Pyogenic liver abscesses due to Klebsiella pneumoniae in a diabetic patient.

Pyogenic liver abscess due to Klebsiella pneumoniae is a rare clinical entity. It has emerged as an important infection complication in diabetics and its incidence in diabetics without intraabdominal or biliary tract infections is increasing. We present herein a case of multiple pyogenic liver abscesses due to K. pneumoniae in a diabetic patient and discuss clinical course, treatment and possible reasons for association between K. pneumoniae liver abscess and diabetes.

Problem solving and coping strategies in persons with spinal cord injury who have and do not have a family history of alcoholism.

Recovery from spinal cord injury (SCI) requires substantial coping by the patient. The coping process reflects both physical adjustment to permanent biological changes and psychological acceptance of these changes and their limitations to function. A history of family alcoholism appears as one prominent factor in persons with SCI. This factor is associated with several personality characteristics that could directly influence adjustment to the injury. As an initial exploration of this premise, the present study examined the relationship between family history of alcoholism and coping processes in SCI patients. Ninety volunteer subjects were selected from inpatient and outpatient populations of a Veterans Affairs spinal cord injury service. Based on structured interviews and responses to a standardized questionnaire, one group of 45 subjects, designated Family History Positive (FHP), were from families in which the father and at least one other second generation relative were alcoholics. The 45 Family History Negative (FHN) subjects were from families with no alcoholism subjects were from families with no alcoholism history. Once assigned to a group, subjects completed the Ways of Coping Questionnaire. Compared to subjects with no family alcoholism history, FHP subjects reported significantly more use of constructive coping strategies as measured by the Ways of Coping Questionnaire, but their alcohol use and anti-social behaviors indicated that they were less effective in actual coping behaviors. Persons with SCI and a family history of alcoholism reported utilization of coping methods that differ from those used by patients with SCI and no family alcoholism history. From the perspective of treatment and rehabilitation, this finding suggests the need to consider different therapeutic approaches for these groups.

Spinal cord injury increases the risk of abdominal aortic aneurysm.

We have observed apparently disproportionate numbers of abdominal aortic aneurysms (AAAs) in chronic spinal cord injury (SCI) patients. To test whether aortic enlargement is more frequent in SCI, we measured maximum infrarenal aortic diameters (AoDmax) by B mode ultrasound in 89 SCI subjects and 223 age and sex matched controls. The average AoDmax in SCI subjects (mean age 60.3 years) was 2.27+/-0.80 cm compared to 2.07+/-0.69cm in the controls. This difference was significant (P = 0.023), as were the proportions of subjects with AoDmax >/- 3cm. A total of 20.2 per cent of the SCI group had AoDmax >/- 3cm compared to 8.9 per cent for the controls (P < 0.0001, chi-square). Race, height, and weight distributions were similar. SCI patients had lower levels of hypertension and cigarette smoking than controls. Within the SCI and control groups, subjects with AoDmax >/- 3cm had increased cigarette consumption compared to /- 3cm group than in the >/- 3cm group, T6 versus T8, but not significantly (P = 0.23)> Based on these results, SCI patients have over a two-fold risk of aortic enlargement as a consequence of spinal cord injury.

Changes in the P300 component of the tactile event-related potential following spinal cord injury.

Previous studies have demonstrated that significant changes in action or behaviour (function) and morphology occur in the deafferentated and the adjacent somatosensory cortex after amputation or experimental spinal cord injury. These studies have shown changes in somatotopic mappings and somatosensory perception as well as altered evoked responses. The purpose of the present study was to examine the potential effect of these changes on cognitive processes using the tactile P300 event-related potential (ERP) in a spinal cord injured (SCI) population. The P300 ERP has been associated with more complex cognitive functioning such as selective attention, memory, and stimulus evaluation rather than earlier sensory processing of stimuli. Three groups consisting of healthy control, paraplegic, and tetraplegic subjects participated in a transcutaneous electrical stimulation 'oddball' task. Results indicate that all groups were successful in maintaining target counts and produced significantly larger P300 amplitudes with longer latencies to target trials compared to non-target trials. The SCI groups, however, produced P300 ERPs for both targets and non-targets that were significantly reduced in amplitude compared to the control group. In the case of the tetraplegia patients, the P300 was almost abolished. No differences in latency of the P300 was observed between any of the groups.

Sensory detection and pain thresholds in spinal cord injury patients with and without dysesthetic pain, and in chronic low back pain patients.

In an effort to understand the mechanisms involved in dysesthetic pain syndrome (DPS) in spinal cord injury (SCI) patients, four groups of 13 subjects each--SCI subjects with DPS, SCI subjects without pain, chronic low back pain subjects, and control subjects--were examined for sensory detection and pain thresholds at forearm, neck, and rostral trunk areas. Results indicated that the SCI pain group had significantly lower pain thresholds at all skin sites, compared to the SCI no-pain and chronic low back pain groups, and at the rostral trunk skin site, compared to the control group. The SCI pain group also showed a lower sensory detection threshold at the rostral trunk skin site than did the SCI no-pain group. Equally important, the SCI no-pain group had detection and pain thresholds significantly higher than those of the control group. The results suggest fundamental differences in somatosensory processing when DPS is or is not a consequence of SCI.

Incidence and characteristics of spinal cord injured patients with a family history of alcoholism.

OBJECTIVE: Of the many factors that affect the occurrence of and rehabilitation from spinal cord injury, alcohol use and abuse are particularly prominent. Persons with a family history of alcoholism are at greater risk for alcohol abuse and alcoholism. Preliminary data show a much higher than normal proportion of these persons in the spinal cord injured population. If these data are reliable, they may show that family history of alcoholism is a premorbid or comorbid factor to the occurrence of accidents that results in catastrophic injuries. Our investigation represented an evaluation of this premise. METHOD: Male volunteer subjects (N = 100) were selected from inpatient and outpatient populations of a Veterans Affairs spinal cord injury service. Subjects received a comprehensive interview and completed two standardized questionnaires and a general information form designed to evaluate their past and present use of alcohol and the use of alcohol by their parents and relatives. RESULTS: The incidence (45%) of spinal cord injured patients with a family history of alcoholism was over four times that found in the general population. Spinal cord injured subjects with a family history of alcoholism reported significantly more problems with alcohol before, at the time of, and after their injury. CONCLUSIONS: The data suggest a relationship between the predisposition to alcoholism and accidents that result in catastrophic injury.

Auditory P3 event related potentials (ERP) and brainstem auditory evoked responses (BAER) after spinal cord injury in humans.

Previous studies have observed altered somatotopic sensory fields after experimental deafferentation in animals as well as enhanced somatosensory evoked potentials and altered cortical motor pathways following spinal cord injury (SCI) in humans. These observations indicate that cortical reorganization may occur subsequent to SCI. In earlier work, we have observed attenuated amplitudes for both tactile P3 and auditory N1/P2 orienting event-related potentials (ERP) in spinal cord injured groups. These results suggest that the reorganization process may have functional perceptual and cognitive consequences. In an effort to determine if deafferentation affects the P3 ERP using stimuli other than somatosensory, we measured brain activity from central recording sites during an auditory "oddball" task. Additionally, we obtained brainstem auditory evoked responses (BAER) in order to assess subcortical primary auditory pathways as well. Results show that the SCI groups produced significantly attenuated N1/P2 complexes and P3 when compared to controls. Also, the quadriplegic group exhibited increased latencies of the P3 at frontal and central sites. There were no differences between groups in BAER results. These findings suggest that primary subcortical auditory information processing stages remain intact after SCI although later stages may be significantly altered.

Maggot therapy for treating pressure ulcers in spinal cord injury patients.

For centuries, maggot therapy (MT) has been recognized as an aid to wound healing. By including live blowfly larvae in wound dressings, earlier physicians noted thorough debridement which hastened wound healing. We initiated a prospective controlled study to evaluate the utility of maggot therapy for treating pressure ulcers in spinal cord injury patients in the modern era. Eight of our patients received MT after a baseline assessment of healing under conventional therapy (defined as any therapy prescribed by the patient's primary care team). Surface area, tissue quality and healing rates were monitored weekly. MT debrided most of the necrotic wounds within one week, which was more rapid than all other non-surgical methods. Wound healing was more rapid during MT than during antecedent conventional therapy (p = 0.01). No complications were seen. We have demonstrated that MT can be beneficial in the treatment of pressure ulcers in persons with spinal cord injuries. MT was significantly more effective and efficient than the current, conventional treatment alternatives being used. MT was also safe, simple and inexpensive. MT can be a valuable modality in the treatment of pressure ulcers.

Spinal cord injury. An overview.

Advancements in the management of urologic complications such as the neurogenic bladder have been essential to improving the quality of life and longevity of patients with spinal cord injury. These advances are discussed in greater detail in the subsequent articles in this issue. Despite the many improvements that have been made in post-trauma care, spinal cord injury remains a devastating lesion of the nervous system. Current therapies have not proved to be particularly effective in preventing or reversing damage to the spinal cord. Still, every effort should be made to preserve remaining function and to prevent complications. The care of these patients has been significantly improved with the development of specialized multidisciplinary centers. The emphasis in current treatment focuses on rehabilitation and adaptation to the disability and on prevention of secondary disabilities. Research in basic and clinical neuroscience will result in better, more useful care and treatment for those with spinal cord injury. However, even then, a neurorehabilitation team will be essential to care for these patients. Continuing efforts must be made to ensure that people with spinal cord injury lead full and productive lives.

Two-point discrimination thresholds in spinal cord injured patients with dysesthetic pain.

We questioned whether deafferentation following SCI would result in an increase in somatic sensitivity possibly due to cortical reorganization. Dysesthetic pain syndrome (DPS) below the level of a spinal cord injury (SCI) is a common complication. We hypothesized that DPS patients would show increased cortical reorganization because of high levels of sensory stimulation following injury. Sixteen dysesthetic pain SCI patients, 15 SCI patients without pain, and 16 control subjects were examined for two-point discrimination thresholds (2PDT) of the forearm, neck, and spine. The SCI pain group had significantly smaller 2PDTs than either SCI no pain or control groups, particularly over the neck and spine. The SCI pain group had a significant inverse correlation between perceived degree of pain (visual analogue scale) and 2PDT in the spinal skin area. The findings indicate that SCI patients with severe DPS have a higher sensitivity to somatosensory stimuli, particularly in skin areas with projections to primary somatosensory cortex areas adjacent to the deafferentated region. The increase in 2PDT may be due to an increase in the size of the somatosensory cortical areas allotted to the corresponding skin areas.

Event-related brain potentials during orienting to auditory and visual stimulation in spinal cord injured humans.

In intact humans, deprivation of somatosensory and kinesthetic sensations result in significant alterations in perception and information processing. There have been very few studies to discover if the loss of sensation with spinal cord injury (SCI) in humans affects perceptual operations. We hypothesized that the SCI participant would either exhibit arousal, perceptual, and information processing alterations similar to experimentally sensory deprived subjects (who provide the closest human analogue), or that the somatosensory cortex would show reorganization for the processing of other modalities of stimulation. The subjects consisted of 16 paraplegic, 13 quadriplegic, and 22 non SCI controls. Subjects received an auditory orienting task consisting of a 500 Hz tone presented 20 times each at 66, 75, 88, and 101 db and a visual orienting task incorporating light flashes of 115, 123, 131, and 140 lux presented 20 times each. EEG information processing data were recorded from C3 and C4 for 100 msec prior to and 500 msec post stimulation. Information processing variables, analyzed as event-related potentials, indicated that the somatosensory cortex of SCI groups had a flattened response to auditory stimulation. The control group had a significantly larger P2 component. We concluded that these data signified that the somatosensory cortex did not reorganize function in response to chronic deafferentation nor was the SCI subject hyperresponsive to stimulation.

Fatal cerebral hemorrhage due to autonomic dysreflexia in a tetraplegic patient: case report and review.

Autonomic dysreflexia is the most important specific complication of high level spinal cord injury both in tetraplegic and in paraplegic patients above the midthoracic neural segment. It is a life threatening emergency that may lead to apoplexy. We present a case of fatal cerebral hemorrhage due to autonomic dysreflexia in order to demonstrate the gravity of this particular syndrome.

The proximal tap or "central Tinel" sign in central dysesthetic syndrome after spinal cord injury.

Diffuse, chronic, and dysesthetic pain following spinal cord injury (SCI) has been described by several authors under different terms. As illustrated by the two patients described here, central dysesthetic syndrome (CDS) can be mistaken for musculoskeletal, peripheral neuropathic or visceral disease in SCI patients. In these patients, an added clue to the central neuropathic nature of their symptoms was allesthesia and allodynia to light touch or tapping over areas rostral to the level of injury; this may be called the proximal tap or "central Tinel" sign.

Decreased systemic clearance of lorazepam in humans with spinal cord injury.

Serum concentration-time course profiles, serum protein binding, and disposition parameters of lorazepam (LRZ), a benzodiazepine with sedative-hypnotic, anxiolytic, and anti-seizure properties, were studied as part of a systematic effort to define population-specific pharmacokinetic behavior in humans with chronic spinal cord injury (SCI). Twenty-four healthy subjects (nine tetraplegic, six paraplegic, nine able-bodied) were given an IV bolus of 2.0 mg of LRZ. Noncompartmental estimation of pharmacokinetic parameters disclosed a 37% decrease in the total systemic clearance (CL) of LRZ in tetraplegic patients. Altered LRZ clearance was observed independently of significant changes in volume of distribution or serum protein binding. The early elimination of LRZ (0-10 hr) was characterized by wide fluctuations in serum concentration suggestive of impaired enterohepatic circulation and could be distinguished from LRZ elimination observed in able-bodied subjects. We conclude that decreased systemic CL and the altered terminal elimination profile of LRZ are attributable to the pathophysiology of SCI.

Computed tomography changes in neurosarcoidosis clearing with steroid treatment.

Contrast enhancement computed tomography (CT) in a patient with central nervous system (CNS) sarcoidosis revealed increased densities particularly in the frontal and temporal areas. Treatment with prednisone improved the condition, and the CT abnormality disappeared. These previously undescribed findings can be of help in establishing the diagnosis and in following the patient's response to treatment.