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Visagan R, Kearney S, Blex C, Serdani-Neuhaus L, Kopp MA, Schwab JM, Zoumprouli A, Papadopoulos MC, Saadoun S. Adverse Effect of Neurogenic, Infective, and Inflammatory Fever on Acutely Injured Human Spinal Cord. J Neurotrauma 2023; 40:2680-2693. [PMID: 37476968 PMCID: PMC11265769 DOI: 10.1089/neu.2023.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
This study aims to determine the effect of neurogenic, inflammatory, and infective fevers on acutely injured human spinal cord. In 86 patients with acute, severe traumatic spinal cord injuries (TSCIs; American Spinal Injury Association Impairment Scale (AIS), grades A-C) we monitored (starting within 72 h of injury, for up to 1 week) axillary temperature as well as injury site cord pressure, microdialysis (MD), and oxygen. High fever (temperature ≥38°C) was classified as neurogenic, infective, or inflammatory. The effect of these three fever types on injury-site physiology, metabolism, and inflammation was studied by analyzing 2864 h of intraspinal pressure (ISP), 1887 h of MD, and 840 h of tissue oxygen data. High fever occurred in 76.7% of the patients. The data show that temperature was higher in neurogenic than non-neurogenic fever. Neurogenic fever only occurred with injuries rostral to vertebral level T4. Compared with normothermia, fever was associated with reduced tissue glucose (all fevers), increased tissue lactate to pyruvate ratio (all fevers), reduced tissue oxygen (neurogenic + infective fevers), and elevated levels of pro-inflammatory cytokines/chemokines (infective fever). Spinal cord metabolic derangement preceded the onset of infective but not neurogenic or inflammatory fever. By considering five clinical characteristics (level of injury, axillary temperature, leukocyte count, C-reactive protein [CRP], and serum procalcitonin [PCT]), it was possible to confidently distinguish neurogenic from non-neurogenic high fever in 59.3% of cases. We conclude that neurogenic, infective, and inflammatory fevers occur commonly after acute, severe TSCI and are detrimental to the injured spinal cord with infective fever being the most injurious. Further studies are required to determine whether treating fever improves outcome. Accurately diagnosing neurogenic fever, as described, may reduce unnecessary septic screens and overuse of antibiotics in these patients.
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Affiliation(s)
- Ravindran Visagan
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
| | - Siobhan Kearney
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
- Neuro Anesthesia and Neuro Intensive Care Unit, St. George's Hospital, London, United Kingdom
| | - Christian Blex
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leonarda Serdani-Neuhaus
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel A. Kopp
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan M. Schwab
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Berlin, Germany
- The Belford Center for Spinal Cord Injury, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
- Departments of Neurology, Physical Medicine and Rehabilitation, and Neurosciences, The Ohio State University, Columbus, Ohio, USA
| | - Argyro Zoumprouli
- Neuro Anesthesia and Neuro Intensive Care Unit, St. George's Hospital, London, United Kingdom
| | | | - Samira Saadoun
- Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
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Song SH, Sankary KM, Burns SP. Vital sign differences between septic patients with tetraplegia and paraplegia. Spinal Cord Ser Cases 2022; 8:87. [PMID: 36433952 PMCID: PMC9700738 DOI: 10.1038/s41394-022-00553-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVES Sepsis is a leading preventable cause of death in patients with chronic spinal cord injury (SCI). Individuals with tetraplegia may exhibit different signs and symptoms of infection compared to those with paraplegia. In this study, we examine differences in vital signs (VS) and mental status between septic patients with tetraplegia and paraplegia with the goal of improving early identification of sepsis in this population. SETTING Veterans hospital in Washington, USA. METHODS Participants consisted of 19 patients with tetraplegia and 16 with paraplegia who were transferred from an SCI Service to a higher level of care with sepsis between June 1, 2010 and June 1, 2018 (n = 35). We compared VS between patients with tetraplegia and paraplegia at baseline and during sepsis including temperature, heart rate (HR), and blood pressure as well as presence/absence of altered mental status (AMS). RESULTS While there were no significant VS differences between groups at baseline, septic patients with tetraplegia had lower maximum temperature (38.2 °C versus 39.2 °C, p = 0.003), lower maximum HR (106 versus 124 beats/minute, p = 0.004), and more frequent AMS compared to septic patients with paraplegia (79% versus 31%, p = 0.007). CONCLUSION Patients with tetraplegia may not be able to mount fever and tachycardia to the same degree as patients with paraplegia and may be more prone to developing AMS during sepsis. These findings suggest that changes to VS parameter cut-offs may improve sensitivity and be useful in identifying sepsis earlier in the tetraplegic population.
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Affiliation(s)
- Shawn H Song
- Spinal Cord Injury Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Kendl M Sankary
- Spinal Cord Injury Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Stephen P Burns
- Spinal Cord Injury Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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Henke AM, Billington ZJ, Gater DR. Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review. J Pers Med 2022; 12:jpm12071110. [PMID: 35887607 PMCID: PMC9320320 DOI: 10.3390/jpm12071110] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 12/20/2022] Open
Abstract
The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1–L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.
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Affiliation(s)
- Austin M. Henke
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.H.); (Z.J.B.)
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
| | - Zackery J. Billington
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.H.); (Z.J.B.)
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
| | - David R. Gater
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.H.); (Z.J.B.)
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence:
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Krapić M, Kavazović I, Wensveen FM. Immunological Mechanisms of Sickness Behavior in Viral Infection. Viruses 2021; 13:v13112245. [PMID: 34835051 PMCID: PMC8624889 DOI: 10.3390/v13112245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/04/2021] [Indexed: 12/11/2022] Open
Abstract
Sickness behavior is the common denominator for a plethora of changes in normal behavioral routines and systemic metabolism during an infection. Typical symptoms include temperature, muscle weakness, and loss of appetite. Whereas we experience these changes as a pathology, in fact they are a carefully orchestrated response mediated by the immune system. Its purpose is to optimize immune cell functionality against pathogens whilst minimizing viral replication in infected cells. Sickness behavior is controlled at several levels, most notably by the central nervous system, but also by other organs that mediate systemic homeostasis, such as the liver and adipose tissue. Nevertheless, the changes mediated by these organs are ultimately initiated by immune cells, usually through local or systemic secretion of cytokines. The nature of infection determines which cytokine profile is induced by immune cells and therefore which sickness behavior ensues. In context of infection, sickness behavior is typically beneficial. However, inappropriate activation of the immune system may induce adverse aspects of sickness behavior. For example, tissue stress caused by obesity may result in chronic activation of the immune system, leading to lasting changes in systemic metabolism. Concurrently, metabolic disease prevents induction of appropriate sickness behavior following viral infection, thus impairing the normal immune response. In this article, we will revisit recent literature that elucidates both the benefits and the negative aspects of sickness behavior in context of viral infection.
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Trbovich M, Ford A, Wu Y, Koek W, Wecht J, Kellogg D. Correlation of neurological level and sweating level of injury in persons with spinal cord injury. J Spinal Cord Med 2021; 44:902-909. [PMID: 32315262 PMCID: PMC8725691 DOI: 10.1080/10790268.2020.1751489] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objective: Thermoregulatory dysfunction after spinal cord injury (SCI) impairs quality of life and predisposes persons to life-threatening sequela of heat-related illness (HRI) in conditions of high ambient temperature. SCI clinicians currently have no objective way to predict which persons are at greatest risk of HRI. Evaporative cooling via sweating is the body's most efficient mechanism of heat dissipation. The relationship between the neurological level of injury (NLOI) and the degree of sudomotor dysfunction is not well defined. This study examines the relationship between the NLOI and sweating level of injury (SwLOI). This information can assist SCI clinicians in identifying individuals with SCI who have most impaired sudomotor function and thus highest risk of HRI.Design: Observational.Setting: Human physiology laboratory.Participants: 10 persons with tetraplegia (TP), 14 with paraplegia (PP) and 10 able-bodied (AB).Intervention: Passive heat stress (1°C rise in core temperature) with sweat responses (SR) quantified with the starch iodine test.Outcome measures: The most caudal dermatomal level in which sweating was visualized was recorded as the SwLOI, which was compared to the NLOI. Minimum, maximum and median differences between NLOI and SwLOI were calculated.Results: Persons with tetraplegia demonstrated no SR. Persons with paraplegia demonstrated SR at a median of 1 level below NLOI. Able-bodied controls demonstrated sweating on all skin surface areas.Conclusions: Persons with motor complete tetraplegia lack evaporative cooling capacity through SR during passive heat stress predisposing them to HRI. Meanwhile, persons with paraplegia sweat on average 1 dermatomal level below their NLOI.
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Affiliation(s)
- Michelle Trbovich
- Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio, Texas, USA,South Texas Veteran’s Health Care System, San Antonio, Texas, USA,Correspondence to: Michelle Trbovich, 7703 Floyd Curl Drive, San Antonio, Texas78229, USA.
| | - Ashley Ford
- Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio, Texas, USA,South Texas Veteran’s Health Care System, San Antonio, Texas, USA
| | - Yubo Wu
- South Texas Veteran’s Health Care System, San Antonio, Texas, USA,Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Wouter Koek
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Jill Wecht
- The National Center of Excellence, James J. Peters VA Medical Center, Bronx, New York, USA,Department of Rehabilitation Medicine Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Dean Kellogg
- South Texas Veteran’s Health Care System, San Antonio, Texas, USA,Department of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
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Krassioukov A, Linsenmeyer TA, Beck LA, Elliott S, Gorman P, Kirshblum S, Vogel L, Wecht J, Clay S. [Formula: see text] [Formula: see text] [Formula: see text] [Formula: see text]Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows. J Spinal Cord Med 2021; 44:631-683. [PMID: 34270391 PMCID: PMC8288133 DOI: 10.1080/10790268.2021.1925058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Andrei Krassioukov
- University of British Columbia, Vancouver, British Columbia, BC
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, BC, Canada
| | - Todd A Linsenmeyer
- Kessler Institute for Rehabilitation, West Orange, NJ
- Rutgers University Medical School, Newark, NJ
| | | | - Stacy Elliott
- University of British Columbia, Vancouver, British Columbia, BC
| | | | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ
- Rutgers University Medical School, Newark, NJ
| | | | - Jill Wecht
- Icahn School of Medicine at Mt Sinai, New York, NY
| | - Sarah Clay
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Krassioukov A, Linsenmeyer TA, Beck LA, Elliott S, Gorman P, Kirshblum S, Vogel L, Wecht J, Clay S. Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows: Management of Blood Pressure, Sweating, and Temperature Dysfunction. Top Spinal Cord Inj Rehabil 2021; 27:225-290. [PMID: 34108837 PMCID: PMC8152175 DOI: 10.46292/sci2702-225] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | | | | | - Stacy Elliott
- University of British Columbia, Vancouver, British Columbia, CA
| | | | | | | | - Jill Wecht
- Icahn School of Medicine at Mt Sinai, New York, NY
| | - Sarah Clay
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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8
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Gajsek U, Sieber A, Finderle Z. Thermal balance of spinal cord injured divers during cold water diving: A case control study. Diving Hyperb Med 2020; 50:256-263. [PMID: 32957128 DOI: 10.28920/dhm50.3.256-263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/17/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION This study compared the thermal balance of spinal cord injured (SCI) divers and able-bodied (AB) divers during recreational cold-water dives. METHODS Ten divers (5 AB, 5 SCI) in matched pairs dived in a shallow lake (temperature 6°C) for 30 to 36 min wearing 5 mm 'Long John' neoprene wetsuits. A gastrointestinal temperature radio pill recorded gastro-intestinal temperature (Tgi) prior to, immediately after and at 5, 10, 15, 30, 60, 120 min post-dive. Subjective ratings of temperature perception were recorded concomitantly using a visual analogue scale (VAS). RESULTS No difference between SCI and AB divers in Tgi before the dive was observed (P = 0.85). After the dive, SCI divers cooled significantly more than AB at all measured time intervals (P < 0.001). Post dive, the mean maximum fall in Tgi during the recovery phase in SCI divers was 0.85°C (SD 0.20) and in the AB group was 0.48°C (0.48). In addition, there was greater individual variation in SCI divers compared to AB divers. There were no statistically significant differences in temperature perception between the groups either before or at any time after the dives. CONCLUSIONS In contrast to AB divers, divers with SCI were unable to maintain Tgi during short shallow dives in 6°C water and their temperatures fell further post-dive. The reduction in Tgi was not reflected in the subjective ratings of temperature perception by the SCI divers. The study was too small to assess how the level of spinal injury influenced thermal balance.
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Affiliation(s)
- Urska Gajsek
- Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital, Sydney, Australia.,Institute of Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Corresponding aurthor: Urska Gajsek, Department of Abdominal and General Surgery, University Clinical Center Maribor Ljubljanska 5, 2000 Maribor, Slovenia,
| | - Arne Sieber
- Seabear Diving Technology, Leoben, Austria.,Chalmers University of Technology, Gothenburg, Sweden
| | - Zarko Finderle
- Institute of Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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9
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Dicks MA, Clements ND, Gibbons CR, Verduzco-Gutierrez M, Trbovich M. Atypical presentation of Covid-19 in persons with spinal cord injury. Spinal Cord Ser Cases 2020; 6:38. [PMID: 32404880 PMCID: PMC7220614 DOI: 10.1038/s41394-020-0289-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Madeline A Dicks
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Nathan D Clements
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - C R Gibbons
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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10
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Trbovich MB, Handrakis JP, Kumar NS, Price MJ. Impact of passive heat stress on persons with spinal cord injury: Implications for Olympic spectators. Temperature (Austin) 2019; 7:114-128. [PMID: 33015240 PMCID: PMC7518736 DOI: 10.1080/23328940.2019.1631730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 01/26/2023] Open
Abstract
Environmental heat stress can negatively impact health, work capacity, and athletic performance and potentially to lead to life-threatening consequences if not mitigated. With the upcoming Toyko Olympic games to be held during anticipated warm ambient temperatures (up to 29°C), and with spectators potentially spending long durations of time outdoors, certain populations of persons with impaired thermoregulatory capacity will be at higher risk of heat-related illness from passive heat stress. Persons with spinal cord injury (SCI) are one of these groups as a result of a decentralized sympathetic nervous system, which leaves them with impairment in convective and evaporative cooling via vasodilation and sweating, respectively. This review summarizes (1) thermoregulatory physiological responses of persons with SCI under passive heat stress: the effect of level and completeness of injury; (2) the impact of passive heat stress on quality of life (QOL), outdoor participation, behavioral thermoregulation, and cognition; (3) recommendations and education for clinicians providing health care for persons with SCI; and (4) suggestions of future directions for exploring the gaps in the literature on passive heat stress in persons with SCI. This article aims to equip consumers with SCI and health-care professionals with the most up-to-date knowledge on passive heat stress responses in persons with SCI, so that their attendance at the Olympic games can be done with maximal safety and enjoyment.
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Affiliation(s)
- Michelle B. Trbovich
- Department of Rehabilitation Medicine, UT Health Science Center at San Antonio, San Antonio, TX, USA
- Spinal cord injury center, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - John P. Handrakis
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, NY, USA
- New York Institute of Technology, Department of Physical Therapy, School of Health Professions, Old Westbury, NY, USA
| | - Nina S. Kumar
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J Peters VA Medical Center, Bronx, NY, USA
| | - Mike J. Price
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
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11
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Trbovich M, Koek W, Ortega C. Efficacy of water spray for evaporative cooling in athletes with spinal cord injury. Spinal Cord Ser Cases 2019; 5:51. [PMID: 31632709 PMCID: PMC6786376 DOI: 10.1038/s41394-019-0194-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/29/2019] [Accepted: 05/09/2019] [Indexed: 01/01/2023] Open
Abstract
Study design Interventional crossover study. Objective Spinal cord injury (SCI) disrupts afferent input to the hypothalamus and impairs efferent vaso- and sudomotor output, especially in lesions above the sympathetic chain (T1-L2). In consequence, persons with SCI under heat stress experience impairment in the ability to dissipate heat proportional to the lesion level. Thermoregulatory dysfunction places an individual at high risk of hyperthermia, which can be life threatening, especially for athletes with SCI during exercise. Current evidence on therapeutic cooling techniques in athletes with SCI is limited, but basic physiologic and research data suggest water spray (WS) might be efficacious, particularly in athletes with tetraplegia (TP), who are most impaired in thermoregulation. The aim of this study was to evaluate the effect of WS on core temperature (Tc) during exercise in athletes with SCI. Setting Texas, USA. Methods Eleven individuals with SCI: seven with TP, four with paraplegia (PP); and sixteen able-bodied (AB) controls underwent a wheelchair intermittent sprint exercise for 90 min under two conditions: (1) WS application every 15 min and (2) control (C), without WS. Tc was measured every 15 min and was analyzed for the effect of group (TP, PP, and AB) and time. Change in Tc (ΔTc) was also compared between groups. Results ΔTc was significantly higher in TP vs. PP (p < 0.0001) and TP vs. AB (p < 0.0001) groups under C treatment. WS significantly attenuated ΔTc in TP (p = 0.001), but did not change ΔTc in PP or AB. Conclusion WS effectively attenuated Tc elevation during exercise in athletes with TP. Sponsorship Texas chapter of the Paralyzed Veterans of America.
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Affiliation(s)
- Michelle Trbovich
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
| | - Wouter Koek
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
| | - Catherine Ortega
- School of Health Professions, Physical Therapy Department, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
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12
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Charles YP. Expert's comment concerning Grand Rounds case entitled "Pure distraction injury of T1-2 with quad fever" by Jun-Yeong Seo et al. (Eur Spine J [2017]: doi:10.1007/s00586-017-5232-2). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1051-1052. [PMID: 28821970 DOI: 10.1007/s00586-017-5254-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Yann Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle (FMTS), Université de Strasbourg, 1, Place de l'Hôpital, B.P. 426, 67091, Strasbourg Cedex, France.
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13
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Tomoda Y, Kagawa S, Kurata S, Tanaka K. Hyperthermia due to heat retention in chronic spinal cord injury: A case report. J Gen Fam Med 2019; 20:111-113. [PMID: 31065476 PMCID: PMC6498100 DOI: 10.1002/jgf2.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 11/06/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022] Open
Abstract
An 80-year-old male with past history of cervical spinal cord injury visited our hospital owing to perforation in the digestive tract. Upon admission to the general ward, he presented with a sustained fever that was unresponsive to acetaminophen and antibiotics. Based on the dry skin and underlying disease, he was diagnosed with hyperthermia due to heat retention. After controlling the room temperature to cool his body and performing evaporative and convective cooling, his symptoms completely resolved. This case highlights that primary physicians should be aware of thermoregulatory dysfunction in patients with cervical spinal cord injury.
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Affiliation(s)
- Yoshitaka Tomoda
- Department of General MedicineSaiseikai Fukuoka General HospitalFukuokaJapan
| | - Satoshi Kagawa
- Department of General MedicineSaiseikai Fukuoka General HospitalFukuokaJapan
| | - Satoshi Kurata
- Department of General MedicineSaiseikai Fukuoka General HospitalFukuokaJapan
| | - Kazutoyo Tanaka
- Department of General MedicineSaiseikai Fukuoka General HospitalFukuokaJapan
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Dutton RA. Medical and Musculoskeletal Concerns for the Wheelchair Athlete: A Review of Preventative Strategies. Curr Sports Med Rep 2019; 18:9-16. [PMID: 30624329 DOI: 10.1249/jsr.0000000000000560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Adaptive sports refers to organized sporting activities that are practiced by individuals with disabilities and are worthwhile to maintain physical and psychological health. As adaptive sports participation continues to rise, health care providers must have an enhanced understanding of injury and illness patterns specific to the adaptive athlete. Early recognition and prevention are important to ensure safe and successful participation in sport. The present review aims to provide a framework for diagnosis and prevention of common conditions specific to the wheelchair athlete. In particular, autonomic dysreflexia, impaired thermoregulation, urinary tract infection, and pressure injuries, as well as shoulder pain, upper-extremity entrapment neuropathies, and osteoporotic fractures will be discussed.
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Affiliation(s)
- Rebecca A Dutton
- University of New Mexico, Department of Orthopaedics and Rehabilitation
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15
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Seven YB, Mitchell GS. Mechanisms of compensatory plasticity for respiratory motor neuron death. Respir Physiol Neurobiol 2019; 265:32-39. [PMID: 30625378 DOI: 10.1016/j.resp.2019.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/22/2018] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Abstract
Respiratory motor neuron death arises from multiple neurodegenerative and traumatic neuromuscular disorders. Despite motor neuron death, compensatory mechanisms minimize its functional impact by harnessing intrinsic mechanisms of compensatory respiratory plasticity. However, the capacity for compensation eventually reaches limits and pathology ensues. Initially, challenges to the system such as increased metabolic demand reveal sub-clinical pathology. With greater motor neuron loss, the eventual result is de-compensation, ventilatory failure, ventilator dependence and then death. In this brief review, we discuss recent advances in our understanding of mechanisms giving rise to compensatory respiratory plasticity in response to respiratory motor neuron death including: 1) increased central respiratory drive, 2) plasticity in synapses on spared phrenic motor neurons, 3) enhanced neuromuscular transmission and 4) shifts in respiratory muscle utilization from more affected to less affected motor pools. Some of these compensatory mechanisms may prolong breathing function, but hasten the demise of surviving motor neurons. Improved understanding of these mechanisms and their impact on survival of spared motor neurons will guide future efforts to develop therapeutic interventions that preserve respiratory function with neuromuscular injury/disease.
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Affiliation(s)
- Yasin B Seven
- Center for Respiratory Research and Rehabilitation, Department of Physical Therapy and McKnight Brain Institute, University of Florida, Gainesville, FL, 32610, USA
| | - Gordon S Mitchell
- Center for Respiratory Research and Rehabilitation, Department of Physical Therapy and McKnight Brain Institute, University of Florida, Gainesville, FL, 32610, USA.
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Abstract
The autonomic nervous system has widespread innervation to nearly every organ system in the body. In order to understand the basics of autonomic function, knowledge of the neuroanatomy of the autonomic nervous system is necessary. Frequently considered to control the "fight or flight" and "rest and digest" functions, the autonomic nervous system has an intricate network of connections to finely tune the systemic response to nearly any situation. Although traditionally considered two discrete systems (sympathetic and parasympathetic), the enteric nervous system is now considered a third component of the autonomic nervous system. This chapter reviews the background of the neuroanatomical distribution of the autonomic nervous system in order to facilitate understanding the basics of autonomic function.
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Affiliation(s)
- Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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17
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Microclimate: A critical review in the context of pressure ulcer prevention. Clin Biomech (Bristol, Avon) 2018; 59:62-70. [PMID: 30199821 DOI: 10.1016/j.clinbiomech.2018.09.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/01/2018] [Accepted: 09/04/2018] [Indexed: 02/07/2023]
Abstract
Pressure ulcers are caused by sustained mechanical loading and deformation of the skin and subcutaneous layers between internal stiff anatomical structures and external surfaces or devices. In addition, the skin microclimate (temperature, humidity and airflow next to the skin surface) is an indirect pressure ulcer risk factor. Temperature and humidity affect the structure and function of the skin increasing or lowering possible damage thresholds for the skin and underlying soft tissues. From a pressure ulcer prevention research perspective, the effects of humidity and temperature next to the skin surface are inextricably linked to concurrent soft tissue deformation. Direct clinical evidence supporting the association between microclimate and pressure ulceration is sparse and of high risk of bias. Currently, it is recommended to keep the skin dry and cool and/or to allow recovery periods between phases of occlusion. The stratum corneum must be prevented from becoming overhydrated or from drying out but exact ranges of an acceptable microclimate are unknown. Therefore, vague terms like 'microclimate management' should be avoided but product and microclimate characteristics should be explicitly stated to allow an informed decision making. Pressure ulcer prevention interventions like repositioning, the use of special support surfaces, cushions, and prophylactic dressings are effective only if they reduce sustained deformations in soft tissues. This mode of action outweighs possible undesirable microclimate properties. As long as uncertainty exists efforts must be taken to use as less occlusive materials as possible. There seems to be individual intrinsic characteristics making patients more vulnerable to microclimate effects.
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Trbovich M, Li C, Lee S. Does the CDC Definition of Fever Accurately Predict Inflammation and Infection in Persons With SCI? Top Spinal Cord Inj Rehabil 2018; 22:260-268. [PMID: 29339867 DOI: 10.1310/sci2016-00049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: Pneumonia and septicemia have the greatest impact on reduced life expectancy in persons with spinal cord injury (SCI). Fever is often the first presenting symptom of infection or inflammation. Thermoregulatory dysfunction in persons with SCI may preclude a typical febrile response to infection or inflammation and thus delay diagnostic workup. Objective: To determine the core temperature of persons with SCI in the setting of infection or inflammation and the frequency with which it meets criteria for the CDC definition of fever (>100.4°F). Methods: Retrospective review of hospitalized SCI patients over 5 years with a diagnosis of infection or inflammation (DI), defined by serum leukocytosis. In this study, 458 persons with paraplegia (PP) and 483 persons with tetraplegia (TP) had 4,191 DI episodes. Aural temperatures (Tau) on the day of DI, 7 days prior, and 14 days afterwards were abstracted from medical records. Main outcome measures were average Tau at DI, frequency of temperatures >100.4°F at DI, and average baseline temperatures before and after DI. Results: Average Tau at DI was 98.2°F (±1.5) and 98.2°F (±1.4) in the TP and PP groups, respectively, with only 11.6% to 14% of DI resulting in Tau >100.4°F. Baseline temperatures ranged from 97.9°F (±0.7) to 98.0°F (±0.8). Conclusion: SCI persons with leukocytosis infrequently mount a fever as defined by the CDC, and baseline temperatures were subnormal (<98.6°F). Thermoregulatory dysfunction likely accounts for these findings. Tau >100.4°F is not a sensitive predictor of infection or inflammation in persons with SCI. Clinicians should be vigilant for alternative symptoms of infection and inflammation in these patients, so diagnostic workup is not delayed.
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Affiliation(s)
| | - Carol Li
- Audie L. Murphy VA, San Antonio, Texas
| | - Shuko Lee
- Audie L. Murphy VA, San Antonio, Texas
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19
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Abstract
Spinal cord injury results in physiologic adaptations affecting heat production (reduced muscle mass) and heat dissipation (blood redistribution and reduced sweating capacity below the level of lesion). However, it is the balance between these factors which determines whether heat balance is achieved. Core temperature estimates are generally consistent with those for the able-bodied, with cooler values reported in some instances. More notable differences are demonstrated through cooler lower-body skin temperatures at rest and a loss of anticipatory control during exposure to heat and cold when compared to the able-bodied. During exercise in cool conditions persons with paraplegia demonstrate similar body temperature responses as for the able-bodied but retain heat during recovery. Persons with tetraplegia demonstrate continual increases in core temperature and thus thermal imbalance along with greater heat retention. During exercise in the heat, athletes with paraplegia appear to be able to regulate body temperature to a similar extent as the able-bodied. Those with tetraplegia again show thermal imbalance but to a much greater extent than in the cold. Future work should focus upon specific sweating responses and adaptations following spinal cord injury, the effects of completeness of lesion, perceptual responses to environmental challenges, and how these translate to undertaking activities of daily living.
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Affiliation(s)
- Mike J Price
- School of Life Sciences, Coventry University, Coventry, United Kingdom.
| | - Michelle Trbovich
- Spinal Cord Injury Unit, San Antonio Veterans Hospital, San Antonio, TX, United States
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20
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Takashima A, Sato K, Takizawa K, Suzurikawa J, Higuchi Y, Huang M, Teshima Y, Tamura T, Kurabayashi D, Inoue T, Ogata T. Construction of a soft wearable body cooling system for persons with spinal cord injury. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:913-916. [PMID: 29060021 DOI: 10.1109/embc.2017.8036973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper describes the construction of a body cooling system to avoid heatstroke for survivors of cervical spinal cord injury. For accomplishment of this purpose, we chose the neck as a cooling point of the body, and we constructed a prototype neck cooling head with a refrigerated circulator. The neck cooling head was made by thin heat-welding thermoplastic films with high thermal conductivity. To test our proposed system, we conducted experiments on two unimpaired participants in a room which simulated a hot summer day (33 [°C], relative humidity 40%). Reduction of sweating were observed, and the average skin temperatures and the core temperature of the head with cooling increased more slowly than those without cooling. The estimated cooling power of the proposed system was about 10 [W] with 50 [W] total power consumption of the cooling head.
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21
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Handrakis JP, Ni Guan Z, Nulty JW, Tascione O, Rosado-Rivera D, White D, Bang C, Spungen AM, Bauman WA. Effect of Heat Exposure on Cognition in Persons with Tetraplegia. J Neurotrauma 2017; 34:3372-3380. [PMID: 28462685 DOI: 10.1089/neu.2016.4850] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Individuals with cervical spinal cord injury (SCI) have impaired thermoregulatory mechanisms attributed to interruption of motor, sensory, and autonomic neuropathways. To determine the effects of heat exposure on core body temperature (Tcore) and cognitive performance in persons with tetraplegia, 8 individuals with chronic tetraplegia (C3-C7, American Spinal Cord Injury Association Impairment Scale A-B) and 9 able-bodied controls were acclimated to 27°C at baseline (BL) before being exposed to 35°C for up to 120 min (Heat Challenge). Rectal temperature (Tcore), distal skin temperatures (Tskavg), sweat rate (QSavg), microvascular skin perfusion (LDFavg), and plasma norepinephrine (NE) were measured. Cognitive performance was assessed using Stroop Color and Word and Wechsler Adult Intelligence Scale-Fourth Edition Digit Span tests at BL and at the end of Heat Challenge. After Heat Challenge, Tcore increased 0.78 ± 0.18°C (p < 0.001) in tetraplegics after an average of 118 ± 5 min. Tcore did not change in controls after 120 min. The increase in QSavg was larger in controls than in tetraplegics (946 ± 672% vs. 51 ± 12%; p = 0.007, respectively). LDFavg increased only in controls (109 ± 93%; p = 0.008). Tskavg appeared to increase less in tetraplegics than in controls. Plasma NE levels remained lower in tetraplegics compared to controls after Heat Challenge (86 ± 64 vs. 297 ± 84 pg/mL, respectively; p < 0.001). Stroop Color, Interference, and WAIS-IV Sequence scores increased only in tetraplegics (19.4 ± 17.2%; p < 0.05, 8.3 ± 5.9%; p < 0.05, 29.1 ± 27.4%; p < 0.05, respectively). Dysfunctional thermoregulatory mechanisms in the tetraplegic group allowed Tcore to rise from subnormal levels to normothermia during heat exposure. Normothermia was associated with improvements in attention, working memory, and executive function.
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Affiliation(s)
- John P Handrakis
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York.,5 New York Institute of Technology , Department of Physical Therapy, School of Health Professions, Old Westbury, New York
| | - Zhen Ni Guan
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York.,5 New York Institute of Technology , Department of Physical Therapy, School of Health Professions, Old Westbury, New York
| | - John W Nulty
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York.,5 New York Institute of Technology , Department of Physical Therapy, School of Health Professions, Old Westbury, New York
| | - Oriana Tascione
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York
| | - Dwindally Rosado-Rivera
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York
| | - Daniel White
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York
| | - Charlene Bang
- 2 Medical Service, James J. Peters VA Medical Center , Bronx, New York.,3 Department of Medicine, The Icahn School of Medicine at Mount Sinai , New York, New York
| | - Ann M Spungen
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York.,2 Medical Service, James J. Peters VA Medical Center , Bronx, New York.,3 Department of Medicine, The Icahn School of Medicine at Mount Sinai , New York, New York.,4 Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai , New York, New York
| | - William A Bauman
- 1 VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York.,2 Medical Service, James J. Peters VA Medical Center , Bronx, New York.,3 Department of Medicine, The Icahn School of Medicine at Mount Sinai , New York, New York.,4 Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai , New York, New York
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22
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Handrakis JP, Rosado-Rivera D, Singh K, Swonger K, Azarelo F, Lombard AT, Spungen AM, Kirshblum SC, Bauman WA. Self-reported effects of cold temperature exposure in persons with tetraplegia. J Spinal Cord Med 2017; 40:389-395. [PMID: 27077570 PMCID: PMC5537955 DOI: 10.1080/10790268.2016.1154670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Cervical spinal cord injury (tetraplegia) is known to interrupt sympathetic vasculature control, thereby preventing shunting of blood from the periphery to central organs when exposed to cold temperatures. As a result, persons with tetraplegia are at risk to develop hypothermia. However, information regarding the discomfort experienced during the cooler months (late fall, winter, early spring) is overwhelmingly anecdotal. It is not known, with any certainty, how those with tetraplegia perceive cold and if discomfort in colder environments restricts them from performing activities that they routinely would perform. DESIGN Prospective, two-group, self-report surveys. SETTING VA Medical Center and Kessler Institute for Rehabilitation. PARTICIPANTS Forty-four subjects with tetraplegia; 41 matched non-SCI controls. OUTCOME MEASURES Tetraplegic and control groups responded "yes" or "no" when asked whether cold seasonal temperatures allowed comfort or negatively affected participation in routine activities. RESULTS Percentage of responses of tetraplegia compared to controls was different as to whether they felt cold when others in the same room were comfortable (82 vs. 24%; χ2 = 28.2, P < 0.0001), felt comfortable outdoors (17 vs. 43%; χ2 = 6.8, P = 0.009), or whether cold negatively affected bathing routines (55 vs. 15%; χ2 = 14.8, P = 0.0001), keeping physician appointments (46 vs. 12%; χ2 = 11.3, P = 0.0008), thinking clearly (41 vs. 7%; χ2 = 12.9, P = 0.0003), and completing usual work duties (46 vs. 10%; χ2 = 13.3, P = 0.0003). CONCLUSION Cold seasonal temperatures have a reported greater negative impact on personal comfort and ability to perform vital activities in persons with tetraplegia than that of non-SCI controls. These findings highlight the need to address thermoregulatory impairment in persons with tetraplegia.
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Affiliation(s)
- John P. Handrakis
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA,New York Institute of Technology, Department of Physical Therapy, School of Health Professions, Old Westbury, NY, USA,Correspondence to: John Handrakis, National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, 130 West Kingsbridge Road, 7A-13, Bronx, NY 10468, USA. E-mail:
| | - Dwindally Rosado-Rivera
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Kamaldeep Singh
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Kirsten Swonger
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Frank Azarelo
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Alex T. Lombard
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Ann M. Spungen
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA,Medical Service, James J. Peters VA Medical Center, Bronx, NY, USA,Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven C. Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - William A. Bauman
- VA RR&D National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, USA,Medical Service, James J. Peters VA Medical Center, Bronx, NY, USA,Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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23
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Goyal J, Jha R, Bhatia P, Mani RK. QUAD fever: beware of non-infectious fever in high spinal cord injuries. BMJ Case Rep 2017. [PMID: 28630243 DOI: 10.1136/bcr-2017-219937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A case of cervical spinal cord injury and quadriparesis with prolonged fever is being described. Initially, the patient received treatment for well-documented catheter-related bloodstream infection. High spiking fever returned and persisted with no obvious evidence of infection. The usual non-infectious causes too were carefully excluded. QUAD fever or fever due to spinal cord injury itself was considered. The pathogenetic basis of QUAD fever is unclear but could be attributed to autonomic dysfunction and temperature dysregulation. Awareness of this little known condition could help in avoiding unnecessary antimicrobial therapy and in more accurate prognostication. Unlike several previous reported cases that ended fatally, the present case ran a relatively benign course. The spectrum of presentations may therefore be broader than hitherto appreciated.
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Affiliation(s)
- Jyoti Goyal
- Internal Medicine, Nayati Medicity Mathura, Mathura, India
| | - Rakesh Jha
- Internal Medicine, Nayati Medicity Mathura, Mathura, India
| | | | - Raj Kumar Mani
- Pulmonology Critical Care, Nayati Multisuperspeciality Hospital, Mathura, India
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24
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Shah NT, Habtegebriel YA, Bloomfield DA. Extreme Hyperpyrexia of Uncertain Origin. J Emerg Med 2016; 51:e33-5. [PMID: 27364825 DOI: 10.1016/j.jemermed.2016.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 12/17/2015] [Accepted: 02/17/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The definition of hyperpyrexia is currently limited to temperatures reaching 106.7°F. A wide range of etiologies have been identified in the literature for an insidious onset of hyperpryexia, however a rapid ascent higher than temperatures of 106.7°F has never been reported nor evaluated. We present the case of a young paraplegic who developed an extreme hyperpyrexia, which to our knowledge is the highest occurring temperature reported in contemporary medical literature. He had a number of medical conditions, none of which are known to produce fever. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Fever, although a common presentation in the ER in the presence of various symptoms and comorbidities can obscure the diagnosis and lead to unwarranted evaluations. As such this patients case identifies a diagnosis of a fatal ascension of fever.
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Affiliation(s)
- Nikita T Shah
- Richmond University Medical Center, Staten Island, New York
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25
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Cardiovascular autonomic control in paraplegic and quadriplegic. Clin Auton Res 2016; 26:117-26. [DOI: 10.1007/s10286-015-0339-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/23/2015] [Indexed: 12/13/2022]
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26
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Handrakis JP, Liu SA, Rosado-Rivera D, Krajewski M, Spungen AM, Bang C, Swonger K, Bauman WA. Effect of Mild Cold Exposure on Cognition in Persons with Tetraplegia. J Neurotrauma 2015; 32:1168-75. [DOI: 10.1089/neu.2014.3719] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- John P. Handrakis
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
- New York Institute of Technology, Department of Physical Therapy, School of Health Professions, Old Westbury, New York
| | - Shou-An Liu
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
- New York Institute of Technology, Department of Physical Therapy, School of Health Professions, Old Westbury, New York
| | - Dwindally Rosado-Rivera
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
| | - Megan Krajewski
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
- New York Institute of Technology, Department of Physical Therapy, School of Health Professions, Old Westbury, New York
| | - Ann M. Spungen
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
- Medical Service, James J. Peters VA Medical Center, Bronx, New York
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Charlene Bang
- Medical Service, James J. Peters VA Medical Center, Bronx, New York
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kirsten Swonger
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
| | - William A. Bauman
- Department of Veterans Affairs Rehabilitation Research and Development Service, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, New York
- Medical Service, James J. Peters VA Medical Center, Bronx, New York
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
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27
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Warren PM, Awad BI, Alilain WJ. Reprint of "Drawing breath without the command of effectors: the control of respiration following spinal cord injury". Respir Physiol Neurobiol 2014; 204:120-30. [PMID: 25266395 DOI: 10.1016/j.resp.2014.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The maintenance of blood gas and pH homeostasis is essential to life. As such breathing, and the mechanisms which control ventilation, must be tightly regulated yet highly plastic and dynamic. However, injury to the spinal cord prevents the medullary areas which control respiration from connecting to respiratory effectors and feedback mechanisms below the level of the lesion. This trauma typically leads to severe and permanent functional deficits in the respiratory motor system. However, endogenous mechanisms of plasticity occur following spinal cord injury to facilitate respiration and help recover pulmonary ventilation. These mechanisms include the activation of spared or latent pathways, endogenous sprouting or synaptogenesis, and the possible formation of new respiratory control centres. Acting in combination, these processes provide a means to facilitate respiratory support following spinal cord trauma. However, they are by no means sufficient to return pulmonary function to pre-injury levels. A major challenge in the study of spinal cord injury is to understand and enhance the systems of endogenous plasticity which arise to facilitate respiration to mediate effective treatments for pulmonary dysfunction.
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Affiliation(s)
- Philippa M Warren
- Department of Neurosciences, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109, USA
| | - Basem I Awad
- Department of Neurosciences, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109, USA; Department of Neurological Surgery, Mansoura University School of Medicine, Mansoura, Egypt
| | - Warren J Alilain
- Department of Neurosciences, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109, USA.
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Fever After Traumatic Spinal Cord Injury: A Case of Brucella Sepsis. PM R 2013; 5:982-4. [DOI: 10.1016/j.pmrj.2013.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/11/2013] [Accepted: 06/14/2013] [Indexed: 11/17/2022]
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29
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Moreschi C, Da Broi U, Rodriguez D, Froldi R, Porzionato A, Macchi V, De Caro R. The Eluana Englaro Case: Cause of death after the withdrawal of artificial nutrition and hydration in a subject in a permanent vegetative state and with quadriplegia. Forensic Sci Int 2013; 231:e24-9. [DOI: 10.1016/j.forsciint.2013.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 03/13/2013] [Accepted: 05/18/2013] [Indexed: 01/09/2023]
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30
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Weaver LC, Fleming JC, Mathias CJ, Krassioukov AV. Disordered cardiovascular control after spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2013; 109:213-33. [PMID: 23098715 DOI: 10.1016/b978-0-444-52137-8.00013-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Damage to the spinal cord disrupts autonomic pathways, perturbing cardiovascular homeostasis. Cardiovascular dysfunction increases with higher levels of injury and greater severity. Disordered blood pressure control after spinal cord injury (SCI) has significant ramifications as cord-injured people have an increased risk of developing heart disease and stroke; cardiovascular dysfunction is currently a leading cause of death among those with SCI. Despite the clinical significance of abnormal cardiovascular control following SCI, this problem has been generally neglected by both the clinical and research community. Both autonomic dysreflexia and orthostatic hypotension are known to prevent and delay rehabilitation, and significantly impair the overall quality of life after SCI. Starting with neurogenic shock immediately after a higher SCI, ensuing cardiovascular dysfunctions include orthostatic hypotension, autonomic dysreflexia and cardiac arrhythmias. Disordered temperature regulation accompanies these autonomic dysfunctions. This chapter reviews the human and animal studies that have furthered our understanding of the pathophysiology and mechanisms of orthostatic hypotension, autonomic dysreflexia and cardiac arrhythmias. The cardiovascular dysfunction that occurs during sexual function and exercise is elaborated. New awareness of cardiovascular dysfunction after SCI has led to progress toward inclusion of this important autonomic problem in the overall assessment of the neurological condition of cord-injured people.
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Abstract
Spinal cord injury (SCI) is a devastating condition that affects approximately 11,000 patients each year in the United States. Although a significant amount of research has been conducted to clarify the pathophysiology of SCI, there are limited therapeutic interventions that are currently available in the clinic. Moderate hypothermia has been used in a variety of experimental and clinical situations to target several neurological disorders, including traumatic brain and SCI. Recent studies using clinically relevant animal models of SCI have reported the efficacy of therapeutic hypothermia (TH) in terms of promoting long-term behavioral improvement and reducing histopathological damage. In addition, several clinical studies have demonstrated encouraging evidence for the use of TH in patients with a severe cervical spinal cord injury. Moderate hypothermia (33°C) introduced systemically by intravascular cooling strategies appears to be safe and provides some improvement of long-term recovery of function. TH remains an experimental clinical approach and randomized multicenter trials are needed to critically evaluate this potentially exciting therapeutic intervention targeting this patient population.
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Affiliation(s)
- W Dalton Dietrich
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL 33136-1060, USA.
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Batchelor PE, Kerr NF, Gatt AM, Cox SF, Ghasem-Zadeh A, Wills TE, Sidon TK, Howells DW. Intracanal pressure in compressive spinal cord injury: reduction with hypothermia. J Neurotrauma 2011; 28:809-20. [PMID: 21250916 DOI: 10.1089/neu.2010.1622] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Most cases of human spinal cord injury (SCI) are accompanied by continuing cord compression. Experimentally, compression results in rapid neurological decline over hours, suggesting a rise in intracanal pressure local to the site of injury. The aim of this study was to measure the rise in local intracanal pressure accompanying progressive canal occlusion and to determine the relationship between raised intracanal pressure and neurological outcome. We also aimed to establish whether hypothermia was able to reduce raised intracanal pressure. We demonstrate that, following SCI in F344 rats, local intracanal pressure remains near normal until canal occlusion exceeds 30% of diameter, whereupon a rapid increase in pressure occurs. Intracanal pressure appears to be an important determinant of neurological recovery, with poor long-term behavioural and histological outcomes in animals subject to 8 h of 45% canal occlusion, in which intracanal pressure is significantly elevated. In contrast, good neurological recovery occurs in animals with near normal intracanal pressure (animals undergoing 8 h of 30% canal occlusion or those undergoing immediate decompression). We further demonstrate that hypothermia is an effective therapy to control raised intracanal pressure, rapidly reducing elevated intracanal pressure accompanying critical (45%) canal occlusion to near normal. Overall these data indicate that following SCI only limited canal narrowing is tolerated before local intracanal pressure rapidly rises, inducing a sharp decline in neurological outcome. Raised intracanal pressure can be controlled with hypothermia, which may be a useful therapy to emergently decompress the spinal cord prior to surgical decompression.
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Affiliation(s)
- Peter E Batchelor
- Department of Medicine, National Stroke Research Institute and University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.
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Unsal-Delialioglu S, Kaya K, Sahin-Onat S, Kulakli F, Culha C, Ozel S. Fever during rehabilitation in patients with traumatic spinal cord injury: analysis of 392 cases from a national rehabilitation hospital in Turkey. J Spinal Cord Med 2010; 33:243-8. [PMID: 20737797 PMCID: PMC2920117 DOI: 10.1080/10790268.2010.11689701] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 02/07/2010] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To determine the incidence and etiology of fever and the risk factors related to fever in adults with spinal cord injury (SCI) at the rehabilitation stage. DESIGN/SUBJECTS A retrospective examination of records of 392 consecutive adult patients with traumatic SCI who received inpatient rehabilitation program. SETTING A national rehabilitation center in Turkey. OUTCOME MEASURES Incidence and etiology of fever, period of hospitalization (days). RESULTS A total of 187 patients (47.7%) had fever at least once during their rehabilitation program. The most common etiology was urinary tract infection. The rate of fever occurrence was significantly higher in patients with complete SCI (P = 0.001). In patients with fever, the use of an indwelling catheter was significantly higher compared with clean intermittent catheterization and spontaneous voiding (P = 0.001). The hospitalization period of patients with fever was significantly longer than that of patients without fever (P = 0.006). CONCLUSIONS A high rate of fever was seen in patients with SCI during rehabilitation. Fever was caused by various infections, of which urinary tract infection was the most common. Patients with motor complete injuries and those with permanent catheters constituted higher risk groups. Fever prolonged the length of rehabilitation stay and hindered active participation in the rehabilitation program.
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Affiliation(s)
- Sibel Unsal-Delialioglu
- Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Ankara, Turkey.
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Sweat testing to evaluate autonomic function. Clin Auton Res 2008; 19:79-87. [PMID: 18989618 DOI: 10.1007/s10286-008-0506-8] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 10/08/2008] [Indexed: 12/20/2022]
Abstract
Sudomotor dysfunction is common in many subtypes of neuropathy but is one of the earliest detectable neurophysiologic abnormalities in distal small fiber neuropathy. Clinical assessments of sudomotor function include thermoregulatory sweat testing (TST), quantitative sudomotor axon reflex testing (QSART), silicone impressions, the sympathetic skin response (SSR), the acetylcholine sweat-spot test and quantitative direct and indirect axon reflex testing (QDIRT). These testing techniques, when used in combination, can detect and localize pre- and postganglionic lesions, can provide early diagnosis of sudomotor dysfunction and can monitor disease progression or disease recovery. In this article, we describe many of the common clinical tests available for evaluation of sudomotor function with focus on the testing methodology and limitations while providing concrete examples of test results.
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Zimmer MB, Nantwi K, Goshgarian HG. Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options. J Spinal Cord Med 2007; 203:98-108. [PMID: 17853653 DOI: 10.1016/j.resp.2014.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/11/2014] [Accepted: 08/12/2014] [Indexed: 02/09/2023] Open
Abstract
Spinal cord injury (SCI) often leads to an impairment of the respiratory system. The more rostral the level of injury, the more likely the injury will affect ventilation. In fact, respiratory insufficiency is the number one cause of mortality and morbidity after SCI. This review highlights the progress that has been made in basic and clinical research, while noting the gaps in our knowledge. Basic research has focused on a hemisection injury model to examine methods aimed at improving respiratory function after SCI, but contusion injury models have also been used. Increasing synaptic plasticity, strengthening spared axonal pathways, and the disinhibition of phrenic motor neurons all result in the activation of a latent respiratory motor pathway that restores function to a previously paralyzed hemidiaphragm in animal models. Human clinical studies have revealed that respiratory function is negatively impacted by SCI. Respiratory muscle training regimens may improve inspiratory function after SCI, but more thorough and carefully designed studies are needed to adequately address this issue. Phrenic nerve and diaphragm pacing are options available to wean patients from standard mechanical ventilation. The techniques aimed at improving respiratory function in humans with SCI have both pros and cons, but having more options available to the clinician allows for more individualized treatment, resulting in better patient care. Despite significant progress in both basic and clinical research, there is still a significant gap in our understanding of the effect of SCI on the respiratory system.
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Affiliation(s)
- M Beth Zimmer
- Department of Anatomy and Cell Biology, Wayne State University, Detroit, Michigan 48201, USA.
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Abstract
DESIGN Retrospective analysis of medical records. BACKGROUND/OBJECTIVES To determine frequency and degree of hypothermic episodes in patients with chronic spinal cord injury (SCI). SETTING Veterans Administration Medical Center. METHODS Research involved analysis of body temperature records of 50 chronic patients with tetraplegia. All patients were men with a length of injury of 19 +/- 6 years. Mean age was 53 +/- 15 (SD) years. Data were derived from the computerized patient record database system of the Veterans Administration Medical Center. Results were classified into 3 groups: (a) hypothermia (< 95 degrees F), (b) subnormal temperature (< 97.7 degrees F), and normal temperatures (97.7 degrees F to 98.4 degrees F). Body temperature was recorded during hospitalization (minimum duration of 30 days) using an oral probe twice a day. Ambient temperature was controlled by a central air-conditioning system and maintained at 72 degrees F to 74 degrees F. RESULTS A total of 867 measurements of body temperature were evaluated; normal temperature was recorded 298 times (35%), subnormal temperature was recorded 544 times (63%), and hypothermia was recorded 25 times (3%). There were 15 patients with 30 hypothermic episodes; subnormal temperature was found in all 50 patients from 1 to 47 times. Regression analysis of age and duration of SCI showed a nonsignificant relationship with body temperature. CONCLUSIONS Our data suggest that patients with tetraplegia after SCI have significant dysfunction of thermoregulation associated with frequent episodes of subnormal body temperature in a normal ambient environment. Further studies are needed to evaluate possible consequences of low temperatures on the general health of patients and to develop preventive interventions.
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Affiliation(s)
- Sofia Khan
- University of Miami School of Medicine, Miami, Florida
| | - Mary Plummer
- University of Miami School of Medicine, Miami, Florida
| | | | - Kresimir Banovac
- University of Miami School of Medicine, Miami, Florida
- Please address correspondence to Kresimir Banovac, MD, University of Miami School of Medicine, Rehabilitation Medicine (D-461), 1611 NW 12 Avenue, Miami, FL 33136; phone: 305.585.5495; fax: 305.585.1340 (e-mail: )
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Urdzíková L, Vanický I. Post-traumatic moderate systemic hyperthermia worsens behavioural outcome after spinal cord injury in the rat. Spinal Cord 2006; 44:113-9. [PMID: 16130024 DOI: 10.1038/sj.sc.3101792] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A standardized rat model of compression spinal cord injury (SCI) was used to test the effect of transient systemic hyperthermia on long-term behavioural and morphometric outcomes. OBJECTIVE To determine the effect of hyperthermia on the development of spinal cord lesion after SCI. SETTING Institute of Neurobiology, Slovak Republic. METHODS Male Wistar rats (n=30) weighing between 300 and 330 g were used in the study. After incomplete spinal injury performed by balloon compression at the Th8-Th9 spinal level, rats were randomly divided into two groups. Rats in the treatment group were maintained hyperthermic for 3 h (rectal temperature at 40.5+/-0.5 degrees C), immediately after SCI; rats from the control group received exactly the same procedure except that their rectal temperature was maintained at 37+/-0.5 degrees C. RESULTS The 3 h of post-traumatic hyperthermic treatment worsened behavioural outcome after SCI. Morphometric analysis showed that hyperthermia had a deleterious effect on white and grey matter, but the results did not reach statistical significance. CONCLUSION These results indicate that systemic hyperthermia exacerbates secondary processes in the lesion and significantly worsens behavioural outcome after traumatic SCI in the rat.
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Affiliation(s)
- L Urdzíková
- Institute of Neurobiology, Slovak Academy of Sciences, Kosice, Slovak Republic
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McKinley W, McNamee S, Meade M, Kandra K, Abdul N. Incidence, etiology, and risk factors for fever following acute spinal cord injury. J Spinal Cord Med 2006; 29:501-6. [PMID: 17274488 PMCID: PMC1949035 DOI: 10.1080/10790268.2006.11753899] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI). DESIGN A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2-year period was performed. SETTING The study was performed at a tertiary care, Level I trauma center. PARTICIPANTS Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study. MAIN OUTCOME MEASURES Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured. RESULTS The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5 degrees F vs 101.1 degrees F on acute and 101.5 degrees F vs 100.7 degrees F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4 degrees F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation). CONCLUSIONS This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost-efficient fever workup in individuals with SCI.
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Affiliation(s)
- William McKinley
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA.
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Steele SR, Martin MJ, Mullenix PS, Long WB, Gubler KD. Fatal malignant hyperpyrexia in a cervical spine- injured patient. ACTA ACUST UNITED AC 2005; 58:375-7. [PMID: 15706204 DOI: 10.1097/01.ta.0000066349.88810.97] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Scott R Steele
- Department of Surgery, Madigan Army Medical Center, Legacy Emanuel Hospital and Health Center, Portland, OR 97227, USA
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40
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Van Someren EJ. Sleep propensity is modulated by circadian and behavior-induced changes in cutaneous temperature. J Therm Biol 2004. [DOI: 10.1016/j.jtherbio.2004.08.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The circadian rhythm of pineal melatonin is the best marker of internal time under low ambient light levels. The endogenous melatonin rhythm exhibits a close association with the endogenous circadian component of the sleep propensity rhythm. This has led to the idea that melatonin is an internal sleep "facilitator" in humans, and therefore useful in the treatment of insomnia and the readjustment of circadian rhythms. There is evidence that administration of melatonin is able: (i) to induce sleep when the homeostatic drive to sleep is insufficient; (ii) to inhibit the drive for wakefulness emanating from the circadian pacemaker; and (iii) induce phase shifts in the circadian clock such that the circadian phase of increased sleep propensity occurs at a new, desired time. Therefore, exogenous melatonin can act as soporific agent, a chronohypnotic, and/or a chronobiotic. We describe the role of melatonin in the regulation of sleep, and the use of exogenous melatonin to treat sleep or circadian rhythm disorders.
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Affiliation(s)
- C Cajochen
- Center for Chronobiology, Psychiatric University Clinic, Wilhelm Kleinstrasse 27, CH-4025 Basel, Switzerland.
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Colachis SC. Hypothermia associated with autonomic dysreflexia after traumatic spinal cord injury. Am J Phys Med Rehabil 2002; 81:232-5. [PMID: 11995611 DOI: 10.1097/00002060-200203000-00013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Individuals with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of both thermoregulatory dysfunction and autonomic dysreflexia. It is unclear, however, what effect reflex autonomic sympathetic outflow has on thermoregulatory dysfunction during episodes of autonomic dysreflexia. The following case of an individual with C5 tetraplegia and both thermoregulatory dysfunction and autonomic dysreflexia illustrates the profound effects that the autonomic nervous system may have on body temperature in individuals at risk for this complication.
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Affiliation(s)
- Sam C Colachis
- Department of Physical Medicine and Rehabilitation, SCI Rehabilitation, The Ohio State University College of Medicine, Columbus 43210, USA
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Lew HL, Han J, Robinson LR, Britell C, Perkash I. Occult maxillary sinusitis as a cause of fever in tetraplegia: 2 case reports. Arch Phys Med Rehabil 2002; 83:430-2. [PMID: 11887128 DOI: 10.1053/apmr.2002.29627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Common causes of fever in tetraplegia include urinary tract infection, respiratory complications, bacteremia, impaired autoregulation, deep vein thrombosis, osteomyelitis, drug fever, and intra-abdominal abscess. We report 2 acute tetraplegic patients who presented with fever of unknown origin. After extensive work-up, they were diagnosed with occult maxillary sinusitis. A search of current literature revealed no reports of sinusitis as a potential source of fever in recently spinal cord--injured patients. Patients with tetraplegia, especially in the acute phase of spinal cord injury, often undergo nasotracheal intubation or nasogastric tube placement, which may result in mucosal irritation and nasal congestion. All of the previously mentioned factors, in combination with poor sinus drainage related to supine position, predispose them to developing maxillary sinusitis. The 2 consecutive cases show the importance of occult sinusitis in the differential diagnosis of fever in patients with tetraplegia.
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Affiliation(s)
- Henry L Lew
- Physical Medicine and Rehabilitation Service, Stanford University School of Medicine/VA Palo Alto Health Care System, 3901 Miranda Avenue, Palo Alto, CA 94304, USA.
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Van Someren EJ. More than a marker: interaction between the circadian regulation of temperature and sleep, age-related changes, and treatment possibilities. Chronobiol Int 2000; 17:313-54. [PMID: 10841209 DOI: 10.1081/cbi-100101050] [Citation(s) in RCA: 191] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The neurobiological mechanisms of both sleep and circadian regulation have been unraveled partly in the last decades. A network of brain structures, rather than a single locus, is involved in arousal state regulation, whereas the suprachiasmatic nucleus (SCN) has been recognized as a key structure for the regulation of circadian rhythms. Although most models of sleep regulation include a circadian component, the actual mechanism by which the circadian timing system promotes--in addition to homeostatic pressure--transitions between sleep and wakefulness remains to be elucidated. Little more can be stated presently than a probable involvement of neuronal projections and neurohumoral factors originating in the SCN. This paper reviews the relation among body temperature, arousal state, and the circadian timing system and proposes that the circadian temperature rhythm provides an additional signaling pathway for the circadian modulation of sleep and wakefulness. A review of the literature shows that increased brain temperature is associated with a type of neuronal activation typical of sleep in some structures (hypothalamus, basal forebrain), but typical of wakefulness in others (midbrain reticular formation, thalamus). Not only local temperature, but also skin temperature are related to the activation type in these structures. Warming of the skin is associated with an activation type typical of sleep in the midbrain reticular formation, hypothalamus, and cerebral cortex (CC). The decreasing part of the circadian rhythm in core temperature is mainly determined by heat loss from the skin of the extremities, which is associated with strongly increased skin temperature. As such, alterations in core and skin temperature over the day could modulate the neuronal activation state or "preparedness for sleep" in arousal-related brain structures. Body temperature may thus provide a third signaling pathway, in addition to synaptic and neurohumoral pathways, for the circadian modulation of sleep. A proposed model for the effects of body temperature on sleep appears to fit the available data better than previous hypotheses on the relation between temperature and sleep. Moreover, when the effects of age-related thermoregulatory alterations are introduced into the model, it provides an adequate description of age-related changes in sleep, including shallow sleep and awakening closer to the nocturnal core temperature minimum. Finally, the model indicates that appropriately timed direct (passive heating) or indirect (bright light, melatonin, physical activity) manipulation of the nocturnal profile of skin and core temperature may be beneficial to disturbed sleep in the elderly. Although such procedures could be viewed by researchers as merely masking a marker for the endogenous rhythm, they may in fact be crucial for sleep improvement in elderly subjects.
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Abstract
OBJECTIVE The author's goal was to develop a pathophysiological model for neuroleptic malignant syndrome with greater explanatory power than the alternative hypotheses of hypothalamic dopamine antagonism (elevated set point) and direct myotoxicity (malignant hyperthermia variant). METHOD Published clinical findings on neuroleptic malignant syndrome were integrated with data from human and animal studies of muscle physiology, thermoregulation, and autonomic nervous system function. RESULTS The data show that the sympathetic nervous system's latent capacity for autonomous activity is expressed when tonic inhibitory inputs from higher central nervous system centers are disrupted. These tonic inhibitory inputs are relayed to preganglionic sympathetic neurons by way of dopaminergic hypothalamospinal tracts. The sympathetic nervous system mediates hypothalamic coordination of thermoregulatory activity and is a primary regulator of muscle tone and thermogenesis, augmenting both of these when stimulated. In addition, the sympathetic nervous system modulates all of the other end-organs that function abnormally in neuroleptic malignant syndrome. CONCLUSIONS There is substantial evidence to support the hypothesis that dysregulated sympathetic nervous system hyperactivity is responsible for most, if not all, features of neuroleptic malignant syndrome. A predisposition to more extreme sympathetic nervous system activation and/or dysfunction in response to emotional or psychological stress may constitute a trait vulnerability for neuroleptic malignant syndrome, which, when coupled with state variables such as acute psychic distress or dopamine receptor antagonism, produces the clinical syndrome of neuroleptic malignant syndrome. This hypothesis provides a more comprehensive explanation for existing clinical data than do the current alternatives.
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Affiliation(s)
- R J Gurrera
- Department of Psychiatry, Harvard Medical School, Brockton-West Roxbury DVA Medical Center, Brockton, MA 02301, USA.
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Smith JE, Jansen AS, Gilbey MP, Loewy AD. CNS cell groups projecting to sympathetic outflow of tail artery: neural circuits involved in heat loss in the rat. Brain Res 1998; 786:153-64. [PMID: 9554992 DOI: 10.1016/s0006-8993(97)01437-6] [Citation(s) in RCA: 204] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In the rat, approximately 20% of total body heat-loss occurs by sympathetically mediated increases in blood flow through an elaborate system of arteriovenous anastomoses in the skin of its tail. In this study, the CNS cell groups that regulate this sympathetic outflow were identified by the viral transneuronal labeling method. Pseudorabies virus was injected into the wall of the ventral tail artery in rats that had their cauda equina transected to eliminate the somatic innervation of the tail. After 4-7 days survival, the pattern of CNS transneuronal labeling was studied. Sympathetic preganglionic neurons in the T11-L2 (mainly L1) levels of the intermediolateral cell column (IML) were labeled by 4 days. After 5 days, sympathetic pre-motor neurons (i.e., supraspinal neurons that project to the IML) were identified near the ventral medullary surface; some of these contained serotonin immunoreactivity. Additional groups of the sympathetic premotor areas were labeled by 6 days post-injection, including the rostral ventrolateral medulla (C1 adrenergic neurons), rostral ventromedial medulla, caudal raphe nuclei (serotonin neurons in the raphe pallidus and magnus nuclei), A5 noradrenergic cell group, lateral hypothalamic area and paraventricular hypothalamic area (oxytocin-immunoreactive neurons). Seven days after the PRV injections, additional cell groups in the telencephalon (viz., bed nucleus of the stria terminalis, medial and lateral preoptic areas and medial preoptic nucleus), diencephalon (viz., subincertal nucleus, zona incerta as well as dorsal, dorsomedial, parafascicular, posterior and ventromedial hypothalamic nuclei) and midbrain (viz., periaqueductal gray matter, precommissural nucleus, Edinger-Westphal nucleus and ventral tegmental area) were labeled. The discussion is focused on the CNS cell groups involved in the control of body temperature and fever.
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Affiliation(s)
- J E Smith
- Department of Anatomy and Neurobiology, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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Abstract
Increasing numbers of patients with spinal cord injury present for surgery or obstetric care. Spinal cord injury causes unique pathophysiological changes. The most important peri-operative dangers are autonomic dysreflexia, bradycardia, hypotension, respiratory inadequacy and muscle spasms. Autonomic dysreflexia is suggested by headache, sweating, bradycardia and severe hypertension and may be precipitated by surgery, especially bladder distension. Patients with low, complete lesions, undergoing surgery below the level of injury, may safely do so without anaesthesia provided there is no history of autonomic dysreflexia or troublesome spasms. An anaesthetist should be present to monitor the patient in this situation. General anaesthesia of sufficient depth is effective at controlling spasms and autonomic dysreflexia but hypotension and respiratory dysfunction are risks. There is a growing consensus that spinal anaesthesia is safe, effective and technically simple to perform in this group of patients. We present a survey of 515 consecutive anaesthetics in cord-injured patients and a review of the current literature on anaesthesia for patients with chronic spinal cord lesions.
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Affiliation(s)
- P R Hambly
- Nuffield Department of Anaesthetics, John Radcliffe, Headington, Oxford, UK
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Reeves RK, Stolp-Smith KA, Christopherson MW. Hyperthermia, rhabdomyolysis, and disseminated intravascular coagulation associated with baclofen pump catheter failure. Arch Phys Med Rehabil 1998; 79:353-6. [PMID: 9523793 DOI: 10.1016/s0003-9993(98)90021-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A 29-year-old man with C6 tetraplegia (ASIA A) using an implanted baclofen pump and intrathecal catheter infusion system for spasticity control developed severe spasticity, hyperthermia, hypotension, rhabdomyolysis, and disseminated intravascular coagulation after catheter disconnection. Tracheal intubation and mechanical ventilation were necessary. Extensive workup for a concurrent infection was negative except for urine cultures. The patient remained febrile for 10 days despite empirical antibiotic trials. Administration of high-dose benzodiazepines was inadequate for spasticity control. Spasticity control and his clinical condition, including body temperature, did not improve until his catheter was surgically replaced and intrathecal baclofen administration was resumed. The pharmacopathology of abrupt baclofen withdrawal and the similarities between this presentation, sepsis, neuroleptic malignant syndrome, and malignant hyperthermia are discussed. High-dose dantrolene was not used; however, based on similarities between this patient's presentation and neuroleptic malignant syndrome, it may have been the drug of choice.
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Affiliation(s)
- R K Reeves
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA
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Bergman SB, Yarkony GM, Stiens SA. Spinal cord injury rehabilitation. 2. Medical complications. Arch Phys Med Rehabil 1997; 78:S53-8. [PMID: 9084368 DOI: 10.1016/s0003-9993(97)90410-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.
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Affiliation(s)
- S B Bergman
- New England Regional Spinal Cord Injury Center-Boston Medical Center, MA 02118, USA
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50
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Abstract
The ability of organisms to respond to fluctuating temperatures is ubiquitous but poorly understood. Recent studies of nematodes reveal specific sensory neurons and interneurons that mediate thermotaxis.
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Affiliation(s)
- J H Thomas
- Department of Genetics, University of Washington, Seattle 98195-7360, USA
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