Lesser metatarsal osteotomies. A biomechanical approach to metatarsalgia.

As with most other orthopedic conditions, a firm understanding of the normal and pathologic biomechanics of the lesser metatarsals is essential when contemplating treatment of metatarsalgia. Despite its prevalence, metatarsalgia remains a technically demanding surgical challenge. Some of the difficulty with treatment of this problem arises because of some of the controversies discussed previously. Many lesser metatarsal osteotomies have been described, and their success depends on many factors. Alleviating the correct amount of pressure underneath the metatarsal head without adversely affecting the biomechanics of the region demands an exacting osteotomy that is stable and readily heals. Much of the research done to date has not proved which procedure can achieve these goals reproducibly for patients. It is hoped that future investigations will guide treatment choices and allow patients to obtain relief from this difficult problem with greater success.

Maternal polydrug use including cocaine and postnatal infant sleep architecture: preliminary observations and implications for respiratory control and behavior.

Twelve-hour overnight pneumocardiograms were assessed for sleep architecture and sleep efficiency in two groups of healthy term newborn infants: a group exposed prenatally to cocaine alone or in combination with other drugs and a non-exposed group. Sleep was differentiated from wakefulness by an increase in heart rate, an increase in or variation in the duration and amplitude of the respiration and increased artifacts on the heart rate channel. Quiet and active sleep were determined by the regularity or irregularity of heart rate and respiration. In a sub-set of infants, the number of arousals during active sleep was calculated. Overall significance was confirmed by ANOVA followed by paired comparisons using the Student's-test. When compared to non-exposed infants within the first week of life, infants exposed prenatally to cocaine alone or in combination with other drugs demonstrated more wakefulness and less sleep (P < 0.05), more frequent arousals during active sleep (P < 0.01), and the tendency of a higher proportion of active sleep compared to quiet sleep. These findings may have implications to both behavioral and respiratory control findings associated with prenatal cocaine exposure.

Hypofibrinolytic and atherogenic risk factors for stroke.

In 87 patients (studied on average 1 year after their strokes) and 26 of their first-degree relatives, our specific aim was to assess the prevalence of the following stroke risk factors: hypofibrinolysis, familial hypofibrinolysis, high lipoprotein (a) level, and dyslipidemia. At least 2 months after their strokes (primarily ischemic), 87 patients had measures of lipids and lipoprotein (a); 69 and 67 patients had measures of basal and stimulated fibrinolytic activity, respectively, four new findings were as follows. (1) Hypofibrinolysis was common, with bottom decile-stimulated tissue plasminogen activator activity (the major stimulator of fibrinolysis) in 21% of stroke probands and in 30% of their first-degree relatives, versus 7% of 29 nomolipidemic control subjects (p = 0.09 and 0.026, respectively). (2) The hypofibrinolysis was mediated by top-decile levels of basal plasminogen activator inhibitor activity (the major inhibitor of fibrinolysis), which were observed in 20% of stroke probands and in 21% of their first-degree relatives, versus 8% of 175 nomolipidemic control subjects (p = 0.007 and 0.04, respectively). Mean (SD) basal plasminogen activator inhibitor activity and antigen level were higher in stroke probands (18 +/- 18 U/ml and 35 +/- 31 ng/ml, respectively) than in the 175 normolipemic control subjects (14 +/- 10 [p = 0.002], 28 +/- 34 [p = 0.016]). (3) Levels of basal tissue plasminogen activator antigen, a probable marker for atherosclerosis, were much higher in stroke probands than in the 175 normolipemic control subjects (15 +/- 7.3 ng/ml vs 7 +/- 3.8, p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Tarsal tunnel syndrome and additional nerve lesions in the same limb.

Compression neuropathy in the lower extremity is common. The occurrence of more than one lesion of the nerve in the same limb is less frequent. Thirteen patients with 15 cases of tarsal tunnel syndrome associated with one or more additional lesions of the sciatic nerve or its branches of the same lower extremity are presented. Electrodiagnostic studies confirmed tarsal tunnel syndrome with conduction abnormalities at a number of locations along the sciatic, common peroneal, posterior tibial, or plantar nerves by mechanical impingement, metabolic axonal abnormality, or both. Seven of the 13 patients were treated with tarsal tunnel release. Six cases treated operatively improved significantly. Surgery on a previously operated foot or the existence of diabetes mellitus carried a fair prognosis. The association of back pain with or without previous surgery did not appear to affect the outcome of the tarsal tunnel release. No improvement in symptoms was apparent in the six unoperated patients during the period of the study. Multiple lesions of the nerves of a single extremity may account for the variable success rate of tarsal tunnel release.

The community hospital-based stroke programs in North Carolina, Oregon and New York--V. Stroke diagnosis: factors influencing the diagnostic evaluation of patients following acute stroke.

Among the 4129 patients of the Community Hospital-based Stroke Program, 30% had an unspecified stroke diagnosis. Since specific diagnosis and, perhaps, eventual treatment, derives in part from diagnostic testing, we examined the effect of clinical condition, geographic and demographic factors on the incidence of certain diagnostic tests after acute stroke. In this multivariable analysis, race, sex, history of hypertension and history of diabetes did not influence the chance of having any test, but older age strongly reduced the chances of receiving extensive evaluation. When CT scanning was available, the utilization of a CT as well as other diagnostic studies including cerebral angiography, radionuclide brain scan, EEG and EKG was increased. The odds of receiving a CT scan increased if the patient was married, and decreased with a history of previous stroke. A history of previous TIA increased the chance of having a cerebral angiogram while a history of cardiac disease decreased the chance. There were striking regional geographic differences in the use of CT, radionuclide brain scanning and cerebral angiography which may, in part, reflect differences between the availability of these technologies in urban and rural hospitals. These results indicate that evaluation of stroke patients remains heterogenous.

Community hospital-based stroke programs in North Carolina, Oregon, and New York. IV. Stroke diagnosis and its relation to demographics, risk factors, and clinical status after stroke.

The use of diagnostic tests, the accuracy of stroke type diagnosis, and their relationship to outcome are important from the standpoint of patient management and health care costs. To address this issue, we examined the differences between stroke types in terms of demographics, risk factors, diagnostic tests, and clinical outcome in the 4,129 patients who comprise the Community Hospital-Based Stroke Program. Previous transient ischemic attacks were equally frequent among patients with embolic and those with thrombotic stroke. For all stroke types, previous stroke was as frequent as previous transient ischemic attacks. Hypertension and cardiac disease were the most common risk factors, but 10% of all stroke patients had no recognized risk factors. Intracerebral hemorrhage was most often associated with death (45%). There was a strong direct relation between in-hospital mortality and a decreased level of consciousness at admission. Overall, 30% of patients did not receive a specific stroke type diagnosis; these patients were elderly, usually nonwhite, and often had an altered level of consciousness at admission but had a risk factor profile similar to that of patients who received a specific stroke type diagnosis. In summary, our findings suggest the continued need for physician education about and refinement of stroke type diagnosis.

Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. I: Goals, objectives, and data collection procedures.

In order to assess the impact of variations in stroke care on outcomes, and to make geographic comparisons, the three Community Hospital-Based Stroke Programs in North Carolina, Oregon, and New York, aggregated their data on 4,132 hospitalized stroke patients. Complete demographic data or "Major Profile" were obtained on 2,390 (57.8%) of the 4,132 stroke patients. This includes those patients on whom informed patient and physician consents were obtained during the hospitalization. Of the major profile patients, 1,490 (62.3%) were followed for periods up to one year, 502 (21.0%) were lost to followup and 398 (16.6%) died within the one year followup period. Incomplete demographic data or "Minor Profile" were observed on 1,742 (42.1%) of the 4,132 patients. Minor profile includes those who died before comprehensive interviews were completed or those for whom informed consent for an interview could not be obtained. Of the minor profile group, 813 (46.7%) died in hospital, and 929 (53.3%) were alive when discharged from the hospital. This paper, which describes the programs, data collection procedures, and study cases, also highlights specific issues on stroke diagnosis, risk factors associated with stroke, and the influence of interventions on stroke outcomes. We conclude that: 1) the merging of data on hospitalized stroke cases from rural and urban hospitals in geographically distinct regions can be used in the study of stroke diagnosis, the use of diagnostic tests, and the effect of interventions on stroke outcomes; and 2) these data are consistent with the hypothesis that part of the national decline in mortality from stroke is due to a decline in stroke severity.

Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. III. Factors influencing survival after stroke: proportional hazards analysis of 4219 patients.

The possible effect of age, race, sex, consciousness upon admission, geographic location, and history of selected risk factors on the survival after stroke due to infarction or hemorrhage was determined using proportional hazards analysis (Cox regression). For each diagnostic category the most significant prognostic factor was consciousness upon admission. Increasing age, cardiac disease, or previous stroke also decreased the survival time of patients with infarctions. For patients with cerebral hemorrhage, no other variable was significant after control for consciousness level.

Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. II: Description of study population.

The three Community Hospital-based Stroke Programs collected data on 4132 stroke patients admitted to acute care hospitals during 1979 and 1980. White female stroke patients were older than the white male, nonwhite female and nonwhite male stroke patients. Nearly one-fourth (23%) of stroke patients were employed at the time of the event. Most (77%) of the patients were hospitalized for first stroke episodes. Eighty-three percent of the patients had at least one of the four major risk factors for stroke, namely, hypertension, diabetes, transient ischemic attacks and cardiac disease. Half (49%) of the patients were alert at the time of admission. The three diagnostic categories included infarction (60%), stroke not otherwise specified (30%) and hemorrhage (10%). Fourteen days was the median length of hospitalization; 50% of the stroke patients were discharged to a home setting, 31% were institutionalized and 19% died while in the hospital. The mean Barthel Index score for 2400 patients at the time of discharge was 61.8 (normal is 100). Of those patients who were working at the time of the stroke, 22% returned to work. In comparison to the patients in the National Survey of Stroke, patients in this Study were less severe at the time of admission (49% of patients in the National Survey of Stroke were stuporous or comatose compared to 21% of the patients in the current Study). The inhospital fatality was 30.7% in the National Survey of Stroke, and 19.7% in the current Study.

Predicting the likelihood of hemorrhage in patients with stroke.

To identify those clinical findings that independently help differentiate intracranial hemorrhage from cerebral infarction, we studied patients who were admitted to a hospital with acute focal neurologic deficits after strokes during a 17-month period. The predictive strength of a decision-making aid incorporating these findings was then assessed by studying patients who were admitted to a different hospital after experiencing strokes. The decision-making aid stratified the patients into groups having probabilities of intracranial hemorrhage ranging from 5% to 67%. The results of this study may facilitate more discriminating test selection during the early evaluation of patients who have had strokes.

Assessment of hospital admission surveillance of stroke in a metropolitan community.

A system of hospital admission surveillance, developed to facilitate the communitywide study of incident stroke, has been evaluated in Monroe County, New York. Of 1604 consecutive patients admitted to the county's seven acute hospitals with a stroke-related diagnosis, 903 were subsequently confirmed as strokes, (predictive value positive = 56%). Among the 701 false positives, 52% were due to TIA or carotid stenosis, while 48% were due to other conditions mimicking stroke. Sensitivity was 68%. Among missed stroke cases 42% were admitted with non stroke-related diagnoses; 25% occurred in hospital; and 32% were missed for clerical reasons. Predictive value positive and sensitivity rates of admission screening were not significantly affected by patient age or sex. In conclusion, admission surveillance has identified a representative sample of hospitalized strokes in a practical and timely manner for studying factors effecting stroke incidence and outcomes on a communitywide basis.

Loss of adrenocortical suppression after acute brain injury: role of increased intracranial pressure and brain stem function.

The function of the pituitary-adrenal axis was studied in 23 acutely brain-injured, comatose patients (14 head trauma and 9 intracranial hemorrhage), who were treated with dexamethasone (16-64 mg/daily). Patients with normal intracranial pressure (ICP) and normal brain stem function (group 1) had decreased plasma cortisol levels (less than or equal to 5 micrograms/dl) within 36 h (mean +/- SEM, 2.4 +/- 0.3 microgram/dl; t 1/2, 18 h). In contrast, patients with elevated ICP (i.e. greater than 20 mm Hg; midline shift, or compressed ventricles) and normal brain stem function (group 2) had persistently elevated cortisol concentrations (15.4 +/- 2.6 micrograms/dl; P less than 0.001). Superimposition of brain stem dysfunction resulted in generally low cortisol levels regardless of the presence (group 4; 3.9 +/- 1.0 microgram/dl; P less than 0.001 compared to group 2) or absence (group 3; 2.1 +/- 0.5 microgram/dl) of elevated ICP. Plasma ACTH levels in 31 samples obtained before or during dexamethasone therapy in 14 patients irrespective of group were not elevated (45.6 +/- 12.5 pg/ml); there was no correlation between plasma ACTH and cortisol levels. Despite elevated cortisol values in group 2, ACTH levels were low (22.4 +/- 10.1 pg/ml). It is concluded that elevated ICP in the presence of normal brain stem function is a potent stimulus for adrenocortical activation which is not associated with elevated ACTH levels, and that the brain stem is involved in this response.

Community surveillance of stroke in persons under 70 years old: contribution of uncontrolled hypertension.

In 1979, a community-wide hospital surveillance system was established in Monroe County, New York (population 702,000), to investigate the continuing contribution of uncontrolled high blood pressure (HBP) to the occurrence of stroke. This paper reports findings among 200 consecutive strokes in persons under 71 years of age. Average age was 58. There was a prestroke history of HBP in 129 (65 per cent) cases. Two-thirds of the 129 had other predisposing conditions (heart disease, diabetes, previous cerebrovascular accident) and 95 per cent had one or more other cardiovascular risk factors (smoking, elevated cholesterol, obesity). Over 90 per cent had visited a physician during the year prior to stroke (average of four visits). Elevated pressures (DBP greater than or equal to 95 or SBP greater than or equal to 160) were recorded at half or more of the visits for 45 per cent of the patients; these cases were classified as uncontrolled. Reduction of "unnecessary" strokes in persons under age 71 should be achievable by giving increased attention to those already under medical care for hypertension who have co-existing stroke risk conditions and cardiovascular risk factors.

Evaluation of the dopamine response to stress in man.

Because the role of circulating dopamine (DA) in the sympathetic nervous system response to stress remains unclear, alterations in peripheral DA concentrations were determined in healthy volunteers after assuming upright posture (n = 6), hand immersion in ice water (cold pressor, n = 6), and insulin-induced hypoglycemia (n = 11) and in 17 comatose patients with severe brain injury (11 head trauma and 6 intracranial hemorrhage). Changes in DA levels were compared to increases in epinephrine (E) and norepinephrine (NE), all of which were measured by the radioenzymatic technique. The minimum sensitivities were 42, 22, and 38 pg/ml, respectively. In 19 normal men and 22 women, basal DA levels were below assay sensitivity in 31 and were 85 +/- 7 (+/- SE) pg/ml in the remainder. Plasma E was measurable in all but 7 subjects, with a mean concentration of 41 +/- 4 pg/ml. NE levels were 201 +/- 17 pg/ml in 30 of the 31 subjects in whom it was detectable. There was no sex difference for any of the catecholamines. Upon standing, neither DA nor E changed significantly, but NE, increased by 176 +/- 40 pg/ml (P less than 0.0025). There were no significant changes in DA or E concentrations during the cold pressor test, while NE increased by 212 +/- 66 pg/ml (P less than 0.025). Compared to the E (1044 +/- 356 pg/ml; P less than 0.02) and NE (233 +/- 62 pg/ml; P less than 0.005) increments after hypoglycemia, the maximal DA increment, although significant (62 +/- 22 pg/ml; P less than 0.025), was less than those of the other catecholamines. DA levels were measurable in only 7 of 40 samples from 17 brain-injured patients and was 72 +/- 13 pg/ml in the remainder. However, E and NE levels were detectable in 79% of the samples and were significantly greater than normal (125.6 +/- 14 and 594 +/- 59 pg/ml; P less than 0.001, respectively). It is concluded that basal DA levels are generally below the assay limits of detectability. Furthermore, measurement of circulating levels suggests that DA participates in the general sympathetic response only when the adrenal component is maximally activated.

Depression and failure to resume social activities after stroke.

In 91 stroke patients, the incidence of depression was 26% (24 patients) 6 months after stroke. Depression was significantly correlated with failure to resume premorbid social activities; depressed patients lost a mean of 67% previous activities while nondepressed patients lost a mean of 43% (p less than 0.01). Depression status was not significantly related to age, sex, marital or cognitive status, or side of brain involvement. Independence in ADL and ambulation or change in residence after stroke also were not significantly related to depression status. Since depression is common after stroke, is associated with failure to return to previous activities, and cannot be predicted by commonly used patient characteristics, the health care team must carefully identify, monitor, and manage depression in the patient recovering from stroke.

Sympathoadrenomedullary hyperactivity in the neuroleptic malignant syndrome: a case report.

The authors describe a patient with the neuroleptic malignant syndrome whose excessive catecholamine excretion indicates hyperactivity of the sympathoadrenomedullary component of the autonomic nervous system. Their finding provides a physiological basis for using catecholamine blocking agents to treat some patients with this syndrome.

Catecholamine-associated refractory hypertension following acute intracranial hemorrhage: control with propranolol.

Seven patients (4 with subarachnoid hemorrhage, 2 with intracerebral hemorrhage, and 1 with massive cerebral infarction) had acute arterial hypertension refractory to control by several antihypertensive drugs (hydralazine, sodium nitroprusside, alpha-methyldopa, and trimethaphan camsylate) used singly or in combination. In each case, catecholamine excretion--measured by urinary norepinephrine plus epinephrine--was markedly elevated, averaging 218 microgram/day. Patients without the acute refractory hypertension had normal or only slightly elevated urinary catecholamine levels (mean, 72 microgram/day). The beta-adrenergic blocking agent propranolol, in doses between 20 and 40 mg every 6 hours, successfully controlled blood pressure, while other agents failed. The intense sympathetic nervous system discharge resulting in acute refractory hypertension may be due to injury to the diencephalon or brainstem (or both) or to diffuse brain dysfunction from increased intracranial pressure or intracranial blood.