Neurosurgical Consultation Referral from the Forces: Regarding 328 Patients Referred to the Department of Neurosurgery, Sainte Anne Military Hospital, France.

INTRODUCTION: There are little data regarding elective referral to the military specialist, especially considering common pathologies such as spinal diseases, which, in the French forces, involve military neurosurgeons. An overview of the management of the military patient referred to neurosurgery consultation, especially considering spinal diseases that both constitute an operational healthissue in the forces and appear of special interest. The objective was to describe the reasons, demographics, and care pathways, addressed to the neurosurgeon. MATERIALS AND METHODS: This retrospective, single-center study focused on all military patients referred for neurosurgery consultation at Sainte Anne Military Hospital in Toulon. Extracted data included demographic characteristics, army, unit, military specialty, the reason for referral, the diagnosis by the neurosurgeon, treatment, and outcome. RESULTS: From January 2018 to December 2019, 352 patients were referred for neurosurgical consultation by the unit general practitioner. Spinal disease (n = 297, 91%) was the most frequent reason. Lumbar degenerative disk disease accounted for 20% of consultations, regardless of the patient's unit or specialty. Most of the patients seen in consultation received nonsurgical management (n = 271, 82.6%). These patients mainly presented with cervical or lumbar degenerative disk disease (n = 99, 36.5%) or cervical or lumbar herniated discs (n = 57, 21.0%). Ninety-eight patients (29.9%) were referred exclusively for medical fitness assessment. Few patients experienced full resolution of their presenting complaint after management (n = 9, 2.8%). CONCLUSIONS: This descriptive study demonstrates the predominance of degenerative spinal diseases in military patients referred to neurosurgery. It reflects the importance of the medical and military competence required to maintain operational capability upstream and downstream of war traumatology. The description of the care pathways invites us to define more proactive multidisciplinary pathways for the management of these diseases in the armed forces.

Accuracy of Resting Energy Expenditure Estimation Equations in Polio Survivors.

OBJECTIVE: To evaluate the accuracy of 4 equations validated for the general population to determine resting energy expenditure (REE) in polio survivors. DESIGN: A descriptive, ambispective, single-center observational cohort study of minimal risk care. SETTING: Tertiary university care hospital. PARTICIPANTS: DATAPOL database of polio survivors followed up in a specialist department (N=298). INTERVENTIONS: None. MAIN OUTCOMES MEASURES: REE measurement by indirect calorimetry and estimated REE using 4 equations and comparing the values with indirect calorimetry. Analysis of correlations between measured REE and weight, height, and body mass index (BMI) and indicators of severity of polio sequelae. RESULTS: Of the 298 polio cases in the database between January 2014 and May 2017, 41 were included (19 men and 22 women). Mean±SD BMI was 26.0±5.6 kg/m2 (56.1% below 25). Measured REE correlated significantly and positively with weight and weaker with BMI. Correlations between measured and estimated REE were strong (between 0.49 and 0.59); correlations were strongest for the simplified World Health Organization and the Harris and Benedict equations. However, the equations systematically overestimated REE by more than 20%, especially in men. We calculated a correction factor for the World Health Organization scale: -340.3 kcal/d for women and -618.8 kcal/d for men. CONCLUSION: Analysis of REE is important for polio survivors; The use of estimation equations could lead to the prescription of a nonadapted diet. We determined a correction factor that should be validated in prospective studies.

Exertional Heatstroke Support at the Acute Phase: Assessment of Professional Practices in the French Military Forces.

INTRODUCTION: Exertional heatstroke (EHS) is defined as a disturbance in consciousness, ranging from confusion to coma, with hyperthermia typically higher than 40 °C that occurs during intense physical activity. It is a life-threatening pathology that has been observed in the military since antiquity. Recent research has changed the understanding of the pathophysiology of EHS and led to the development of gold-standard treatment, which includes intrarectal temperature monitoring and cooling the patient as quickly as possible. The objective of this study was to describe the theoretical knowledge of French military unit practitioners regarding the latest recommendations for the treatment of EHS and their management of this condition in practice. MATERIALS AND METHODS: We conducted a web-based survey from August 2 to December 31, 2020, including all French military practitioners. The questionnaire, sent via email, aimed to describe practitioners' theoretical knowledge of EHS and its practical management. Practitioners who had a local management protocol were asked to include it with their responses to analyze and determine if protocols complied with the latest recommendations. The responses were collected by name, anonymized, and analyzed by a single investigator. This observational study was exempted from ethics board approval by the French Military Health Service's research department. RESULTS: Of the questionnaires sent, 84 practitioners responded, describing their theoretical knowledge of EHS. Of the respondents, 42 had experience managing EHS and described their practical management of EHS in the field. In addition, 15 local protocols were analyzed. Intrarectal temperature measurement was recommended by 71 physicians (84.5%), and cooling was preferably achieved by immersion in cold water by 65 practitioners (77.4%). If this method was unavailable, only 36.9% (24/65) of practitioners submerged patients in water at room temperature. Nine practitioners (10.7%) had perfect theoretical knowledge, and 36 (42.9%) knew the optimal management of EHS. There was no difference in the frequency of perfect theoretical knowledge between practitioners who had experience with EHS (9/36) and those who did not (12/48; P = 1). Practitioners who had experience with EHS had better optimal management knowledge than those who did not (61.1% vs.29.1%; P = .03). In practice, 21 (50%) cases had intrarectal temperature monitoring, and only 6 (14.3%) were immersed in cold water. Logistical challenges prevented optimal cooling methods in 29 (90.6%) cases. Concerning the other aspects of management, four (26.7%) practitioners recommended tympanic temperature measurement, two (20%) did not indicate immersion for cooling, and one (6.7%) administered paracetamol. CONCLUSIONS: French military practitioners' theoretical knowledge of EHS is insufficient for a lethal pathology that is common in the military. Thus, improvements must be made in training and disseminating up-to-date knowledge. In practice, a lack of adequate logistics and the fact that first responders are rarely practitioners increase the suboptimal care of EHS. First responders should be equipped with valid and adapted protocols and adequate logistical means to manage this condition. By establishing a cohort of well-treated patients, we will be able to develop evidence-based recommendations for when to cease cooling and identify intrinsic susceptibility to EHS.

Influence of the scale reduction in designing sockets for trans-tibial amputees.

The development of artificial prosthetic lower limbs aims to improve patient's mobility while avoiding secondary problems resulting from the use of the prostheses themselves. The residual limb is a pressure-sensitive area where skin injuries and pain are more likely to develop. Requirements for adequate prosthetic limbs have now become urgent to improve amputee's quality of life. This study aims to understand how socket design parameters related to geometry can influence pressure distribution in the residual limb. A finite element model was developed to simulate the mechanical loading applied on the residual limb of a below-knee amputee while walking. A sensitivity analysis to socket initial geometry, scaling the socket downward in the horizontal plane, was performed. Recordings include stress levels on the skin and in the residual limb deep soft tissues. Peak stress was reduced by up to 51% with a limited reduction of the socket size. More important scale reduction of the residual limb would lead to possible negative effects, such as stress concentrations in sensitive areas. This result confirms the interest of the prosthetist to develop a well-fitting socket, possibly a little smaller than the residual limb itself, in order to avoid residual limb mobility in the socket that could cause friction and stress concentrations. Non-homogeneous geometrical reductions of the socket should be further investigated.

Is skin pressure a relevant factor for socket assessment in patients with lower limb amputation?

BACKGROUND: Prosthetic rehabilitation improves the overall quality of life of patients, despite discomfort and medical complications. No quantitative assessment of prosthesis-patient interaction is used in routine protocols and prosthesis quality still results from the manufacturer's know-how. OBJECTIVE: Our objective is to investigate whether pressure can be a relevant factor for assessing socket adequacy. METHODS: A total of 8 transtibial amputee volunteers took part in this experimental study. The protocol included static standing and 2 minutes walking tests while the stump-to-socket interface pressures were measured. Questionnaires on comfort and pain were also conducted. RESULTS: During static standing test, maximum pressures were recorded in the proximal region of the leg, with a peak value reaching 121.1 ± 31.6 kPa. During dynamic tests, maximum pressures of 254.1 ± 61.2 kPa were recorded during the loading phase of the step. A significant correlation was found between the pain score and static maximum recorded pressure (r= 0.81). CONCLUSIONS: The protocol proposed and evaluated in this study is a repeatable, easy-to-set quantified analysis of the patient to socket interaction while standing and walking. This approach is likely to improve feedback for prosthesis manufacturers and consequently the overall design of prostheses.

Prosthesis to Enable a Patient with Above-Elbow Amputation to Resume Hunting.

BACKGROUND: Creating a custom prosthetic device is challenging. The requirements of the patient's life must be taken into consideration when manufacturing the device. After having met the requirements for an autonomous daily life, adjustments can be made for recreational activities. SUBJECT AND METHODS: A 67-year-old patient with an above-elbow amputation following a hunting accident wanted to use a rifle to hunt again. We considered her desires, the short stump, and the constraints of the type of hunting and environment, bearing in mind the safety of the patient and other hunters. RESULTS AND CONCLUSION: An orthopaedic prosthetic system was developed to allow her to pick up the rifle, aim (sight), and shoot with recoil. The 2 rifle supports are fixed onto a bolero vest. The supports are made of carbon fibre, which is lightweight, and the gun can be aimed between them. Appropriate safety was achieved. The efficiency depends on the patient. There are few publications regarding amputation cases of this type, in which the specification goals were precision and the ability to walk with the prosthesis. Multi-disciplinary collaboration enabled us to create a device that met the requirements of this case.

Two new risk factors for heterotopic ossification development after severe burns.

OBJECTIVES: Life after severe burns is conditioned by the remaining sequelae. The pathophysiology and risk factors of Heterotopic Ossification (HO) after burns are still poorly understood. The aim of this study was to determine: 1) the incidence of HO after burns and 2) the risk factors associated with HO development, in a large retrospective study. METHODS: A case-control study of patients admitted to the burns intensive care unit of Percy Hospital, Paris, from the 1st January 2009 to the 31st December 2013 and then admitted to one of three centres specialised in the rehabilitation of patients with burns. Multivariate analysis was carried out to analyse the relationship between HO development and demographic and clinical data. RESULTS: 805 patients were included. 32 patients (4.0%) developed a total of 74 heterotopic ossifications, that is a little higher incidence than the incidence found in the literature. The epidemiological characteristics of the population studied was similar to the literature. HOs were mainly localized around the elbows, followed by the hips, shoulders and knees. Each case-patient was paired with 3 control-patients. There were significant associations between HO development and the length of stay in the burns intensive care unit, the extent and depth of the burns, the occurrence of pulmonary or cutaneous infections, use of curare and use of an air-fluidized bed. CONCLUSION: In addition to recognized risk factors (duration of stay in the intensive care burns unit, extent and depth of burns, pulmonary and cutaneous infections), the use of curare and the use of a fluidized bed (with the duration of use) were significantly associated with HO formation.

Orthopaedic shoes along with physical therapy was effective in Charcot-Marie-Tooth patient over 10 years.

BACKGROUND: The aim was to investigate the effectiveness of custom-made orthopaedic shoes (derby shoes) along with physiotherapy (twice a week) on a person with Charcot-Marie-Tooth over a period of 10 years. CASE DESCRIPTION AND METHODS: A 66-year-old woman with Charcot-Marie-Tooth disease, who did not have other health conditions, complained of pain and frequent falls. Physical examination, including ankle, knee and hip muscle strength; sensory evaluation of foot and joint range of motion; self-reported assessment of pain, frequency of falls and sprains; and gait analyses, including spatial and temporal parameters and motion analyses, were performed in 2001, 2007 and 2011. FINDINGS AND OUTCOMES: During the 10 years of follow-up, the physical examination parameters had stabilized since 2001; falls, sprains and walking distance had improved as compared to 2000; pain had alleviated since 2001 and gait parameters had improved up to 2007 and stabilized between 2007 and 2011. CONCLUSION: Bracing with orthopaedic shoes along with physical therapy was effective in treating pain, improving the gait and enhancing the walking distance (>500 m) without assistive device in a person with Charcot-Marie-Tooth disease. CLINICAL RELEVANCE: Orthopaedic shoes along with physical therapy can be a good option for treating Charcot-Marie-Tooth associated pain, foot drop, falls and sprains, improving the gait abnormalities and also increasing the walking distance.

Bimanual training in stroke: How do coupling and symmetry-breaking matter?

BACKGROUND: The dramatic consequences of stroke on patient autonomy in daily living activities urged the need for new reliable therapeutic strategies. Recently, bimanual training has emerged as a promising tool to improve the functional recovery of upper-limbs in stroke patients. However, who could benefit from bimanual therapy and how it could be used as a part of a more complete rehabilitation protocol remain largely unknown. A possible reason explaining this situation is that coupling and symmetry-breaking mechanisms, two fundamental principles governing bimanual behaviour, have been largely under-explored in both research and rehabilitation in stroke. DISCUSSION: Bimanual coordination emerges as an active, task-specific assembling process where the limbs are constrained to act as a single unit by virtue of mutual coupling. Consequently, exploring, assessing, re-establishing and exploiting functional bimanual synergies following stroke, require moving beyond the classical characterization of performance of each limb in separate and isolated fashion, to study coupling signatures at both neural and behavioural levels. Grounded on the conceptual framework of the dynamic system approach to bimanual coordination, we debated on two main assumptions: 1) stroke-induced impairment of bimanual coordination might be anticipated/understood by comparing, in join protocols, changes in coupling strength and asymmetry of bimanual discrete movements observed in healthy people and those observed in stroke; 2) understanding/predicting behavioural manifestations of decrease in bimanual coupling strength and/or increase in interlimb asymmetry might constitute an operational prerequisite to adapt therapy and better target training at the specific needs of each patient. We believe that these statements draw new directions for experimental and clinical studies and contribute in promoting bimanual training as an efficient and adequate tool to facilitate the paretic upper-limb recovery and to restore spontaneous bimanual synergies. SUMMARY: Since bimanual control deficits have scarcely been systematically investigated, the eventual benefits of bimanual coordination practice in stroke rehabilitation remains poorly understood. In the present paper we argued that a better understanding of coupling and symmetry-breaking mechanisms in both the undamaged and stroke-lesioned neuro-behavioral system should provide a better understanding of stroke-related alterations of bimanual synergies, and help clinicians to adapt therapy in order to maximize rehabilitation benefits.