A Supranuclear Disorder of Ocular Motility as a Rare Initial Presentation of Motor Neurone Disease.

A case is described of motor neurone disease presenting with an ocular motor disorder characterised by saccadic intrusions, impaired horizontal and vertical saccades, and apraxia of eyelid opening. The occurrence of eye movement abnormalities in motor neurone disease is discussed.

Motor unit discharge rates of the anconeus muscle during high-velocity elbow extensions.

Motor unit recruitment and motor unit discharge rate (MUDR) have been widely studied in isometric conditions but minimally during velocity-dependent contractions. For isometric contractions, surface electromyography (EMG) activity of the elbow extensors plateaus at near maximal torques (Le Bozec et al. 1980; Le Bozec and Maton 1982). One study (Maton and Bouisset 1975) recorded single motor unit (MU) activity at maximal velocities; however, only the rate of the first interspike interval (ISI) was reported and likely was not representative of the average MUDR of the MU train. The purpose was to calculate average MUDRs of the anconeus during loaded velocity-dependent contractions from zero velocity (isometric) up to maximal velocity (V(max25)) through a large range of motion. A Biodex dynamometer was used to record elbow extension torque, position, and velocity. Single MU potentials were collected from the anconeus with intramuscular EMG, and surface EMG was sampled from the lateral head of the triceps brachii during maximal voluntary isometric contractions (MVCs) and velocity-dependent contractions loaded at 25% MVC over 120° range of motion at five target velocities (0, 25, 50, 75, 100%V(max25)). Elbow extension velocities ranged from 93 to 494°/s and average MUDR ranged from 11.8 Hz at 25%MVC to 39.0 Hz at 100%V(max25.) Overall average MUDRs increased as a function of velocity, although the root mean square of triceps brachii surface EMG plateaued at 50%V(max25). Piecewise regression analysis revealed two distinct linear ranges each described by a unique equation, suggesting that MUDRs of the anconeus enter a secondary range of firing, characterized by a steeper slope as velocity approaches maximum.

Eye movement recordings to investigate a supranuclear component in chronic progressive external ophthalmoplegia: a cross-sectional study.

BACKGROUND: It has been postulated that eye movement disorders in chronic progressive external ophthalmoplegia (CPEO) have a neurological as well as a myopathic component to them. AIM: To investigate whether there is a supranuclear component to eye movement disorders in CPEO using eye movement recordings. METHODS: Saccade and smooth pursuit (SP) characteristics together with vestibulo-ocular reflex (VOR) gain and VOR suppression (VORS) gain in 18 patients with CPEO and 34 normal patients were measured using Eyelink II video-oculography. RESULTS: The asymptotic values of the peak velocity main sequence curves were reduced in the CPEO group compared to those of normal patients, with a mean of 161 degrees/s (95% CI 126 degrees/s to 197 degrees/s) compared with 453 degrees/s (95% CI 430 to 475 degrees/s), respectively. Saccadic latency was longer in CPEO (263 ms; 95% CI 250 to 278), compared to controls (185 ms; 95% CI 181 to 189). Smooth pursuit and VOR gains were impaired in CPEO, although this could be explained by non-supranuclear causes. VORS gain was identical in the two groups. CONCLUSIONS: This study does not support a supranuclear component to the ophthalmoplegia of CPEO, although the increased latencies observed may warrant further investigation.

Intercalary femoral reconstruction with extracorporeal irradiated autogenous bone graft in limb-salvage surgery.

Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96). There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)). Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%). The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035). A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading. Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur.

Autonomic dysfunction in dementia.

BACKGROUND: There are no studies of autonomic function comparing Alzheimer's disease (AD), vascular dementia (VAD), dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD). AIMS: To assess cardiovascular autonomic function in 39 patients with AD, 30 with VAD, 30 with DLB, 40 with PDD and 38 elderly controls by Ewing's battery of autonomic function tests and power spectral analysis of heart rate variability. To determine the prevalence of orthostatic hypotension and autonomic neuropathies by Ewing's classification. RESULTS: There were significant differences in severity of cardiovascular autonomic dysfunction between the four types of dementia. PDD and DLB had considerable dysfunction. VAD showed limited evidence of autonomic dysfunction and in AD, apart from orthostatic hypotension, autonomic functions were relatively unimpaired. PDD showed consistent impairment of both parasympathetic and sympathetic function tests in comparison with controls (all p<0.001) and AD (all p<0.03). DLB showed impairment of parasympathetic function (all p<0.05) and one of the sympathetic tests in comparison with controls (orthostasis; p = 0.02). PDD had significantly more impairment than DLB in some autonomic parameters (Valsalva ratio: p = 0.024; response to isometric exercise: p = 0.002). Patients with VAD showed impairment in two parasympathetic tests (orthostasis: p = 0.02; Valsalva ratio: p = 0.08) and one sympathetic test (orthostasis: p = 0.04). These results were in contrast with AD patients who only showed impairment in one sympathetic response (orthostasis: p = 0.004). The prevalence of orthostatic hypotension and autonomic neuropathies was higher in all dementias than in controls (all p<0.05). CONCLUSION: Autonomic dysfunction occurs in all common dementias but is especially prominent in PDD with important treatment implications.

En-bloc resection, extracorporeal irradiation, and re-implantation in limb salvage for bony malignancies.

We treated 50 patients with bony malignancy by en-bloc resection, extracorporeal irradiation with 50 Gy and re-implantation of the bone segment. The mean survivor follow-up was 38 months (12 to 92) when 42 patients were alive and without disease. There were four recurrences. The functional results were good according to the Mankin score (17 excellent, 13 good, nine fair, three failures), the Musculoskeletal Tumour Society score (mean 77) and the Toronto Extremity Salvage score (mean 81). There was solid union, but bone resorption was seen in some cases. The dose of radiation was lethal to all cells and produced a dead autograft of perfect fit. Extracorporeal irradiation is a useful technique for limb salvage when there is reasonable residual bone stock. It allows effective re-attachment of tendons and produces a lasting biological reconstruction. There should be no risk of local recurrence or of radiotherapy-induced malignancy in the replanted bone.

Ilizarov wire tensioning and holding methods: a biomechanical study.

AIM: To investigate and compare two specific methods of Ilizarov wire tensioning and hold. METHOD: This study utilised the vertical Hounsfield test machine H25KS, a stress/strain device with a load-cell linked to a computer program. Firstly, the department's present mechanical tensioners were assessed. Secondly, the method of twisting the three designs of wire holding bolts to achieve wire tension, as described by Ilizarov, was assessed. These bolts are described as "cannulated", "slotted" and "Russian" (which are hexagonal headed with a slot down one side). RESULTS: The mechanical tensioners were found to be accurate, if inefficient, with a maximum producible tension of 1330N. The most effective bolts for creation of tension were the Russian, which produced mean wire tensions of 785N at 45 degrees; 1200N at 90 degrees; 1695N at 135 degrees. The cannulated and slotted bolts regularly broke the wires at 90 degrees twist. CONCLUSION: The findings demonstrated two effective methods. The present tensioners were found to be inefficient when compared to the simple twisting of the wire holding bolts, which created equivalent tensions with ease and are capable of producing greater wire tensions. The Russian bolts are recommended for use when wire tension is created by bolt twisting.

The biomechanics of wire fixation in the Ilizarov system.

The purpose of this study was to establish the optimal fixation of tensioned wires to the frame construct in the Ilizarov system. The usual torque to which the fixation bolts were tightened in clinical practice was established by serial testing of orthopaedic surgeons' work in our unit. The force required to produce wire slippage from the different types of wire fixation bolts, tightened to a predetermined torque, was measured using a testing rig. Analysis of the usual torque to which bolts were tightened in clinical practice, revealed values in the range of 5-10Nm. The load required to cause failure of the tensioned wire varied considerably depending on the bolt configuration used and the applied torque. In clinical practice, wires are tensioned using a dynamometer to a variety of loads, depending on the clinical situation, up to 1275N. In applying multiple wires across a single ring, as is normal practice, these loads may be increased still further. The total load transmitted by single wires in weightbearing may be up to 2000N. Utilising the results of our work has enabled us to choose, where practically possible, the optimal bolt configuration for wire fixation. In addition, this work has revealed that in order to withstand the loads seen in clinical practice, wire fixation bolts should be tightened to at least 10Nm. Post-operatively, we now tighten all our wire fixation bolts to 10Nm, using a calibrated torque wrench.

Rock-paper-scissors.

A study of 20 doctors in their first or second postgraduate year highlighted deficiencies in their knowledge of the nerve supply of the hand and forearm. The children's game rock-paper-scissors (Figs. 1-3) can be used as a simple aide-memoir for the nerve supply to the hand and forearm. The median nerve creates the "rock position" of the pronated fist (Fig. 1). The radial nerve extends the wrist and hand forming the "paper position" (Fig. 2a and b) and the ulnar nerve creates the "scissor position" (Fig. 3), by clawing the ring and little fingers and spreading the index and middle and adducting the thumb and flexing the interphalangeal joint.

Calculation of erythema dose-response curves using a spreadsheet.

A method of using an Excel spreadsheet is described which allows dose and erythema index values to be entered, a sigmoid curve fitted to the data, and a report generated. Summary statistics may be derived from the fitted curve. Data and statistics may be saved in a simple database. It is suitable for implementation by people who have no previous programming experience, although basic familiarity with spreadsheets is assumed.

Community-based case management for chronically ill older adults.

A comparison study was done between case managed and non-case managed chronically ill older adults. A decrease in emergency department visits, hospital admissions, hospital length of stay and primary care physician visits resulted. In addition, a +93,519.97 difference in lost net reimbursement was found between the two groups.

Studying the human-environment phenomenon using the science of complexity.

The principal argument of the present article is that a new theoretical paradigm capable of facilitating the understanding of complex phenomena is necessary to study nursing's claim to its science as the science of unitary human beings, or the integrality between humans and the environment. A research study of the complex human-environment phenomenon illuminating a four-phase methodology is presented. It is argued that much can be learned by the use of the science of complexity to integrate data gleaned from different approaches to knowledge generation into a comprehensive understanding of the human being in the environment as a unified whole.

Repatterning of stroke rehabilitation clients following return to life in the community.

The purpose of this study was to learn more about problems stroke patients experience after rehabilitation and how they perceive and interact with their environment. Findings indicate that nurses need to consider individual life patterns, current goals and the resources and impediments of the home and community environment in planning interventions. Subjects wanted a challenging but not overly stressful environment. Most of their energy was consumed with accomplishing the activities of daily living. Complex planning and timing were necessary to continue a few pleasurable activities. Advocates are needed for better design and accessibility in the environment of our aging population, with increasing numbers of chronically ill and disabled, and for all people.