Iodine-Starch test for assessment of hyperhidrosis in amputees, evaluation of different methods of application.

PURPOSE: Hyperhidrosis is a common problem for amputees. The iodine-starch test is frequently used to assess hyperhidrosis, but a method for its application has not been described for amputees. METHODS: We performed an unblinded comparison of the iodine-starch test using various methods to protect the prosthesis in 10 prosthetic limb users with hyperhidrosis. RESULTS: Plastic wrap produced a diffuse pattern of sweating in 70% of subjects. Forty percent had complaints about this method, and 50% experienced leakage of iodine stain onto prosthetic liners. The prosthetic sheath produced a focal or multifocal reaction in 100% of subjects after 10 min of ambulation. Eighty percent had minor leakage onto the liner, and complaints were noted in 10%. The proportion that experienced diffuse sweating was significantly higher in the plastic wrap condition (p = 0.016; difference in proportions = 70%; 95% confidence interval = 32-100%). The prosthetic sock was tested in four subjects and all had at least mild complaints; three had minor leakage onto the liner. Repeated complaints and lack of stain prevention led to discontinuation with this method. CONCLUSIONS: Of the three methods, the sheath produces a focal or multifocal reaction after 10 min of ambulation and tends to cause less subject complaints. It should be the preferred method to apply the iodine-starch test to amputees. Implications for rehabilitation Hyperhidrosis is a common problem in amputees which negatively affects quality of life. The iodine-starch test is commonly used to guide treatment decisions for hyperhidrosis, but a preferred method for applying it in amputees has not been described. This study describes different methods for applying the iodine-starch test. A prosthetic sheath covering should be the preferred method for the iodine-starch test in amputees.

Prolonged, severe intrathecal baclofen withdrawal syndrome: a case report.

Intrathecal baclofen (ITB) withdrawal is a well-recognized complication when drug delivery is disrupted for any reason. ITB withdrawal varies widely in its severity and poses the very real possibility of death if not promptly managed. Cases of withdrawal lasting greater than 1 or 2 weeks, however, are sparse. We report the case of an 11-year-old girl with spastic quadriplegic cerebral palsy who developed an infected pump and subsequent meningitis, prompting the removal of her pump and catheter. She subsequently developed a severe, prolonged baclofen withdrawal syndrome marked by increased spasticity, agitation, hypertension, and tachycardia that lasted nearly 2 months, requiring intensive care and continuous intravenous sedation with benzodiazepines and opiates. Her pump was eventually replaced on hospital day 56 and within 24 hours her symptoms dramatically improved. She was eventually weaned off sedating medications and returned to baseline functional status. Typical management of baclofen withdrawal is reviewed. To date, the literature has not discussed the potential role for opiates in managing baclofen withdrawal, yet a growing body of literature is examining the interplay between opiates and gamma-aminobutyric acid B pathways. A potential role for opiates in managing severe baclofen withdrawal is proposed.

Residual Limb Hyperhidrosis Managed by Botulinum Toxin Injections, Enhanced by the Iodine-Starch Test: A Case Report.

Hyperhidrosis of the residual limb is a common condition affecting patients with amputations. The iodine-starch test is used by dermatologists to identify focal areas of hyperhidrosis before treatment with botulinum toxin. Here, we describe a case of a patient with a transtibial amputation with moderate-to-severe hyperhidrosis who received intradermal botulinum toxin injections to treat residual limb hyperhidrosis, with particular emphasis given to the utility of the iodine-starch test in managing this common condition. The iodine-starch test successfully identified hyperhidrotic areas before treatment as well as confirmed the physiologic anhidrotic effect of the botulinum toxin treatment. LEVEL OF EVIDENCE: V.

Incidence, severity, and impact of hyperhidrosis in people with lower-limb amputation.

To assess the incidence and severity of self-reported hyperhidrosis in patients with amputation and understand its effects on prosthetic fit or function, a cross-sectional survey of patients at two amputee clinics was performed. Responses from 121 subjects with lower-limb amputation were analyzed. Of these subjects, 66% reported sweating to a degree that it interfered with daily activities, as measured by the Hyperhidrosis Disease Severity Scale. There was a significant association between sweating and interference with prosthetic fit and function. Sweating was more severe in cases of transtibial amputations, patients under the age of 60, warm weather, and vigorous activity. There was no relationship between severity of sweating and time since amputation, etiology of amputation, duration of daily prosthetic use, or reported ability to perform functional tasks. Subjects reported trying multiple interventions, but the self-reported effectiveness of these treatments was low. Hyperhidrosis, a common problem associated with prosthetic usage, varies in severity and often interferes with daily activities. Sweating severity is associated with poor prosthetic fit and function. Risk factors include younger age and transtibial amputation status. Treatment strategies generally lack efficacy. The results of this study may provide guidance for future interventions and treatment options.