Treatment of severe tetanus with intrathecal baclofen via implantable infusion device: a case report.

OBJECTIVE: Severe tetanus remains a serious issue in less developed countries, leading to prolonged hospitalization due to prolonged neuromuscular contraction of muscles. We present a case of severe tetanus in the United States that was successfully managed with intrathecal baclofen. CASE REPORT: A 42-year-old male without tetanus vaccination history presented to the emergency department with intractable jaw pain and worsening diffuse muscle contractures due to severe generalized tetanus requiring prolonged paralysis and ventilator support. After 14 days of continuous neuromuscular treatment with benzodiazepines, vecuronium, propofol, and magnesium sulfate, a baclofen pump trial was performed 14 days post-admission as an alternative to prolonged neuromuscular blockade. After demonstrable improvement in spasms and paroxysmal contractures due to intrathecal baclofen (ITB), a baclofen pump was implanted on hospital day 17. The catheter was threaded to T4 for maximal effect of intrathecal baclofen on the upper and lower extremities at an initial rate of 100 µg/day. ITB was titrated upward, the vecuronium was slowly weaned, and the patient was weaned off a ventilator by day 14 of ITB treatment. At an ITB dose of 450 µg/day, propofol was discontinued. ITB was continued over the next four weeks and eventually weaned over the next two weeks. The ITB pump was removed eight weeks after placement, and the patient was successfully discharged to home. CONCLUSION: Due to prolonged muscle weakness associated with long-term use of paralytic agents and sedation, early ITB trial and pump placement should be considered as an alternative in the treatment of severe tetanus to shorten length of stay and improve the functional outcome of the patient.

Effect of object transport on grasp coordination in multiple system atrophy.

We examined the effects of the parkinsonian variant of multiple-system atrophy (MSA-P) on grasp and forward transport and release of an object. Twelve patients with MSA-P and 10 age-matched control subjects performed the task with each of three object weights (200, 400, 800 gm). Subjects moved at a self-selected pace using a precision grip. The grip (normal) and load (tangential) forces and the object position were recorded. Results indicate subjects with MSA-P have temporal and force coordination deficits. Temporal delays were seen in all subjects with MSA-P, leading to prolonged overall movement times compared to control subjects. These delays occurred throughout the task, with significantly longer transport phases and delays releasing the object. Despite demonstrating an appropriate anticipatory scaling of forces, with increasing grip and load forces for heavier weights, force coordination was compromised in subjects with MSA-P. These subjects generated significant negative load forces prior to transporting the object. In addition, during the transport phase, subjects with MSA-P generated highly variable grip forces. Overall, the results indicate that subjects with MSA-P demonstrate bradykinesia and difficulty coordinating components of an object transport task.

The Downstart Program: a hospital-based pediatric healthy lifestyle program for obese and morbidly obese minority youth.

Although obesity affects all cultures, ethnic groups and social strata, this disorder affects African Americans, Hispanics and the poor at a disproportionate rate. The Downstart Pediatric Healthy Lifestyle Program was developed to provide a multi-disciplinary behavioral modification program for inner city families in Brooklyn, New York interested in leading a healthier, more active lifestyle. The Downstart Program uses a four-pronged approach of medical evaluation, exercise, nutritional education and lifestyle modification. A psychological evaluation is performed to determine the individual's ability and readiness to participate in group activities. Baseline physical fitness, flexibility and muscle strength are measured, followed by a twice-weekly karate/martial arts/dance program, incorporating principles established by the President's Council on Exercise. Nutritional and behavioral modification aspects of the program consist of weekly education about food groups, portion control, goal setting and appropriate rewards for attaining goals. Our preliminary results indicate that the Downstart Program may be a viable intervention for weight loss. Further study is needed to improve strategies for motivating patients and means and criteria for assessing long-term effects on health and lifestyle.