Hypothalamic-pituitary function in patients with prolonged coma.

In eight patients (six males and two females) hospitalized for prolonged coma (164-1320 days; five patients were in traumatic coma, two after cardiac arrest during surgery, and one after a venomous scorpion sting), diurnal variation of cortisol secretion, human (L) GH, PRL, TSH secretion as well as the release of the pituitary hormones after TRH and L-dopa stimulation were assessed. Serum T4 cortisol, hGH, hPRL, and hTSH levels were normal. The cortisol diurnal variation was preserved in six patients. In seven of eight patients, the hPRL and hTSH responses to TRH test were normal and in five patients, there was a rise of more than 150% in serum hGH concentrations. After L-dopa administration, five patients responded with a rise in hGH. In three patients, there was no response of hGH to TRH or L-dopa. Five patients responded with significant reduction in the serum hPRL concentration after L-dopa, and in three patients, no change was observed. It was concluded that patients with prolonged coma have variable hypothalamic pituitary function. They preserve the cortisol diurnal variation and the hypothalamic-pituitary-thyroid axis as well as PRL secretion; however, hGH secretion may respond abnormally to various stimuli.

Gender differences in platelet count and its association with cigarette smoking in a large cohort in Israel.

Cigarette smoking has an effect on platelet function and aggregation although the sensitivity of platelet count in reflecting this phenomenon is not known. The association of platelet count with smoking habits was examined in a cohort of 5017 Israeli industrial workers aged 20-64 years. Males had a significantly lower age-adjusted mean platelet count than females (225,600 vs 247,800/microliters; p less than 0.001). Female smokers had lower platelet counts than non-smokers (231,000 for heavy vs 252,000 for never smokers) with a strong dose-response relationship (p less than 0.0001), whereas among males platelet count was slightly higher in smokers (224,000 for non-smokers vs 227,000 for heavy smokers; p = 0.243). The difference in platelet count between the sexes remained almost identical after controlling for smoking status and hematocrit. In multiple regression analysis, the negative association between smoking and platelet count in women remained highly significant (p less than 0.001) after controlling for ethnic origin, alcohol consumption, body mass, hematocrit, cholesterol and HDL-cholesterol, whereas for males the slight positive association was not significant. The reduced platelet count observed in males compared with females and in female smokers, suggests that platelet count may reflect sex differences in hemostasis and the effects of smoking on the hemostatic system. This may have implications for the mechanisms underlying the pathogenesis of ischemic heart disease and should be explored further.

The value of electroencephalography in prolonged coma: a comparative EEG-computed axial tomography study of two patients one year after trauma.

Interest was aroused in two patients of 16 and 17 years of age and similar craniocerebral trauma, but who had differing EEG's 1 year after injury while their later situation was the reverse of what the EEG would have led one to expect. The patient with an iso-electric EEG showed clinical improvement during the course of the second year, as indicated by a rise in his Glasgow coma rating from 8 to 11. This patient had marked cortical atrophy with discrete central atrophy, shown by computed axial tomography (CT); the isotope cisternogram showed good peripheral absorption of the isotope and no penetration into the ventricles. The other patient showed diffuse slow-wave activity in his EEG but failed to improve clinically or electroencephalographically. His CT-scan showed marked central and discrete cortical atrophy; his isotopic cisternogram showed penetration of isotope into the ventricles with poor peripheral absorption. These two cases illustrate the hazard of relying on an iso-electric EEG after 1 year of coma as an indicator of brain death, and the value of the CT-scan in the initial assessment of such cases.

Late neuropsychologic status after childhood head trauma.

A neurologic and neuropsychologic test battery was administered to a sample of 35 children drawn from all those in a defined geographic area who had been hospitalized for head trauma before age 7 during the years 1970-1976. Examination was performed 3 1/2 to 10 years after injury, at age 6-15. Twelve subjects had been diagnosed at the time of injury as suffering moderate insult and had been referred to the metropolitan neurosurgical center, while twenty-three with only mild injury had been retained for observation in a local pediatric ward. The twelve with more severe insult were significantly inferior to the other subjects on the Block Design and Coding subtests of the revised Wechsler Intelligence Scale for Children. The Koppitz score of the Bender Test, the WISC-R scatter, the Benton Visual Retention Test, the GATB Motor Speed Test and the Bourdon-Wiersma Vigilance Test showed less diagnostic power and failed to distinguish between the group with more severe injury and that with less. A detailed and carefully scored neurologic examination also failed to distinguish between the two groups. The findings suggest that relatively common traumatic injury may be associated with detectable late cognitive deficit, and that some WISC-R subtests may be among the best measures for detecting such deficit.

Widespread periarticular new-bone formation in long-term comatose patients.

Widespread periarticular new-bone formation (myositis ossificans) was studied in 45 patients with brain damage who were in long-term coma. Thirty-six of these patients displayed myositis ossificans around at least one major joint. The development of myositis ossificans was shown to be independent of the sex and age of the patient and also of the aetiology, duration and outcome of the coma. Radiographic evidence first appeared between one and two months after the onset of coma. The maximal spread of myositis ossificans was reached in the first five months after the onset of coma. Progression of the disease was not observed after 14 months. Myositis ossificans was defined as a progressive self-limiting disease found in comatose patients.

Biomechanical and physiological evaluation of FES-activated paraplegic patients.

Four paraplegic patients with traumatic upper motor neuron lesions at the spinal levels between D5 and D12 were activated by functional electrical stimulation (FES) and evaluated biomechanically and physiologically. After a training program aimed at strengthening the muscles of the lower legs, the patients were able to stand up, maintain the standing position, and walk for short distances while being supported. Biomechanical evaluation included weight bearing on the patients' own legs during standing as measured on a force platform and analysis of the time-distance parameters of the stride during walking as measured on a walkway. Physiological evaluation included heart rate and oxygen consumption at rest, when activated by FES in the sitting position, during standing, and during walking. The results obtained indicate that while significant standing and walking performances are achieved, the corresponding physical effort can reach relatively high levels requiring the support of anaerobic energy sources. The practical implications of these results are discussed.

Tests of auditory perception in the assessment and management of patients with cerebral cranial injury.

Special listening tests have been applied to patients with cerebral cranial injury to determine whether such tests of auditory performance will provide functional evidence of lesions which are difficult to examine physically. There have been many reports in the literature on the apparent relationship between lesions affecting portions of the central auditory nervous system and results on tests of auditory perception for speech which is either distorted in some way or presented in competing arrangements to the two ears. The premise is that these tests require integrative function of the brain while reducing the effects of conditions of the peripheral organ of hearing and of basic language functions such as symbolization and memorization. Much of the previous literature has been concerned with infiltrative lesions, such as tumors. Our rehabilitation facility serves a number of patients whose lesions are the result of injuries rather than growths or vascular accidents. The present study was undertaken, therefore, to explore the contribution of information derived from such test procedures to diagnosis and to the planning of individual programs of rehabilitation. Preliminary findings are presented for a series of patients with cerebral cranial injury.

The influence of the deep femoral artery on wound healing in amputees.

Seventeen patients with arterial occlusive disease, of whom 14 were diabetics, were studied by angiography after amputation of the lower extremity. In one patient the angiography was normal and the stump wound healed well. In two patients the angiographic findings indicated extremely severe impairment of blood supply and wound healing was considerably delayed. Of the remaining 14 patients: in five the superficial femoral artery alone was occluded and wound healing was normal and in nine patients, both the superficial and deep femoral arteries were occluded and wound healing was delayed. Wound healing of the stump after amputation of the lower extremity due to extensive arterial occlusive disease is decided by the patency of the deep femoral artery.

Arterial occlusive disease in amputee patients: assessment with the Doppler ultrasound flowmeter and correlation with rehabilitation.

The vascular status of 14 below-knee (BK) amputee patients and 12 above-knee (AK) amputee patients who had undergone amputation for arterial occlusive disease was assessed with the Doppler ultrasound technique. Ten healthy subjects were investigated as a control group. The ankle-arm pressure index in the sound leg and thigh-arm pressure index in the stump were classified in 4 grades. Rehabilitation was graded according to the amputee patients' ability to use their prostheses. The vascular condition of the BK amputees was generally better than that of the AK amputees. The vascular condition of the stump in both groups was better than that of the sound leg. A good correlation was found between prosthetic rehabilitation and the vascular condition of the sound leg, but not with that of the stump. It is suggested that amputation removes the most severely affected part of the lower extremity and the so-called sound leg thus becomes the restricting factor in rehabilitation.

Acidophilic adenoma of the pituitary with polyneuropathy.

An acromegalic man aged 70 developed progressive polyneuropathy affecting mainly the extremities. The peripheral nerves showed hypertrophic neuropathy and accumulation of acid mucopolysaccharides in the nerve without `onion bulb' formation. The myelin showed a lamellar disintegration and vesicular formation. It is suggested that the association of these findings represents a pathological entity, acromegalic polyneuropathy.

Prediction of functional outcome in hemiplegic patients.

A follow-up study of 40 hemiplegic patients two years after discharge from hospital was aimed at (a) identifying variables capable of predicting general functional ability in everyday life (work, home, family and social life) and (b) examining the relationship between levels of functioning and subjective evaluation of their rehabilitation state. The results showed that a composite measure of functioning ability was closely related to self-reports of satisfaction in significant areas of life: physical well-being, emotional security, satisfaction of family and social needs and vocational self-actualization. The best objective predictor of overall domestic and outdoor functioning was the primary ADL (eating, dressing, bathing, etc.). Other significant variables were ambulation (walking freely for 300 meters), sustaining mental load and emotional acceptance of disability. Predisposing and concurrent diseases (such as congestive heart failure, diabetes mellitus, hypertension and others) were not found to be of predictive value. The findings thus obtained could provide the physician with a good prognostic tool to evaluate the rehabilitation outcome of hemiplegic patients. They also suggested that intervention aimed at emotional acceptance of disability could facilitate the rehabilitation process.

The "key-form" system for data collection in disability evaluation.

A new system for comprehensive disability evaluation has been developed in the framework of our Hospital. This system is based on multidisciplinary evaluation during one day of tests and the summarization of the data collected. The process takes place at the Institute for Functional Evaluation, a joint project of the National Insurance Institute and the Loewenstein Hospital in Israel. The process was designed to provide the basis for the determination of the degree of disability according to the requirements of the General Disability Law. In order to carry out the experimental program a computerized system of recording was created. The method of recording is based upon the "Key-form" where the different systems of the body appear one after the other and next to them the term "normal" or "abnormal". In the case of an abnormal mark, the tester goes on to the next stage which involves completion of a detailed form for that system. The forms are coded for the transfer of information to the computer without intermediary stages and this enables processing of a vast amount of data with relative ease. The system enables compilation of individual profiles and statistical tables and analysis. Theoretical and practical applications of the system are discussed on the basis of the pilot study.

Gastrointestinal hemorrhage in long-lasting traumatic coma.

Sixteen cases, aged 19 to 61 years and suffering from traumatic coma were studied for periods varying from 7 to 20 months. Obvious or occult gastrointestinal hemorrhage appeared in every case, the earliest presentation being after a few weeks and the latest at 20 months. Gastric acidity was normal in 15 cases. Five patients had duodenal ulceration in repeated roentgenological examination. Concomitant clinical findings included clubbing and paraarticular new bone formation in 9 patients. In addition, hypoxia with repeated values between 63 and 88 mm was observed in 13 of the 16 patients. The latter observation strongly suggests that hypoxia of gastrointestinal mucosa may, indeed, play a pathogenetic role in gastrointestinal hemorrhage of patients with C.C.I.

Temporal characteristics of tapping responses in healthy subjects and in patients who sustained cerebrovascular accident.

Tapping responses were recorded in a group of patients who sustained lesions from cerebrovascular accidents and from an age-matched group of healthy subjects. In each experiment the stimuli were an auditory signal, a flash, or a light touch on the arm, delivered either at random intervals or at fixed time intervals of 1, 2, 3, or 4 s. The tapping response was done with each hand separately (first experiment) or with each hand alternately (second experiment). Healthy subjects, 'predicted' the stimuli (response time less than 150 ms), when the 'preferred' fixed time interval was used. One group of patients (n = 3), did not predict the stimuli at the preferred fixed intervals when tapping was done with the hand related to the involved hemisphere. The second group of patients (n = 3) did not predict the stimuli when tapping was done with either hand.