Comparison of Esophageal Acidity between Nasogastric Tube Feeding and Percutaneous Endoscopic Gastrostomy Tube Feeding in Brain Injured Patients

OBJECTIVE: The aim of this study is to evaluate the change of esophageal acidity when feeding via nasogastric tube is replaced by via percutaneous endoscopic gastrostomy (PEG) tube. METHOD: Fourteen patients with brain injury participated in the study. 24-hour pH monitoring was performed during nasogastric tubal feeding. After PEG tube insertion, 24-hour pH monitoring was followed up. There was no difference in medication affecting to esophageal acidity in same patient at both pH monitorings. The results of pH monitorings analyzed with Wilcoxon signed rank test. RESULTS: The total time below pH 4.00 was 135.43+/-190.69 minutes for the patients with nasogastric tube and 25+/-42.74 minutes for PEG tube (p=0.013). The numbers of acid reflux was 42.07+/-47.03 and 21.93+/-22.77 respectively (p=0.074). Of the 14 patients, 9 had acid reflux in nasogastric tubal feeding, which was improved in all 9 patients after PEG. Of the 14 patients, 5 had no acid reflux in nasogastric tubal feeding but 3 of the 5 developed new acid reflux in PEG tubal feeding. CONCLUSION: Percutaneous endoscopic gastrostmy tube feeding was better for acid reflex control. But careful observation is needed after PEG because PEG can develop new acid reflux.

The Proper Timing of the Replacement of the Percutaneous Endoscopic Gastrostomy Foley Catheter in Brain Injured Patients

OBJECTIVE: To help adjusting the proper timing of replacement of the percutaneous endoscopic gastrostomy (PEG) Foley catheter in brain injured patients. METHOD: Twenty one brain injured patients with PEG Foley catheter were studied and divided into three groups by indwelling duration. The balloon of Foley catheter was inflated with 5 ml of normal saline. We calculated the deflating velocity of the balloon by estimating remained amount of normal saline and indwelling duration at the time of replacement. RESULTS: In 6 patients, the PEG Foley catheter was pulled out easily before aspiration of remained normal saline. In all of these cases, remained amount of normal saline was less than 2 ml. The deflating velocities of the balloons were 0.057 +/- 0.024 ml/day in cases with 3 to 4weeks of indwelling duration, 0.066 +/- 0.005 ml/day with 4 to 5 weeks, 0.067 +/- 0.012 ml/day with above 5weeks. The mean deflating velocity was 0.063 +/- 0.016 ml/day in human. The deflating velocity was slower than that of the previous study in vitro. CONCLUSION: The mean days of deflation of the balloon of total PEG Foley catheter down to 2.5 ml were 42.1 days. We suggest that the PEG Foley catheter would be replaced within 42 days after exchange.

Expected Durability of Percutaneous Endoscopic Gastrostomy Foley Catheter

OBJECTIVE: The purposes of this study are to estimate the proper replacement time of percutaneous endoscopic gastrostomy Foley catheter for prevention of accidental expulsion from the stomach, and to identify factors influencing deflation of balloon. METHOD: Silicone Foley catheters (22 Fr) were placed and compared in the different environments: 1) different acidity (pH 1, 2, 3, 4, 7), 2) static versus dynamic (100 RPM) environment. The balloon capacity of 30 ml versus 5 ml inflated with 5 ml of normal saline were compared. Mean time interval of deflation of balloon down to the capacity of 2.5 ml and 1 ml was estimated and compared respectively. RESULTS: The results showed no significant difference of the decrease of the balloon of the Foley catheters in each acidity except for pH 1 and dynamic environment. But capacity of balloon could affect deflation. The mean days of deflation of total Foley catheter down to 2.5 ml and 1 ml were 23.5+/-5.3 and 42.2+/-7.2 days respectively. CONCLUSION: Physiological gastric acidity and dynamic environment did not affect the deflation of the Foley catheter significantly, but the capacity of the balloon affected it. And suggested proper time of the replacement of the Foley catheter gastrostomy tube is ranged from 24 to 42 days after exchange.

A Case of Work-Related Cubital Tunnel Syndrome Due To Repetitive Motions / 대한산업의학회지

OBJECTIVES: To report cubital tunnel syndrome due to repetitive motions. METHODS: A worker complaining muscle weakness and atrophy of the right hand intrinsic muscles admitted to a hospital. We evaluated him with blood tests, neurophysiologic studies (NCV & EMG), plain X-ray and US at the both elbows. We investigated his occupational history, and videotaped his work motions based on the work cycle at his previous work site. Finally, an ergonomics expert analyzed the motions using rapid upper limb assessment (RULA). RESULTS: NCV & EMG studies reveals slow conduction velocity on both ulnar nerve across the elbow, more severely in the right side. US shows us compatible finding with diffuse neuritis of both ulnar nerves at both elbows. RULA score is 7. CONCLUSION: We confirmed that the workers symptoms were related to his previous jobs demanding repetitive motions using the elbow joints. It is necessary that we should prepare appropriate measures to evaluate, prevent, rehabilitate, and help injured workers to return to work.

Dorsomedial Cutaneous Nerve Conduction Study in Hallux Valgus

OBJECTIVE: To show the prevalence of the dorsomedial cutaneous nerve (DMCN) injury in the hallux valgus and to evaluate whether the sensory nerve damage contributes to pain and sensory impairment in the great toe. METHOD: Sixty feet of healthy adults (normal group) and 26 feet of patients with hallux valgus (hallux valgus group) were evaluated with sensory nerve conduction study of DMCN. The prevalence of the nerve injury was compared between the two groups. Sensory nerve action potentials of DMCN in hallux valgus feet were analyzed and compared according to the patient's symptom and the severity of the radiographic measurements of the feet. RESULTS: The prevalence of DMCN injury was 42.3% of the hallux valgus group. The peak latency of the DMCN sensory action potential of the symptomatic feet showed statistically significant delay compared to the asymptomatic group (p<0.05). Delay of the peak latency and decrement of the amplitude of the DMCN were statistically significant among the three groups as the valgus deformity worsened (p<0.05). CONCLUSION: DMCN injury should be considered in addition to soft tissue injury or arthritis in the differential diagnosis of the pain, burning sensation or numbness associated with hallux valgus.

Soleus Myopathy Induced by Passive Stretch in a Stroke Patient: A case report

We present a 50-year-old woman who sustained spastic left hemiplegia secondary to the right thalamic hemorrhage 6 years ago. She complained of persistent severe left calf pain after serial casting for the treatment of shortened plantar flexors of the left ankle. Two months later, magnetic resonance T1-weighted images showed diffuse high signal intensity involving the whole muscle bulk of the soleus and normal signal intensity of thin atrophied gastrocnemius. Needle electromyography of the soleus revealed myopathic patterns. Histologic findings of the soleus showed necrotic muscle fibers with phagocytosis, endomyseal collagen and fat deposition. We concluded that prolonged passive stretch of spastic plantar flexors of the ankle under serial casting induced soleus myopathy with segmental myonecrosis, and which developed left calf pain. Selective induction of soleus myopathy could be explained by the higher stretch tension produced by ankle dorsiflexion in the soleus compared to the gastrocnemius because of different proximal ends.

The Effects of Botulinum Toxin Injections on the Persistent Contractions of Levator Labii Superioris Muscle in Patient with Encephalopathy

We report the case of a 40-year-old hypoxic encephalopathy patient who suffered from dry mouth and frequent poor oral hygiene secondary to a prominent nasolabial fold and elevated upper lip, exposing the canine teeth at rest. This expression was confirmed secondary to persistent contraction of the levator labii superioris muscle with electromyography (EMG) study. We have injected 6 units of Botulinum toxin A in levator labii superioris muscle with electromyographic guidance. Elevation of upper lip at rest causing exposure of canine teeth has been nearly disappeared 3 days after the injection. We suggest that chemical weakening of the levator labii superioris muscle using Botulinum toxin A could be possibly responsible for the dramatic reduction of elevated upper lip exposing canine teeth in patients with hypoxic encephalopathy.

Relationship between the Type of Laryngeal Penetration and Severity of Tracheal Aspiration in the Brain Injured

OBJECTIVE: To assess the incidence of tracheal aspiration in the brain injury patients with laryngeal penetration, and to investigate the relationship between the type of laryngeal penetration and the severity of tracheal aspiration. METHOD: One hundred videofluoroscopic swallowing tests in brain injury patients who showed laryngeal penetration were analyzed retrospectively. Laryngeal penetrations were classified into three groups: anterior, posterior and both. The incidence of the tracheal aspiration among the laryngeal penetration was evaluated. The severity of the tracheal aspiration was analyzed into the three groups: mild, moderate and severe. Each type of the laryngeal penetration were compared with the severity of the tracheal aspiration. RESULTS: Seventy-one patients showed the tracheal aspiration among the 100 patients with laryngeal penetration. The incidence of tracheal aspiration according to the type of the laryngeal penetration was 100% in both, 86.8% in posterior, and 50.9% in anterior type. The more severe tracheal aspiration was associated with the higher proportion of the posterior and both types. CONCLUSION: The incidence of tracheal aspiration in laryngeal penetration was 71%. More severe tracheal aspiration occurred with both & posterior laryngeal penetration than anterior type.

Serotonin Syndrome in Traumatic Brain Injury Patient: A case report

We report a 47-year old traumatic brain injury male patient who was treated for the rigidity and tremor with sinemet (carbidopa levodopa) and artane (trihexyphenidyl). He came to the emergency room ten days after the stopping of sinemet. Acute onset of increased obtunded, immobile, rigid, deep coma, and minimal response to a deep pain was presented. There was no evidence of the focal neurological signs. Over the next two days, he awoke with a normal mental status. His muscle tone become normal and he returned to home without residual medical problems or complications. We report a serotonin syndrome in a traumatic brain injury patient who was treated with sinemet and artane, which resulted in a dysregulation of serotonin activity.

Stress Fracture of Talus as a Complication of Phenol Block: Case Report

Motor point block with phenol solution has the advantage of technical ease, bedside performance, and repetition as necessary in reducing spasticity. To our knowledge, however, complicating stress fracture that occur during the course of treatment after motor point block has not been described. We report the occurance of stress fracture of the head of right talus after motor point block with phenol solution. A 17-year-old boy had a gait disturbance due to excessive plantar flexion and inversion of right ankle by spasticity. Percutaneous motor point block to right tibialis posterior and right gastrocnemius was done with 7% aqueous phenol solution. Just after the block, he began to bear his weight on right heel and physical therapy including gait training was started. He complained of right ankle pain a week after resumption of weight-bearing while walking. Bone scan and magnetic resonance imaging of right ankle revealed stress fracture of talus of right foot. This case illustrated that physiatrists involved in the management of such patients should be aware that secondary stress fractures can occur.

Electrodiagnostic Study in Rett Syndrome:A case report

Rett syndrome is a progressive encephalopathy in females that appears during the first 18 months of the life. A few neurophysiologic investigations of peripheral nerve and electrodiagnostic studies in Rett syndrome has proposed mild distal axonopathy. However, the electrodiagnostic study shows demyelination rather than axonopathy in presenting patient with Rett syndrome. An 11-year-old female had normal birth history, no perinatal problems and normal development until age of 18 months. Developmental regression was recognized by her parent and slowly progressed. At physical examination at her age of 7 years, stereotypic hand movements was present and she could walk with frequent fall. Brain Computed Tomography was not specific and electrodiagnostic study revealed slow conduction velocity in all nerves tested. After follow-up for 4 years, hand wringling was remained and she became to be unable to walk alone. Electrodiagnostic study revealed as follows; 1) Compound muscle action potentials and sensory nerve action potentials in all the nerves tested revealed prolonged distal latency with normal amplitude. 2) F waves were evoked with prolonged latency in the all the nerves tested. 3) H-reflex were absent, bilaterally. 4) Facial motor conduction study and blink reflex showed normal findings. 5) Auditory evoked potential and visual evoked potential studies showed normal findings. These electrodiagnostic study indicates demyelinating neuropathy.