Scar traction appliance for a patient with microstomia: a clinical report

This clinical report illustrates how an active traction appliance was made for a patient with severe microstomia by attaching custom-made lip retractors to an orthodontic headgear. A steady, light tensile force was imparted to the lips with the elastic bands between the retractors and the headgear.

Energy expenditure of walking for adult patients with spinal cord lesions using the reciprocating gait orthosis and functional electrical stimulation

A major factor influencing compliance with walking orthoses following spinal cord damage, is the energy requirement associated with them. We compared ambulatory energy expenditure in subjects using the reciprocating gait orthosis (RGO) with and without functional electrical stimulation (FES) of the thigh muscles at self selected walking speeds. Five adult subjects (median age 34 years, range 24-37) with spinal cord lesions ranging from C2 (incomplete) to T6 volunteered to participate in this study. All subjects were successful RGO users (median use 5.7 years, range 4.1-7.3). Walking speed (m/s), ambulatory energy consumption (J/kg/s) and energy cost (J/kg/m) were derived from oxygen uptake determined using the Douglas bag technique. We anticipated that subjects walking with FES would either: (a) walk at the same speed but reduce their energy cost or (b) increase their walking speed for the same (or less) energy cost. Walking speed and energy cost remained unchanged in one subject. One subject increased his walking speed by 14.0% and increased his energy consumption by 8.4%. His energy cost remained unchanged. Three subjects increased their walking speeds (by 12.4, 12.7 and 6.8%), energy consumption (by 25.9, 20.4 and 18.4% respectively) and energy cost (by 11.6, 6.8 and 10.5% respectively). We did not find a substantial benefit, in terms of energy expenditure, from the hybrid system when walking continuously for 5 min. We suggest that the hybrid system may be of greater benefit during prolonged walking, although other limitations, inherent in the RGO itself, may prevent an increase in compliance. Repetition of walking speed tests supported the reliability of our results. Tests on comparably aged, able-bodied subjects showed that an increase in energy cost of up to 5.8% was within the biological variability of the subject and the error of the methodology.

The effect of long-term thyroxine on bone mineral density and serum cholesterol

The effect of thyrotrophin suppression on bone mineral density (BMD) and serum cholesterol concentration was assessed in 31 treated hypothyroid women. Measurements of the BMD of the lumbar spine and femoral neck were repeated in seven of those with the lowest value after an average period of 22.7 months. Final cholesterol concentrations were compared with values before thyroxine was started. The dose of thyroxine was based on clinical assessment, serum triiodothyronine concentrations kept within the normal range, and thyrotrophin values within the normal range or suppressed. The patients had taken thyroxine replacement for a mean of 12.7 years. Two-thirds (21 subjects) had suppressed thyrotrophin concentrations, and it was normal in one-third (10). Fifteen subjects had a past history of thyrotoxicosis. BMD and cholesterol concentrations were compared between those with suppressed and normal thyrotrophin concentrations and between those with and without a past history of thyrotoxicosis. No patient had a pathological fracture. One had a Z value for the femoral neck of -1.6, denoting early but definite osteoporosis, and five had borderline osteoporosis with Z values for one or other site between -1.1 and -1.5. None of the seven with the lowest BMDs had any significant change when measurements were repeated. The difference in Z values between subjects with suppressed and normal thyrotrophin concentrations was not significant for either the lumbar spine (p = 0.68) or the femoral neck (p = 0.28). A past history of thyrotoxicosis had a greater effect on BMD for both sites than thyrotrophin suppression, but again the difference between those with and without a past history of thyrotoxicosis was significant neither for the lumbar spine (p = 0.18) nor for the femoral neck (p = 0.34). The combination of thyrotrophin suppression and a past history of thyrotoxicosis also failed significantly to reduce the BMD of the lumbar spine (p = 0.38) or femoral neck (p = 0.30) in comparison with those who had neither thyrotrophin suppression nor a past history of thyrotoxicosis. The mean fall in serum cholesterol concentration was 2.1 mmol/l (SD 1.78) (p = 0.001) in those with a suppressed thyrotrophin concentration taking a mean daily dose of thyroxine of 171 micrograms (SD: 34.7), compared with a fall of 0.89 mmol/l (SD: 1.04) (p = 0.065) in those whose thyrotrophin concentration was not suppressed on a mean daily thyroxine dose of 140 micrograms (SD: 50). No patient had atrial fibrillation or cardiographic evidence of coronary artery disease (CAD). The serum cholesterol concentration should play at least as important a part in influencing the dose of thyroxine as a fear of osteoporosis. Fractures are not a feature in the natural history of treated hypothyroidism, whereas CAD is a common cause of death in these patients.

The reciprocating gait orthosis: long-term usage patterns

OBJECTIVE

To investigate the frequency of nonusage of the reciprocating gait orthosis (RGO) in 85 patients supplied between 1986 and 1993. Reasons for nonusage and usage patterns were examined.

DESIGN

Nonusage was determined from patient records and clinical knowledge. Patients were surveyed using a detailed questionnaire to produce information on usage patterns.

SETTING

All patients had been treated as hospital outpatients.

PATIENTS

Most patients had congenital or acquired spinal cord lesions. Postal questionnaires were sent to 81 patients 5 to 55 years of age (mean 20.4 years). Thirty-five patients replied.

RESULTS

At a mean follow-up of 5.4 years, 71% of patients were classified as nonusers. Of the 35 respondents to the questionnaire (mean follow-up 5.5 years, range 4 to 7 years), 20 patients were nonusers. Median usage was 27 months in patients under age 18 and 24 months in adult patients. Significant differences were observed between nonusers and users in the areas of perception of the RGO as a functional tool, independence, and reliability and between the adult and the under 18 groups in the areas of weekly usage, function, independence, and reliability.

CONCLUSION

The high level of nonusage of the RGO has implications for prescription practice. Identifying reasons for nonusage and acknowledging differences in use between age groups will help in patient assessment.

Accidental hypothermia with cardiac arrest: recovery following rewarming by cardiopulmonary bypass

A 22-year-old man eventually had a good neurologic recovery following prolonged coma after extracorporeal rewarming from profound hypothermia (24 degrees C) due to exposure. The patient was in full arrest for 60 minutes prior to institution of cardiopulmonary bypass (CPB). Total bypass time was 50 minutes. Cardiopulmonary bypass is the current rewarming method of choice for severe hypothermia associated with a persistent nonperfusing cardiac rhythm. CPB provides the most rapid core rewarming with the additional benefit of circulatory support during the period of cardiac instability.

Epidemiologic changes in gunshot wounds in Washington, DC, 1983-1990

The purpose of this study was to examine temporal patterns in gunshot wound admission rates and wound profiles from 1983 through 1990 at a level I trauma center in Washington, DC. Data on trauma admissions were collected at the time of admission. Records were reviewed to identify patients admitted for gunshot wounds from assaults. Data on the number and location of entrance gunshot wounds, survival, complications, length of stay in the intensive care unit, and total inpatient days were recorded. Admissions due to gunshot wounds grew at an exponential rate beginning in 1987 and reached a level from 1989 through 1990 three times higher than the preepidemic rate. The mean number of entrance gunshot wounds per patient grew from 1.44 before the epidemic to 2.04 from 1988 through 1990. Multiple thoracic wounds became relatively more common from 1988 through 1990. This increase was partially responsible for reversing a downward trend in patient mortality. Temporal changes in admission rates and wound profiles were consistent with the city's epidemic of drug-related violence and with a shift in weaponry toward high-capacity, semiautomatic handguns.

Sensitivity of urine-grown cells of Providencia stuartii to antiseptics

Urine-grown cultures of 23 clinical isolates of Gram-negative bacteria having a range of minimum inhibitory concentration values for chorhexidine were challenged with various concentrations of this antiseptic. The results suggest that cells of Providencia stuartii, in particular, exhibit a considerable degree of resistance to chlorhexidine under these conditions, concentrations of up to 10 000--20 000 microgram/ml of urine being necessary to produce complete loss of viability of such cultures. Of the other two antiseptics tested, phenoxyethanol proved to be the more effective, the recommended use concentration of 2% v/v producing reductions in viable counts of greater than six logarithms in all the strains examined. It is suggested that phenoxyethanol may be a suitable alternative to the cationic agents for use in antiseptic policies for bladder management of urinary tract infections with Providencia stuartii.