Relation of changes in radionuclide measures of effective renal plasma flow and glomerular filtration rate in spinal cord injury patients.

The association of changes in radionuclide measures of effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) in relation to the time since spinal cord injury (SCI) was investigated in 30 male SCI patients ages 28-72 (mean 49), with intervals from injury ranging from two to 48 years. ERPF and GFR were determined from plasma clearance curves following bolus injections of I-131 orthoiodohippurate (OIH) and Tc-99m diethylenetriaminepentaacetic acid (DTPA) respectively, and were compared with published age-adjusted normal values. Fifteen patients had decreased ERPF and 13 had decreased GFR, with decline in ERPF tending to precede a similar change in GFR. Among 18 patients < or = 20 years post-SCI, GFR was abnormal in six (33 percent), while ERPF was decreased in 10 (56 percent). In twenty-four patients (80 percent), GFR and ERPF were either both normal (n = 13) or both abnormal (n = 11), but filtration fraction (FF = GFR/ERPF) was increased to > 0.23 in 18 patients, including nine with normal GFR. Only 2 patients had normal ERPF/abnormal GFR, both of whom were > 35 years post-SCI and had FF < 0.20. In the SCI population, decreases in ERPF tend to precede similar changes in GFR, with resultant increase in FF in the majority of patients.

Medical, functional, and legal aspects of vocational rehabilitation for people with multiple sclerosis.

A majority of individuals with multiple sclerosis (MS) are not employed, even though most are at an age of prime employability and have been successfully employed in the past. Factors that have been shown to decrease employment in these individuals include mobility impairment, bladder and bowel dysfunction, impairment in activities of daily living, cognitive dysfunction, social and family issues, lack of physical and functional access to the workplace, and attitudes of the patient, family, and employer about chronicity and disability in MS. This paper reviews the functional, psychosocial, and legal barriers to employment in these individuals and discusses effective interventions to maintain or regain successful employment in this population.

The use of oral mexiletine for the treatment of pain after peripheral nerve injury.

Neuropathic pain is often a difficult condition to treat. Clinical and laboratory studies using intravenously administered local anesthetics or antiarrhythmic agents support the use of these drugs for the treatment of neuropathic pain. The availability of the oral antiarrhythmic medication, mexiletine, has made it possible to study the effects of an orally administered medication on chronic neuropathic pain. The study used a double-blind placebo-controlled design to examine 11 subjects in whom treatment with conventional pain medications had been unsuccessful. Subjects had a history of peripheral nerve injury or dysfunction, and all complained of symptoms consistent with neuropathic pain. After baseline pain measurements, mexiletine or placebo was given in gradually increasing doses to a maximum daily dose of 750 mg mexiletine. After 1 month at steady state, the subject received the alternative medication. Mexiletine was found to produce a statistically significant reduction in reported pain when compared to baseline or placebo. Pain scores were rated on a scale from 0 (no pain) to 10 (unbearable pain). Median pain scores prior to mexiletine were 7, after placebo treatment 7, and while receiving mexiletine (750 mg/day) 4. Side effects were mild and well-tolerated. Mexiletine may be effective in reducing neuropathic pain for patients in whom alternative pain medications have been unsatisfactory.

Diagnostic imaging of heterotopic ossification with coexistent deep-venous thrombosis in flaccid paraplegia.

Heterotopic ossification and deep-venous thrombosis can coexist. This raises potential problems because diagnosis depends heavily on imaging studies, and an ideal imaging study which will cost-effectively and noninvasively diagnose both conditions simultaneously is not readily available. A case of coexistent heterotopic ossification and deep-venous thrombosis in flaccid paraplegia is presented. In this case, deep-venous thrombosis and pulmonary embolus were diagnosed and treatment was begun without knowledge of the coexistent heterotopic ossification. Alternative imaging and laboratory diagnostic strategies are discussed. It was concluded that, at this time, clinical acumen and judicious use of traditional diagnostic alternatives is the best means of selecting appropriate treatment. Awareness of the coexistence of the two conditions are careful attention to the patient's clinical course can minimize treatment delays and resultant morbidity.

Lower extremity manifestations of spasticity in chronic spinal cord injury.

The prevalence of various manifestations of spasticity from questionnaire responses and from clinical examination of chronic spinal cord injured patients is reported. Extensor spasms, flexor withdrawal spasms, and clonus were reported by most subjects. Those with incomplete lesions reported more interference with activities, more pain, and less functional usefulness, than did those with complete lesions. Extensor spasms were reported to interfere more with transfers, whereas flexor withdrawal spasms were reported to be more frequent at night and to interfere more with sleep. Increased muscle tone was observed more often in extensor than in flexor muscles. Those with incomplete lesions had more hypertonus and more limited passive joint movements than did those with complete lesions. Flexor withdrawal reactions and extensor spasms were also more pronounced in those with incomplete lesions, particularly those with Frankel grade C lesions.

Diagnostic ultrasound: its value in acute urinary tract infection in spinal cord injury.

Two cases of acute urinary tract infection in patients with spinal cord injury highlight the complications of calculus and perinephric abscess. Rather than waiting the customary 48 hours to assess response to antibiotics before evaluation for secondary complications, diagnostic ultrasound is advocated upon diagnosis of pyelonephritis. The potential benefits of early imaging seem to far outweigh the negligible risk and expense.