Corticosteroids and neuromuscular blockers in development of critical illness neuromuscular abnormalities: A historical review.

Weakness is common in critically ill patients, associated with prolonged mechanical ventilation and increased mortality. Corticosteroids and neuromuscular blockade (NMB) administration have been implicated as etiologies of acquired weakness in the intensive care unit. Medical literature since the 1970s is replete with case reports and small case series of patients with weakness after receiving high-dose corticosteroids, prolonged NMB, or both. Several risk factors for weakness appear in the early literature, including large doses of steroids, the dose and duration of NMB, hyperglycemia, and the duration of mechanical ventilation. With improved quality of data, however, the association between weakness and steroids or NMB wanes. This may reflect changes in clinical practice, such as a reduction in steroid dosing, use of cisatracurium besylate instead of aminosteroid NMBs, improved glycemic control, or trends in minimizing mechanical ventilatory support. Thus, based on the most recent and high-quality literature, neither corticosteroids in commonly used doses nor NMB is associated with increased duration of mechanical ventilation, the greatest morbidity of weakness. Minimizing ventilator support as soon as the patient's condition allows may be associated with a reduction in weakness-related morbidity.

Functional limb weakness and paralysis.

Functional (psychogenic) limb weakness describes genuinely experienced limb power or paralysis in the absence of neurologic disease. The hallmark of functional limb weakness is the presence of internal inconsistency revealing a pattern of symptoms governed by abnormally focused attention. In this chapter we review the history and epidemiology of this clinical presentation as well as its subjective experience highlighting the detailed descriptions of authors at the end of the 19th and early 20th century. We discuss the relevance that physiological triggers such as injury and migraine and psychophysiological events such as panic and dissociation have to understanding of mechanism and treatment. We review many different positive diagnostic features, their basis in neurophysiological testing and present data on sensitivity and specificity. Diagnostic bedside tests with the most evidence are Hoover's sign, the hip abductor sign, drift without pronation, dragging gait, give way weakness and co-contraction.

Neuromuscular electrostimulation techniques: historical aspects and current possibilities in treatment of pain and muscle waisting.

Application of electricity for pain treatment dates back to thousands of years BC. The Ancient Egyptians and later the Greeks and Romans recognized that electrical fishes are capable of generating electric shocks for relief of pain. In the 18th and 19th centuries these natural producers of electricity were replaced by man-made electrical devices. This happened in following phases. The first was the application of static electrical currents (called Franklinism), which was produced by a friction generator. Christian Kratzenstein was the first to apply it medically, followed shortly by Benjamin Franklin. The second phase was Galvanism. This method applied a direct electrical current to the skin by chemical means, applied a direct and pulsed electrical current to the skin. In the third phase the electrical current was induced intermittently and in alternate directions (called Faradism). The fourth stage was the use of high frequency currents (called d'Arsonvalisation). The 19th century was the "golden age" of electrotherapy. It was used for countless dental, neurological, psychiatric and gynecological disturbances. However, at beginning of the 20th century electrotherapy fell from grace. It was dismissed as lacking a scientific basis and being used also by quacks and charlatans for unserious aims. Furthermore, the development of effective analgesic drugs decreased the interest in electricity. In the second half of the 20th century electrotherapy underwent a revival. Based on animal experiments and clinical investigations, its neurophysiological mechanisms were elucidated in more details. The pain relieving action of electricity was explained in particular by two main mechanisms: first, segmental inhibition of pain signals to the brain in the dorsal horn of the spinal cord and second, activation of the descending inhibitory pathway with enhanced release of endogenous opioids and other neurochemical compounds (serotonin, noradrenaline, gamma aminobutyric acid (GABA), acetylcholine and adenosine). The modern electrotherapy of neuromusculo- skeletal pain is based in particular on the following types: transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS or electro-acupuncture) and spinal cord stimulation (SCS). In mild to moderate pain, TENS and PENS are effective methods, whereas SCS is very useful for therapy of refractory neuropathic or ischemic pain. In 2005, high tone external muscle stimulation (HTEMS) was introduced. In diabetic peripheral neuropathy, its analgesic action was more pronounced than TENS application. HTEMS appeared also to have value in the therapy of symptomatic peripheral neuropathy in end-stage renal disease (ESRD). Besides its pain-relieving effect, electrical stimulation is of major importance for prevention or treatment of muscle dysfunction and sarcopenia. In controlled clinical studies electrical myostimulation (EMS) has been shown to be effective against the sarcopenia of patients with chronic congestive heart disease, diabetes, chronic obstructive pulmonary disease and ESRD.

Possibility of dying as a unified explanation of why we discount the future, get weaker with age, and display risk-aversion.

I formulate a simple and parsimonious evolutionary model that shows that because most species face a possibility of dying because of external factors, called extrinsic mortality in the biology literature, it can simultaneously explain (a) why we discount the future, (b) get weaker with age, and (c) display risk-aversion. The paper suggests that testable restrictions­across species, across time, or across genders­among time preference, aging, and risk-aversion could be analyzed in a simple framework .

Elementary, my dear Dr. Allen: the case of barium toxicity and Pa Ping.

OBJECTIVE: We aimed to review the English and Chinese literature on Pa Ping and to confirm by personal interview the story of how its pathogenesis was uncovered. BACKGROUND: In 1930, Dr. Alexander Stewart Allen noticed a pattern of illness arising in the region of Kiating, China. Area residents began presenting to local hospitals with nausea, vomiting, and diarrhea, and what emerged was a clinical picture of a gradual ascending paralysis that could result in death, termed Pa Ping. All 3 patients observed by Dr. Allen were male, had no family history of the disease, and had recently eaten before the onset of paralysis. Pa Ping developed in Dr. Allen himself, but he survived. METHODS: Medical literature was reviewed for primary sources. Interviews of living descendants and friends of the doctors in China and North America were conducted and information was corroborated by written records. RESULTS: Dr. Huang, with the National Central University College of Medicine, noticed a striking similarity between Pa Ping and familial periodic paralysis in 12 patients and reported 2 patients with Pa Ping treated with potassium citrate who experienced a reversal of the paralysis. Dr. K.T. Du analyzed meals of patients with Pa Ping seen by Dr. Zhe Tung and found barium in concentrations as high as 25.7%. This finding was confirmed by administering barium chloride to animals, which recapitulated the human syndrome. CONCLUSIONS: Although Dr. Huang had correctly noticed an underlying potassium depletion in patients with Pa Ping, the observations of Dr. Zhe Tung and Dr. K.T. Du ultimately established barium-induced hypokalemia as the underlying cause.

Lou Gehrig, rawhide, and 1938.

Lou Gehrig was one of the most talented baseball players of all time; yet he is also remembered for ALS, the disease that took his life and still bears his name as its eponym. There is speculation about when his symptoms began. Some authorities believe that Gehrig showed signs of ALS when he starred in the film Rawhide in January 1938, which would mean that he played the entire 1938 season with symptomatic ALS. Additionally, some photographs of Gehrig showing atrophy of hand muscles have been dated incorrectly because of misinterpreted logos on his uniform. We examined the film and photos taken of Gehrig from 1937 to 1939 to determine whether he showed signs of weakness in the film and when visible evidence of ALS could be documented. Specific scenes from Rawhide were chosen to grade Gehrig's motor function using the ALS Functional Rating Scale (ALSFRS). Dates of photos and uniform logos were verified with the Baseball Hall of Fame. Examination of Rawhide showed that Gehrig functioned normally in January 1938. His ALSFRS score, modified to account for limitations of on-screen activities, was normal. The New York Yankees wore logos in 1938 that were labeled with the year 1939 to advertise the 1939 World's Fair; the uniforms displayed a centennial patch during the 1939 season. A photograph of Gehrig from October 1939 showed hand atrophy. Photos from the spring of 1938 showed normal hand muscles and leg function, implying that visible signs first appeared after May 1938.

Motor testing in neurology: an historical overview.

Systematic testing of muscle tone, bulk, and strength and analysis of the distribution of abnormal findings is a key element of bedside cerebral localization. A codified neurological examination was developed in the 20th century, but physicians have commented on weakness since antiquity. The ancient Egyptians, Greeks, and Romans described weakness in patients with head injuries and strokes, explaining it in terms of the pathophysiology of their times. Diagnostic principles of lateralization and localization developed in the Enlightenment, alongside an understanding of the anatomy of the motor system. In the 19th century, the work of Romberg, Todd, Charcot, and Gowers popularized the use of motor localization by demonstrating the power of scientific reasoning at the bedside. The concept of the upper motor neuron, as elaborated by Gowers, has enduring clinical utility.