Dermatome electrical stimulation as a therapeutic ambulatory aid for incomplete spinal cord injured patients.

Electrical stimulation of the L-3,4 dermatome during treadmill walking is proposed as a gait training modality in incomplete spinal cord injured patients. The dermatome stimulation proved to be efficient in diminishing the extensor tone occurring after loading of the paralyzed limb during the stance phase of walking and resulting in improved flexion of the leg during the swing phase.

FES Rehabilitative Systems for Re-Education of Walking in Incomplete Spinal Cord Injured Persons.

Objective. The aim of the paper is to present various relatively simple functional electrical stimulation (FES) systems that affect neural circuits and reflex behavior by providing necessary peripheral input to the lower extremities of incomplete spinal cord injured (SCI) persons. Methods. The proposed FES re-education walking systems make use of feedback information that is transmitted from the paralyzed limb to the nonparalyzed part of the patient's body. A single gait variable can be analogously transmitted to the walking subject in a form of sensory stimulation. The information about several gait variables can be first integrated and afterwards delivered to the walking subject as a single command. Conclusions. Significant improvements in the duration of the double support phase, metabolic energy expenditure, and physiologic cost index were observed when using FES-assisted training of walking in incomplete SCI persons.

Effects of respiratory muscle training and electrical stimulation of abdominal muscles on respiratory capabilities in tetraplegic patients.

Thirteen tetraplegic patients were included in the study of the effects of respiratory muscle training and of electrical stimulation of the abdominal muscles on their respiratory capabilities. Each patient was subjected for three 1 month lasting periods of the study: for inspiratory muscle training, expiratory muscle training and for a period without training. The sequence of these three periods was random for each patient. Respiratory tests (RT) measuring forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were conducted before and following each monthly period. Measurements were taken under four sets of conditions: the patients' unassisted efforts, their efforts combined with pressure manually applied by a therapist to the upper part of their abdomen, and their efforts accompanied by electrical stimulation (ES) of the abdominal muscles during the early phase of expirium, once triggered by the therapist and once by the patients themselves. RT values were increasing following respiratory muscle training and inspiratory training apparently had a slightly greater effect than its expiratory counterpart. The increments of values of RT were statistically significant (P < 0.05) after the inspiratory muscle training. RT measurements were greater when the patient's voluntary effort was combined with ES of abdominal muscles than when it was not. This study concludes that respiratory muscle training is a potentially effective approach and that ES of the abdominal muscles has potentials to improve coughing in tetraplegic patients.

Improvement in step clearance via calf muscle stimulation.

The aim is to study the influence of electrically stimulated calf muscles on the effectiveness of the swinging leg movement. The study is carried out with a group of patients with incomplete spinal cord injuries both under stationary conditions and during crutch-assisted walking. Before stimulation is applied to the ankle plantar flexors, the knee extensors are inactivated. In each cycle, after ankle plantar flexor stimulation, peroneal stimulation is started, triggering the flexion reflex. From a biomechanical point of view, functional electrical stimulation (FES) of the ankle plantar flexors results in increased ground clearance of the lower extremity. Additionally, the FES-assisted lifting of the heel results in the elimination of extensor tone and thus shortens the swing time.

Influence of electrically stimulated ankle plantar flexors on the swinging leg.

The influence of functional electrically stimulated ankle plantar flexors on the swinging lower extremity was studied in incomplete spinal cord injured persons. Stimulation sequences with different time and frequency parameters were delivered to ankle plantar flexors and knee extensors and to the peroneal nerve. The results of kinematic assessment showed that stimulated calf muscles provide noticeable forward and upward propulsion to the swinging leg.

The prediction of cardiac risk in patients undergoing vascular surgery.

In an attempt to determine whether noninvasive cardiac testing could be used to assess cardiac risk in patients undergoing surgery for vascular disease, the authors studied 96 patients. Seventy-seven patients eventually underwent major vascular surgery with 11 (14%) experiencing a significant cardiac complication. Thallium imaging was much more likely to be positive (p less than 0.01) in patients with a cardiac complication; however, there was a significant number of patients with cardiac complications who had a positive history or electrocardiogram for myocardial infarction. When grouped by complication and history of infarction, thallium imaging, if negative, correctly predicted low cardiac risk in the group with a history of infarction. Thallium imaging, however, did not provide a clear separation of risk in those without a history of infarction. Age and coronary angiography, on the other hand, did reveal significant differences within the group without a history of infarction. The resting radionuclide ejection fraction followed a similar pattern to thallium imaging. It is concluded that a positive history of myocardial infarction at any time in the past is the strongest risk predictor in this population and that the predictive value of noninvasive testing is dependent on this factor. Considering these findings, a proposed scheme for assessing risk that will require further validation is presented.

Axillofemoral bypass. Expectations and results.

We studied 33 patients who received axillofemorofemoral or axillofemoral polytef (polytetrafluoroethylene [PTFE]) grafts. The follow-up period ranged from six to 60 months. Most patients were operated on for limb salvage. The 30-day operative mortality was 7% for elective or urgent procedures and 67% for emergency procedures. Twelve amputations were performed, but nine were necessitated by preexisting tissue loss and three were performed below rather than above the knee following proximal revascularization. Cumulative graft patency was 91% at three years and 75% at five years. Patient survival was only 54% at three years and 41% at five years. Graft patency exceeded patient survival at every interval. In a select group of high-risk patients requiring proximal revascularization for limb salvage, axillofemorofemoral bypass offers an acceptable alternative to an in situ aortofemoral graft.

Chylous ascites after abdominal aortic surgery.

Chylous ascites is an unusual postoperative complication that can lead to significant mechanical, nutritional, and immunologic consequences. We present the report of a patient with chylous ascites after abdominal aortic aneurysm repair. Paracentesis is essential for diagnosis and is often useful in the initial management of the patient with mechanical respiratory distress. Nonoperative management is appropriate, but careful attention must be given to the patient's nutritional status. Elemental diet supplementation or total parenteral nutrition may be necessary to minimize lymph flow. The sequestration of lymphocytes into the ascitic fluid may result in a profound decrease in absolute lymphocyte count. With appropriate nutritional support the prognosis of postoperative chylous ascites is excellent and reoperation rarely necessary.

A critical review of amputation in vascular patients.

A study was made of 53 patients who underwent amputation for peripheral vascular disease over a 5-year period at West Virginia University Medical Center. The follow-up period ranged from 1 to 6 years. Data concerning operative deaths, risk factors, use of prosthetic devices, and ultimate self-sufficient living were obtained. The functional outcome for this group of patients was encouraging with modern prosthetic fitting and social rehabilitation. Approximately 75% of the patients were returned to a useful life with a prosthetic limb or in a wheelchair. Amputation is a less desirable alternative than successful revascularization, but with the prostheses available today, amputation does not foreshadow a dismal existence.

The relationship of the possible hepatic toxicity of chemotherapeutic drugs and carcinoembryonic antigen elevation.

The value of the serum level of carcinoembryonic antigen (CEA) as an indicator of recurrent colorectal carcinoma has been accepted, and the use of serial CEA levels to monitor postoperative chemotherapy has been suggested, However, elevated CEA levels may be associated with nonneoplastic conditions, of which the most difficult to evaluate is hepatic disease. The effect of chemotherapy on hepatic function and therefore on CEA level is not clear. We discuss a patient who, after a potentially curative resection for adenocarcinoma, demonstrated a rise in CEA level in the absence of recurrent carcinoma. This rise correlated with administration of intravenous 5-fluorouracil. Liver biopsy demonstrated severe fatty infiltration with no evidence of cirrhosis. The possible liver toxicity of chemotherapeutic drugs must be considered as a factor responsible for the rise in CEA. Simultaneous assessment of hepatic function is essential to the accurate interpretation of CEA levels, especially in patients receiving chemotherapy.

Spontaneous aorto-vena caval fistula: hemodynamic monitoring.

Rupture of an atherosclerotic abdominal aortic aneurysm into the inferior vena cava presents a challenging surgical problem. Marked hemodynamic changes are produced by the large arteriovenous shunt. Hemodynamic monitoring with a Swan-Ganz catheter will quantitate these alterations and can help direct appropriate therapy. A case illustrating this unusual lesion and the preoperative, intraoperative and postoperative cardiovascular changes is presented.

Advances in the management of gastroschisis.

Twenty-eight cases of gastroschisis have been treated over a five-year period. Twenty-two silos were placed and 19 infants had uncomplicated silo closure. Enlargement of the abdominal wall defect to allow optimum reduction of the edematous bowel was essential to closure in less than a week. Rapid removal of the prosthesis and strict adherence to aseptic technique prevented septic complications. Inability to return the bowel to the abdominal cavity within five to six days mandated re-exploration to determine the cause for failure to reduce the silo. Accordingly, three infants were re-explored. Two patients had unrecognized intestinal lesions and a third infant, whose defect had not been enlarged, had infarction of the midgut. Six infants underwent primary closure; two with preinatal evisceration and four who had concomminant cutaneous enterostomies performed for intestinal atresia. Intestinal atresia or stenosis occurred in 25% of these infants. Postoperative management was facilitated by insertion of a gastrostomy tube, early peripheral venous nutrition and later insertion of a central venous catheter for nutrition. The one postoperative death (3.5% mortality rate) resulted from failure to follow the principles of silo management as outlined in this report.

Gastroschisis update.

Sixty-four infants with gastroschisis have been managed in the 9-yr period, 1970-1979, with four postoperative deaths. The silo technique has been the standard method of management in this series, permitting initial expansion of the abdominal cavity without increased abdominal pressure and respiratory embarassment. Removal of the silo and complete closure of the abdominal wall deficit were possible 5-12 days later. A high proportion of the infants were below 2500 g in weight at birth (61%); and although 3 of the 4 postoperative deaths occurred in the low birth weight group, this did not appear to be a factor in mortality. Associated anomalies occurred in 25 of the 64, but only the coincident intestinal atresias (6) were of major significance. These additional anomalies were not responsible for deaths. Two deaths occurred from problems dating from birth, one from aspiration and the second from sepsis. The other two resulted from postoperative complications resulting in infarction of the midgut. Both were caused in part by failure to adequately enlarge the abdominal wall defect at the time of the initial procedure. Other postoperative complications were relatively few. Although all required intravenous nutritional support, the long term results in terms of growth and development and of intestinal function were quite satisfactory.

Mass lesion of the breast after augmentation mammoplasty.

Examination of the breast after augmentation mammoplasty may be relatively easy, but the evaluation of a mass lesion presents particular possibilities and problems. Closed compression capsulotomy occasionally results in rupture of the gel prosthesis, and when silicone contacts the surrounding breast tissue, a firm granuloma can result. A patient after augmentation mammoplasty had a mass lesion of the breast following trauma. At operation, the gel prosthesis was found to have ruptured and resulted in a silicone granuloma. A history of closed compression capsulotomy or trauma is important in the preoperative evaluation of such patients, and both the surgeon and the patient should be prepared to procede with replacement of the implant at the time of biopsy.