Management of the multiple limb amputee.

ISSUE: Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization. METHOD: A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation. CONCLUSION: Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.

Save that arm: a study of problems in the remaining arm of unilateral upper limb amputees.

A study has been made by questionnaire, personal examination and telephone interview of unilateral upper limb amputees seen at the Prince Henry Hospital, Australia between 1994 and 1997. There were 60 questionnaires posted. Replies were received from 46. Problems were noted in the remaining arm of 23 (50%). The respondents' problems not only consisted of overuse symptoms, but also of an exacerbation of pre-existing arthritis and injury due to trauma to the remaining arm during the accident. Case histories are given in 3 typical cases. Treating professionals are warned about the hazards that one arm amputations present to the remaining arm.

The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney, Australia.

A follow-up study by questionnaire or interview has been made of the 27 respondents of 41 upper limb amputees (66%) treated at the Royal South Sydney Hospital between 1981 and 1990. Prosthetic use of 8 h/day or more was 37% and occasional use was 18.5%. The prosthetic users were more likely to be distal amputees. The reason for the low level of prosthetic use is not known. The majority of non-users discarded prostheses after leaving their rehabilitation programme. Occupational changes were made by 72% of the amputees. The unemployment rate at follow-up was similar to the rest of the community, which is a better outcome than 25 years ago. Activities of daily living had been affected in all patients, but to a lesser extent in prosthetic users. Leisure pursuits were changed in 70% of patients, with these activities being more sedentary and indoor in nature. Of the 18 car drivers, 15 drove automatic cars with modifications. Phantom pain was experienced by 16 of the respondents (59%) and stump pain was experienced by seven. Only 26% used medication or alcohol for the pain. Pain did not affect prosthetic use or functional ability.

Impact of a quality assurance program on gastrointestinal endoscopy.

The impact of a quality assurance committee on documentation and use of gastrointestinal endoscopy was assessed. The committee, fulfilling Joint Commission on Accreditation of Healthcare Organizations criteria, performed retrospective (1984-1985) and prospective (1986-1988) reviews of all endoscopies. Criteria were developed from American College of Physicians and American Society for Gastrointestinal Endoscopy guidelines. All reviews of procedures that were questioned were returned to physicians for clarification. After reconsideration of the response, procedures were judged either justified or unjustified. There has been significant improvement in the quality of endoscopy reporting and documentation. The rate of questioned procedures decreased from 21.6% (95% confidence interval (CI), 20.1-23.1) in 1984-1985 to 9.2% (95% CI, 7.9-10.4) (P less than 0.01) in 1988. Improvement in use was reflected in the significant decrease in the rate of unjustified procedures from 8.2% (95% CI, 7.2-9.2) in 1984-1985 to 1.5% (95% CI, 1.0-2.0) (P less than 0.01) in 1988. Most importantly, this process curtailed the previously noted 10% annual increase in the number of endoscopic procedures (P less than 0.01).

Percutaneous transhepatic cholangiography combined with liver biopsy in the early and accurate diagnosis of jaundice.

By means of a new thin needle (Chiba), percutaneous transhepatic cholangiography was carried out in 60 jaundiced patients admitted to a general surgical unit over a period of 12 months. In patients in whom the technique was technically unsuccessful, or in whom inadequate information was obtained, a liver biopsy was performed. Our results indicate that this is a safe and reliable method of achieving an early and accurate diagnosis in the majority (91%) of jaundiced patients.

A search for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in an environment exposed annually to 2,4,5-trichlorophenoxyacetic acid ester (2,4,5-T) herbicides.

As part of a broad study to determine whether 2,3,7,8-tetrachlorodibenzo-P-dioxin (TCDD) is accumulating in the environment due to approved uses of 2,4,5-trichlorophenoxyacetic acid (2,4,5-T) based herbicides, samples of fish, water, mud and human milk were collected from areas in Arkansas and Texas where 2,4,5-T herbicides are used and were analyzed for TCDD. No TCDD was detected by a GC-MS procedure with a detection limit which averaged less than 10 ppt.