Methane and hydrogen positivity on breath test is associated with greater body mass index and body fat.

CONTEXT: Colonization of the gastrointestinal tract with methanogenic archaea (methanogens) significantly affects host metabolism and weight gain in animal models, and breath methane is associated with a greater body mass index (BMI) among obese human subjects. OBJECTIVE: The objective of the study was to characterize the relationship between methane and hydrogen on breath test (as a surrogate for colonization with the hydrogen requiring methanogen, Methanobrevibacter smithii), body weight, and percent body fat in a general population cohort. DESIGN AND SUBJECTS: This was a prospective study (n = 792) of consecutive subjects presenting for breath testing. SETTING: The study was conducted at a tertiary care center. OUTCOME MEASUREMENTS: BMI and percent body fat were measured. RESULTS: Subjects were classified into 4 groups based on breath testing: normal (N) (methane <3 ppm and hydrogen <20 ppm at or before 90 minutes); hydrogen positive only (H+) [methane <3 ppm and hydrogen ≥20 ppm); methane positive only (M+) (methane ≥3 ppm and hydrogen <20 ppm), or methane and hydrogen positive (M+/H+) (methane ≥3 ppm and hydrogen ≥20 ppm]. There were significant differences in age but not in gender across the groups. After controlling for age as a confounding variable, M+/H+ subjects had significantly higher BMI than other groups (N: 24.1 ± 5.2 kg/m(2); H+: 24.2 ± 4.5 kg/m(2); M+: 24.0 ± 3.75 kg/m(2); M+/H+: 26.5 ± 7.1 kg/m(2), P < .02) and also had significantly higher percent body fat (N: 28.3 ± 10.0%; H+: 27.5 ± 9.0%; M+: 28.0 ± 8.9%; M+/H+; 34.1 ± 10.9%, P < .001). CONCLUSIONS: The presence of both methane and hydrogen on breath testing is associated with increased BMI and percent body fat in humans. We hypothesize that this is due to colonization with the hydrogen-requiring M smithii, which affects nutrient availability for the host and may contribute to weight gain.

An unusual case of Dantrolene sodium-induced urinary retention in post-traumatic minimally responsive state.

INTRODUCTION: An unusual case of urinary retention is reported occurring during the inpatient rehabilitation of minimally responsive state (MRS) following severe traumatic brain injury (TBI). CLINICAL PICTURE: Urodynamic evaluation showed detrusor acontractility and subsequent management involved intermittent bladder catheterization and treatment of a single urinary tract infection. TREATMENT: Factors contributing to her bladder paralysis included severe immobility, tetraplegia and treatment of diffuse spasticity with oral Dantrolene sodium 250 mg per day. Constipation, diabetes and spinal cord injury were absent. In addition, she received unilateral partial sciatic neurolysis with 50% alcohol for severe knee flexor spasticity and intra-muscular Botulinum toxin A to both spastic upper limbs. OUTCOME: Bladder acontractility resolved completely when Dantrolene was reduced with subsequent achievement of a catheter-free status and small post-void residual volumes. Repeat urodynamics showed spontaneous detrusor contractions. CONCLUSION: A discussion of possible aetiologic factors for detrusor acontracility following TBI is presented including a brief review of the literature.

Rehabilitation outcome after primary subarachnoid haemorrhage.

Functional outcome of primary subarachnoid haemorrhage survivors was examined following rehabilitation in Singapore. Thirty-nine inpatients admitted over a 4-year period were studied retrospectively. There were 21 (53.8%) males and 18 (46.2%) females, mean age 50.9 (SD 12.7) years, at 37.3 days (SD 16.8) post-injury. Seven (17.9%) had dysphagia and 12 (30.8%) had dysphasia; 17 (43.6%) nondysphasics had cognitive impairment; 26 patients (66.7%) had Medical Research Council motor power under grade 4. Modified Barthel Index on Admission (MBIA) and Discharge (MBID) were 45.7 (SD 22.3) and 78.3 (SD 18.9), respectively (p = 0.001). Correlation between MBIA and MBID was statistically significant (r = 0.529, p = 0.001). Mean length of stay in rehabilitation was 42.3 days (SD 27.6). Thirty-four patients (87.2%) were discharged home. Nine out of 24 previously employed patients (37.5%) returned to gainful employment. Despite multiple deficits, the patients made significant functional improvement.

Intramuscular neurolysis with alcohol to treat post-stroke finger flexor spasticity.

OBJECTIVE: To evaluate the effectiveness of intramuscular neurolysis with alcohol for the treatment of finger flexor spasticity in individuals with stroke. DESIGN: Case series. SETTING: Outpatient clinic of a tertiary rehabilitation facility. SUBJECTS: Thirty patients with a mean age of 60.2 years and post-stroke duration of 8.3 months with finger flexor spasticity. INTERVENTIONS: Intramuscular neurolysis or motor point blocks of the finger flexors of the hemiplegic upper extremity with 50% ethyl alcohol. MAIN OUTCOME MEASURES: The severity of spasticity as measured by the Modified Ashworth Scale (MAS) and the passive range of motion of the proximal interphalangeal joints of the second to fifth digits. RESULTS: The mean baseline MAS score was 4.0 +/- 0.5 and this improved to 2.0 +/- 0.6, 2.2 +/- 0.6 and 2.6 +/- 0.6 at four weeks, three months and six months post neurolysis respectively. The gains in range of motion were 18.5 +/- 6.7, 17.5 +/- 6.4 and 14.9 +/- 4.8 degrees at four weeks, three months and six months post neurolysis respectively. These improvements were statistically significant (p < 0.05). Two subjects developed temporary dysesthetic pain of the forearm and palm. CONCLUSION: Intramuscular neurolysis with alcohol provides good relief of finger flexor spasticity in hemiplegic individuals.

Clinical and functional outcome after alcohol neurolysis of the tibial nerve for ankle-foot spasticity.

PURPOSE: To report one's experience of using 50-100% alcohol for neurolysis of the tibial nerve in chronic ankle-foot spasticity. METHODS: The records of patients who received alcohol neurolysis of the tibial nerve were retrospectively reviewed. Repetitive monopolar nerve stimulation was used to localize the tibial nerve. Outcome measures included muscle tone as measured by the Modified Ashworth Score (MAS), passive ankle range of motion (PROM), effect on clonus, plantar flexor motor strength, visual gait analysis and use of orthoses. RESULTS: A total of 21 tibial nerves were neurolysed in 18 patients (mean age 38.9 +/- 15.8 years, 12 males, six females). Mean duration post-event was 14.8 +/- 3.9 months. The mean pre-neurolysis MAS was 2.50 +/- 0.77 and this improved to 0.97 +/- 0.88 (p < 0.001) and 0.93 +/- 0.85 (p < 0.001) at 1 and 6 months post-procedure, respectively. Average duration of effect was 10.5 +/- 8.9 months. Eleven out of 12 patients (91.7%) with sustained ankle clonus had complete abolishment lasting 6 months. Mean gain in PROM was 24.6 +/- 16.1 degrees and 32.6 +/- 19.0 degrees at 1 and 3 months post-neurolysis, respectively (p < 0.001, < 0.02). No decrease in motor strength was seen post-neurolysis. All 13 ambulant patients had visible improvements in gait. Complications were transient and included dysesthetic pain (4), sensory loss (1) and distal limb oedema (1). CONCLUSION: Alcohol neurolysis (50-100%) of the tibial nerves is an effective and safe method of managing ankle-foot spasticity.

Botulinum toxin A in the treatment of hemiplegic spastic foot drop--clinical and functional outcomes.

PURPOSE OF STUDY: This study investigated the effects of intramuscular Botulinum toxin A (BTX-A) in 7 ambulatory chronic hemiplegic subjects (5 male, 2 female) who had spastic hemiplegic foot drop. BASIC PROCEDURES: An open label study involving intramuscular injections of Botulinum toxin A (dilution 10 U/0.1 ml) was performed in ambulatory chronic hemiplegics. Tone as measured by the Modified Ashworth Scale (MAS), passive ankle joint range of motion (PROM), briskness of ankle reflexes, gait velocity, motor functional status and effects on the use of walking aids were measured at baseline, 3 and 12 weeks post-injection. MAIN FINDINGS: All subjects except I showed a significant decrease in MAS from 3.43 +/- 0.54 at baseline to 2.0 +/- 1.15 at 3 weeks post-injection, which was maintained during the 3 month study duration. The median change in PROM was 17.0 degrees (SD 12.1 degrees) at 3 weeks and 5.0 degrees (SD 7.1 degrees) at 12 weeks (p = 0.25) Gait velocity and Modified Barthel Index mobility scores which measured motor functional status were not significantly altered post-injection. The injections were generally well-tolerated and there were no serious adverse side effects. PRINCIPAL CONCLUSIONS: Although significant decreases in muscle tone were observed and maintained after intramuscular Botulinum toxin A during the 3 month study period, this regional intervention did not significantly influence functional status, gait velocity and the use of ambulatory aids.

Alcohol neurolysis of the sciatic nerve in the treatment of hemiplegic knee flexor spasticity: clinical outcomes.

OBJECTIVE: To study clinical outcomes after 50% to 100% alcohol neurolysis of the sciatic nerve in the treatment of chronic hemiplegic knee flexor spasticity. DESIGN: Case series using a convenience sample. SETTING: Rehabilitation teaching hospital. PATIENTS: Eight patients (mean age, 55.1 +/- 12.1 yr; mean duration to block, 4.4 +/- 3.7 mo) with chronic hemiplegia and severe spasticity (modified Ashworth scale [MAS] score < 2) secondary to cerebrovascular accidents (n = 5) and traumatic brain injuries (n = 3). Two patients were ambulant, 6 were wheelchair-bound. INTERVENTIONS: Fifty percent to 100% alcohol neurolysis of the sciatic nerve using repetitive electric stimulation to localize the sciatic nerve. MAIN OUTCOME MEASURES: MAS score, gain in knee range of motion (ROM), and visual inspection of gait at 0, 1, and 6 months postneurolysis. Nonparametric tests were used in statistical analysis. RESULTS: The mean preinjection MAS score was 2.8 +/- 0.7, which improved to 1.4 +/- 0.7 at 1 month (p = .005), and 1.8 +/- 0.9 (p = .01) and 1.9 +/- 1.1 (p = .02) at 3 and 6 months postinjection, respectively. The mean gain in knee ROM was 34.4 degrees +/- 15.7 degrees at 1 month postinjection and was maintained at 6 months postinjection. Improvements in gait were noted in both ambulant patients, and improved positioning in 3 of 6 wheelchair-bound patients. The incidence of dysesthetic pain was 0%. CONCLUSION: Fifty percent to 100% alcohol neurolysis of the sciatic nerve is a safe and effective method for treatment of hemiplegic knee flexor spasticity, with therapeutic effects lasting 6 months.

Phenytoin-induced asterixis--uncommon or under-diagnozed?

Asterixis is a recognized but uncommon clinical sign of phenytoin toxicity. A case is presented in which asterixis and acute cerebellar dysfunction occurred when the phenytoin levels reached the toxic range. It disappeared when the drug levels normalized. Asterixis is now classified as a form of negative myoclonus, which is characterized by irregular myoclonic lapses of posture. The neurochemistry and physiology of phenytoin causing asterixis has yet to be elucidated.

Pain and loss of function in head and neck cancer survivors.

Head and neck cancers are relatively uncommon malignancies and the characteristics of pain and functional impairments in survivors are not well studied. To characterize the incidence, location, severity, types and causes of pain; associated functional impairments, and pain management methods, the medical charts of 40 consecutive outpatients with biopsy-proven head and neck cancers were reviewed. Pain was severe in 52% (N = 21), and was located near sites of tumor origin. Pain was caused by tumor recurrence in 35% (N = 14), treatment sequelae in 30% (N = 12), multiple etiologies in 25% (N = 10), and unrelated causes in 10% (N = 4). Pains were mixed nociceptive and neuropathic pain in 37.5% (N = 15), nociceptive pain in 32.5% (N = 13), myofascial in 13.0% (N = 6), neuropathic in 7.5% (N = 3); and other mixed types in 7.5% (N = 3). Despite the high prevalence of dysphagia (82%), 60% used orally administered opioid-nonopioid analgesics. Physical disfigurement (87.5%; N = 35), dysphagia (62.5%, N = 25), and jaw dysfunction (40.0%; N = 16) were the most frequent physical impairments. Multiple regression analysis showed that the presence of skull base or mandibular bone involvement had significant influence on the severity of pain (P = 0.03, adjusted R2 0.25) We conclude that pain in head and neck cancer can be chronic, severe, and persistent despite completion of oncologic treatment.

Neurolysis of the musculocutaneous nerve with alcohol to treat poststroke elbow flexor spasticity.

OBJECTIVE: To evaluate the effectiveness of alcohol in neurolysis of the musculocutaneous nerve for the treatment of elbow flexor spasticity in individuals with a stroke. DESIGN: Case series. SETTING: Outpatient clinic of a tertiary rehabilitation facility. PARTICIPANTS: Twenty patients with a mean age of 62.8 years and poststroke duration of 12.3 months with elbow flexor spasticity. INTERVENTION: Musculocutaneous nerve block of the hemiplegic upper extremity with 50% ethyl alcohol. OUTCOME MEASURES: The severity of spasticity as assessed by the modified Ashworth scale (MAS) score and the elbow passive range of motion (PROM). RESULTS: The mean baseline MAS score was 3.7 +/- 0.6, and this improved to 1.7 +/- 1.0, 2.0 +/- 0.8, and 2.1 +/- 0.8 at 4 weeks, 3 months, and 6 months postneurolysis, respectively. The elbow PROM was 87.3 degrees +/- 20.2 degrees, 104.3 degrees +/- 20.1 degrees, 103.8 degrees +/- 18.9 degrees, and 101.6 degrees +/- 19.7 degrees, respectively. These improvements were statistically significant (p < .05). Four subjects had concomitant improvement of finger flexor spasticity and another four had relief of shoulder pain. Three subjects developed temporary dysesthetic pain over the lateral forearm. CONCLUSION: Neurolysis of the musculocutaneous nerve with alcohol provides good relief of elbow flexion spasticity in hemiplegic individuals.

Rehabilitation outcome following traumatic brain injury--the Singapore experience.

The objectives of this study were to define (1) demographic and injury characteristics for acute traumatic brain injury (TBI) patients admitted to rehabilitation; (2) admission and discharge functional status; (3) discharge disposition and vocation status at follow-up. The charts of 80 consecutive TBI admissions (64 males, 16 females) were reviewed. Outcome measures included admission and discharge Modified Barthel Index (MBI) scores, length of rehabilitation stay, discharge disposition and return-to-work status at 1 year post-injury. Fifty-seven (71.3%) of patients were aged 40 years or less. Motor vehicle accidents accounted for 70.0% (56) of injuries. Sixty-one (76.3%) had severe head injuries. Diffuse cerebral oedema was present in 41.3% (33) and 52.5% (42) had intracranial haematoma. Admission and discharge MBI scores were 49.6 +/- 33.7 and 76.9 +/- 25.6 respectively. This difference was significant (P < 0.001). Memory and planning/organization deficits were present in 68.6% and 70.5% of patients (51 tested). Multiple regression analysis showed that admission MBI score had significant influence on discharge functional outcome (Multiple R 0.66, R2 0.40, P < 0.001). Seventy-two (90%) were discharge home and 25% (20) returned to work at 1 year post-injury. We conclude that this cohort of TBI patients showed significant improvement in functional status after rehabilitation, and admission functional status had the most impact on discharge functional outcome.

Clinical characteristics and functional outcome of stroke patients 75 years old and older.

OBJECTIVE: To examine the demographic and clinical characteristics of stroke patients 75 years old and older admitted for rehabilitation, to study medical complications that occurred during rehabilitation, and to document functional outcome and possible factors influencing outcome. DESIGN AND SETTING: A case series of 59 consecutive inpatients admitted to a rehabilitation facility with confirmed strokes over a 2-year period. MEASURES: Patients were selected by rehabilitation physicians for admission into the rehabilitation program. Measures for outcome include the Modified Barthel Index (MBI) and the patient's discharge disposition. RESULTS: The mean age of this cohort was 80.4+/-3.2 years, and mean lengths of stay in the acute and rehabilitation facilities were 15.2 and 37.4 days. Twelve patients had three or more medical illnesses; hypertension and diabetes were the most common. Cognitive impairment, urinary incontinence, and dysphagia requiring tube feeding were present in 45.1%, 33.9%, and 11.9% of patients, respectively. Nineteen patients (32.2%) developed medical complications, and urinary tract infection was the most common. Improvements in functional status, motor power, continence, and dysphagia were noted after rehabilitation. Fifty-three patients (89.8%) were successfully discharged home, 28.8% of whom employed domestic maids as caregivers. The discharge MBI score was strongly predicted by the admission MBI and cognition scores. CONCLUSION: Despite their age, significant functional improvements were documented in this cohort of aged stroke patients, and the majority were discharged home. Admission MBI and cognition scores strongly predicted functional outcome.

Active Wegener's granulomatosis is associated with HLA-DR+ CD4+ T cells exhibiting an unbalanced Th1-type T cell cytokine pattern: reversal with IL-10.

Wegener's granulomatosis (WG) is a granulomatous vasculitis that affects the upper respiratory tract, lung, and kidney. Since T cells make up a significant proportion of cells infiltrating granulomatous lesions in WG, we investigated the proliferative response and cytokine profile of T cells from these patients. PBMCs were isolated from 12 patients with active WG, 7 patients with inactive disease, and 12 healthy normal donors. PBMCs from clinically active WG patients exhibited increased proliferation following stimulation with either PMA/ionomycin or anti-CD2 and anti-CD28, when compared with normal donors. In addition, these PBMCs exhibited increased secretion of IFN-gamma, but not of IL-4, IL-5, or IL-10. Furthermore, TNF-alpha production from PBMCs and CD4+ T cells isolated from patients with WG was elevated, when compared with healthy donors. In further studies, we investigated the ability of WG patients' monocytes to produce IL-12 and showed that both inactive and active patients produced increased amounts of IL-12. Finally, the in vitro IFN-gamma production by WG PBMC is inhibited in a dose-dependent manner by exogenous IL-10. These data suggest that T cells from WG patients overproduce IFN-gamma and TNF-alpha, probably due to dysregulated IL-12 secretion, and that IL-10 may therefore have therapeutic implications for this disease.

Rehabilitation challenges in craniospinal injury: two case reports.

Craniospinal injuries affect young patients with catastrophic morbidity and impact on society with regards to potential economic losses and medical costs. With improved neurosurgical and orthopaedic management, many more are surviving. Outcomes in this group of patients may be unpredictable because of the complex interactions between their cognitive, physical and behavioural deficits. Rehabilitation issues are often multiple and complex. An interdisciplinary approach to rehabilitation of these patients may aid them towards functional, community and vocational reintegration. We report the rehabilitation courses of 2 patients with combined traumatic brain and spinal cord injury.

Functional outcome in brain stem stroke patients after rehabilitation.

OBJECTIVE: To document functional outcome before and after rehabilitation in a group of brain stem stroke patients and to analyze possible factors influencing outcome. DESIGN AND SETTING: A case series of 53 consecutive inpatients admitted to a rehabilitation facility with confirmed brain stem strokes over a period of 6 years. PATIENTS AND OUTCOME MEASURES: Patients were selected by physiatrists for admission into the rehabilitation program. Outcome was measured by the Modified Barthel Index (MBI) for mobility and activities of daily living. RESULTS: The mean age of this cohort was 57.9 +/- 11.9 years and the pons was involved in 55% of cases. Ataxia (68%) and hemiplegia (70%) were the most frequent neurological deficits. Twenty-one patients (40%) had significant dysphagia with risk of aspirin and 16 patients (30%) were incontinent of urine. Aspiration pneumonia and urinary tract infection were present in 8 (15%) and 13 (25%) patients, respectively. Significant improvements in functional status, motor strength, swallowing, and continence status were documented on discharge (p < .05). The total admission MBI was the only significant factor influencing total discharge Barthel Index ( Beta = .597, adjusted R2 = .476, p < .0001). Fifty-one (96%) were discharged home after rehabilitation. CONCLUSIONS: Despite multiple physical deficits, this cohort of brain stem stroke patients made functional gains during rehabilitation with significant improvements in mobility and self-care skills, motor strength, severity of ataxia, continence and swallowing status.

Paroxysmal hypertension in a C4 spinal cord injury--a case report.

Hypertension in a patient with acute spinal cord injury is commonly caused by autonomic dysreflexia, which is a syndrome of paroxysmal hypertension associated with headaches, relative bradycardia and vasomotor instability secondary to sympathetic overactivity. Life-threatening complications such as seizures and intracerebral haemorrhage are largely preventable. We report both acute and chronic forms of autonomic dysreflexia due to underlying urinary and faecal impaction in a 33-year-old female with traumatic C4 quadriplegia. She was successfully managed with a combination of physical and pharmacological measures including calcium channel and sympathetic blockers.

Serum magnesium, copper, and zinc concentrations in acute myocardial infarction.

This study was carried out to assess the serum levels of magnesium, copper, and zinc after an acute episode of myocardial infarction. Determination of the metal concentrations were carried out on 41 patients with myocardial infarction and 41 healthy controls matched for age and sex. A slight decrease in the mean level of magnesium (P less than .05) was observed in patients (2.0 mg/dl) compared with the controls (2.1 mg/dl). The mean serum copper concentration was significantly higher (P less than .001) in patients (138 micrograms/dl) than in controls (98 micrograms/dl), while the mean serum zinc concentration was significantly lower (P less than .001) in patients (75 micrograms/dl) than in controls (100 micrograms/dl). The differences in serum copper and zinc levels between patients and controls were magnified considerably when the copper/zinc ratios were calculated for both groups (P less than .001). The mean copper/zinc value obtained for patients (1.91) was almost double that for the controls (1.02).

Integrated laboratory information system in a large hospital laboratory in Singapore.

This paper describes an integrated approach to the computerization of all major disciplines of laboratory medicine and pathology. Installed in the Department of Pathology, Singapore General Hospital (SGH), the computer system discussed comprises a RISC-based Data General Aviion 6200 computer and Meditech MAGIC software. The system has been interfaced with the hospital host IBM computer and supports patient information transfer, result reporting, phlebotomy management, and compilation of laboratory and financial management reports. The main functions of the system include: on-line and off-line acquisition of patient information and test data; preparation of single/combined/cumulative reports; transmission of reports within and between laboratories; instantaneous provision of data in response to telephone enquiries; calculations of quality control/workload/productivity statistics and indices; and generation of billing lists. The computer enables reports to be provided on patient tests results in individual wards, at various specialist out-patient clinics, and in the Accident and Emergency Department of the SGH through the IBM mainframe, as well as to remote printers installed at several other major hospitals.The use of the MAGIC integrated laboratory information system has resulted in a significant increase in laboratory efficiency and productivity.