Poliomyelitis sequels in France and the clinical and social needs of survivors: a retrospective study of 200 patients

INTRODUCTION

Polio survivors in France are estimated at 50,000. This study aimed at describing their needs from their clinical and vocational conditions.

METHOD

A retrospective study of our physical and rehabilitation medicine (PRM) consultation activity.

RESULTS

One hundred and fifteen women/85 men, with a mean age of 51years±14.3 (17 to 82). Paralysis involved only one lower limb in 108 patients, the two lower limbs in 56 patients and only one upper limb in 4. At the time of the first consultation 137 patients had experienced functional worsening. The complaints were pain (105 subjects), fatigue (59) and new paresis (58). Only 25% had retired. Post-polio syndrome criteria were present in 46 subjects (23%). Patients who had contracted poliomyelitis in France (56%) differed from the other subjects with regard to age (58.4 versus 41.5), professional status and frequency of PPS (30.9% versus 12.6%).

CONCLUSION

These polio survivors were not particularly aged and they had often experienced functional worsening. The evolution of their disease shall represent a public health issue over the decades to come.

Upper limb surgery for tetraplegia: assessment of a 10-point strategy

PURPOSE

Palliative motor surgery of the tetraplegic upper limb is well-defined, with relatively precise indications that however vary somewhat from team to team. Our personal indications originated mainly from Zancolli, and were applied by the same surgeon in two independent rehabilitation centers. The goals of this study were to assess the application of these indications with time.

METHODS

Our retrospective study included three parts: summarization of our initial indications into a 10-point reference strategy; gathering the medical records related to all of the tetraplegic upper limb operations from 1989 to 2006, except for those related to complications and/or salvage procedures. For each patient, collected data corresponded to the 10 strategic points (SP); comparison of the collected data with the reference strategy, upper limb by upper limb, point by point, in order to identify and document any deviations.

RESULTS

We assessed the use of the reference strategy in 272 consecutive operations (139 upper limbs, 96 patients). Overall nonconformity rate with the use of the 10-point strategy was 27% (38/139). Except for one very atypical case, all of the exceptions from the reference strategy were due to specific anatomical or physiological conditions.

CONCLUSIONS

Our reference strategy has remained noticeably stable over time. However, three important evolutionary modifications occurred: systematic choice of biceps instead of deltoid to restore elbow extension; addition of the split distal flexor pollicis longus tenodesis procedure; and removal of extensor carpi radialis brevis from the list of potential flexor pollicis longus motors. Two issues, dealing with the systematic use of lassos and with brachio radialis to extensor digitorum communis transfer, are likely to be revisited in the future.

How do C6/C7 tetraplegic patients grasp balls of different sizes and weights? Impact of surgical musculo-tendinous transfers

STUDY DESIGN

Prospective control cohort study.

OBJECTIVES

To develop a new test to analyse qualitatively grasping strategies in C6/C7 tetraplegic patients, and to quantify the effect of musculo-tendinous transfers.

SETTING

France.

METHODS

Twelve C6/C7 tetraplegic adults (17 arms; 31.3+/-7.9 years) and 17 healthy subjects (30.9+/-9.4 years) completed the study. We assessed participants' ability to grasp, move and release standardized balls of variable sizes and weights.

OUTCOME MEASURES

Failures, movement duration (MD), grip patterns, forearm orientation during transport.

RESULTS

In patients as well as in controls, the number of digits involved in prehension increased proportionally to the size and weight of the ball. C6 non-operated tetraplegic patients failed 38.2% of the tasks. They frequently used supine transport (51.4% of successful tasks). MD was longer, with a large distribution of values. The presence of active elbow extension poorly influenced the amount of failure nor grip configuration, but significantly reduced MD and supine transport (34%). Patients who were evaluated after hand surgery showed a trend towards improved MD and more frequent completion (failure 30%), especially for middle-sized and middle-weighted balls. Grip patterns were deeply modified, and all transports were made in pronation.

CONCLUSION

The 'Tetra Ball Test' evidences the characteristics of grasping in tetraplegic patients and those influenced by surgery. It may be useful in understanding effects of surgical procedures. This preliminary study must be completed to evaluate the quantitative responsiveness and reproducibility of this test and to develop instrumented electronic balls to optimise it.

Paraplégie à la suite d'une infiltration foraminale lombaire : revue de la littérature à partir d'un cas

OBJECTIVES

We report a patient in whom paraplegia developed following transforaminal epidural injection of a corticosteroid and discuss the physiopathology of this complication, based on a literature survey.

CASE REPORT

A 40-year-old man presented with low-back pain and symptoms of L4 radiculopathy due to degenerative disc herniation resistant to conventional medical treatment. Computed tomography revealed posterolateral L4-L5 disc protrusion. A dosage of 125 mg of hydrocortisone was given by epidural transforaminal L4-L5 left injection under radioscopy guidance. Within minutes following the injection, intense pain developed in both legs, with T12 complete paraplegia. Emergency magnetic resonance imaging (MRI) 2 hours later did not reveal spinal cord abnormalities. The patient underwent immediate surgery consisting of excising the protruding disc and extensive L3-L5 laminectomy. MRI performed 3 months later did not reveal medullar abnormalities. Six months later, the patient continued to show slow neurologic improvement, permitting him to walk with crutches and to stop intermittent self-catheterisation.

DISCUSSION

The occurrence of paraplegia following epidural transforaminal injection of corticosteroids is a rare complication. To our knowledge, only 5 similar cases have been described. Most of the authors proposed that the mechanism of this complication is ischemia of the terminal cone due to accidental suppression of medullary blood supply. Direct lesion of a medullar artery, arterial spasm, or corticosteroid-induced occlusion due to undetected intra-arterial injection could lead to this medullar infarction. Anatomical variations of the path followed by the Adamkievicz artery strongly support this hypothesis.

Health related quality of life in people with hereditary neuromuscular diseases: an investigation of test-retest agreement with comparison between two generic questionnaires, the Nottingham health profile and the short form-36 items

The present work attempts to define reproducibility, test-retest and internal consistencies of two standardised tools that measure health related quality of life (HRQoL), specifically as they apply to hereditary neuromuscular disease (HNMD): the Nottingham health profile (NHP) and the medical outcome study 36-item short-form questionnaire (MOS SF-36). A cross sectional survey of 108 hereditary neuromuscular disease patients completed the questionnaires consecutively in the course of multidisciplinary consultations in Reims between April 2002 and February 2005. The results of the study confirm the acceptability of using generic questionnaires such as the Nottingham health profile and the SF-36, and show good reliability for these instruments. For both instruments, reproducibility (test-retest) appears excellent for the physical dimensions explored, and satisfactory for the mental dimensions. There is nonetheless a need for health related quality of life measures validated for neuromuscular disease patients. Health related quality-of-life (HRQoL) measures provide information on how patients assess their health and the care provision they are offered.

[Constituted adult equine from the ankle: surgical treatment by Ilizarov external fixator]

INTRODUCTION

Ilizarov's external fixator indications are classically used in children to lengthen the lower limbs. This technique is used for adults to gradually correct articular limitations, especially in the knee, ankle and foot.

METHOD AND RESULTS

We report a case of a 53-year-old patient with distal microangiopathy of the lower limbs leading to amputation of the toes and a bilateral, direct, irreducible, isolated equine feature? from the back foot to 0/50/60 degrees? on retraction of the Achilles tendon. The aim of patient management was to regain walking ability. Because of vascular and cutaneous fragility, the classical surgical treatment was contra-indicated. Progressive reduction by Ilizarov's external fixator was tried. Dorsal inflection was obtained by twice-daily screwing until a radiological angle of 90 degrees was obtained between the tibia and talus. At ten weeks post-surgery, the dorsal voluntary inflection ankle amplitude was symmetrical to 0/10/60 degrees. The patient walked with orthopaedic shoes compensating for the few degrees of residual equine.

DISCUSSION

Correction of adult equine without osseous deformation by Ilizarov's external fixator should be considered when conventional surgery is contra-indicated.

Intérêt du dépistage actif des bactéries multirésistantes dans les services de médecine physique et réadaptation

OBJECTIVES

The objective of this study was to evaluate the epidemiology of antibiotic-resistant bacteria among motor impaired patients admitted to an acute rehabilitation unit.

METHODS

From January 2000 to December 2002, the acute rehabilitation units of R. Poincare Hospital have screened patients for methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase enterobacteria (ESBL-EB) carriage by nasal and rectal swab at admission, every month and exit.

RESULTS

Finally, MRSA was isolated form screening or diagnosis samples of 360 patients and ESBL-EB from screening or diagnosis samples of 170 patients, corresponding respectively to an incidence of 3.6 for 1000 days of hospitalization (DH) and 1.7 for 1000 DH. 66% (236/360) of MRSA carriers and 58% of ESBL-EB carriers were identified only by screening samples. Carriage origin was identified for year 2002: Cases were imported for 40% (26/65) of MRSA carriers and 43% (18/42) of ESBL-EB carriers. The median acquisition delays were of 31 days [3-154] for MRSA and 19 days [3-317] for ESBL-EB.

CONCLUSION

This allowed to set up contact precautions for more than 2 fold patients that would have allowed diagnosis samples alone.

[Extensor tenodesis to the retinaculum extensorum: anatomic and biomechanical study]

INTRODUCTION

The extensor tenodesis is a direct dynamic tenodesis which is activated by wrist flexion due either to hand weight or flexor carpi radialis. This tenodesis is usually performed to the distal radius, but it is possible to fix EDC (extensor digitorum communis) to the retinaculum extensorum.

MATERIAL AND METHODS

Biomechanical study concerned 12 anatomical subjects (24 wrists). The biometric and radiological analysis of retinaculum displacement distalwards was made under low (1 kg) and moderate (6 kg) pulling. Surgical clips were placed on the proximal and distal limits of the retinaculum in order to study their positions on roentgenograms.

RESULTS

Average width of the retinaculum was 19 mm. Average movement under 1 kg drive was 6 mm and 8.6 mm under 6 kg drive. X-rays showed that the proximal border of the retinaculum was always located proximally to the wrist rotate centre, whatever the traction.

DISCUSSION

We found the same anatomical features described by different authors, except for the width of the retinaculum. Our study suggests that the retinaculum is strong enough to support a surgical tenodesis.

[Cup and cone arthrodesis of the thumb in palliative surgery for tetraplegia. Retrospective study of 57 cases]

INTRODUCTION

The cup and cone technique, first described by Carrol and Hill is very simple. It affords excellent contact between bones, and allows all possible adjustments of the arthrodesis in three planes before its final fixation.

MATERIAL AND METHODS

Fifty seven cup and cone arthrodesis of the thumb were performed in 41 adult tetraplegic patients. Level of arthrodesis was i.p. in 28 cases, TM in 25 cases and MP in 4 cases. Distribution in Giens classification was 3 group 1, 14 group 2, 9 group 3, 23 group 5, 2 group 6, 1 group 7, 2 group 10. Mean follow-up was 51 months. Three criteria were retrospectively studied: the clinical strength of arthrodesis, its position, and the potential existence of complications.

RESULTS

Clinical fusion was obtained in 8 week in all cases, without any infection. No delayed union was observed. In only one case, a surgical revision was required, due to initial bad setting of TM arthrodesis and an intermetacarpal arthrodesis was performed with a bony graft. In all other cases, position of arthrodesis was correct. In a few cases, only minor or non specific drawbacks were observed: TM arthrodesis were sometimes painful during the first 6 months postoperatively; transient dystrophy of the thumb nail occurred two times in i.p. arthrodesis; the worst drawback was the shortening of the thumb, which impaired the key-grip in cases where the thumb was preoperatively short.

DISCUSSION

In tetraplegic patients, stabilization of the thumb can be obtained either by split distal FPL tenodesis or by an arthrodesis at TM, MP or i.p. level of the thumb. When the provided thumb length is adequate arthrodesis is preferred. The cup and cone technique is very simple and effective. It is fit particularly in tertraplegic patients, whatever the level of the thumb arthrodesis.

Late superior mesenteric artery syndrome in paraplegia: case report and review

STUDY DESIGN

A case report of superior mesenteric artery syndrome (SMA syndrome) occurring in a paraplegic patient 3 months after injury.

OBJECTIVES

To report an unusual case and review the literature of SMA syndrome in spinal cord injured patients, focusing on paraplegic subjects and on tardive presentations.

SETTING

A Physical Medicine and Rehabilitation Center in Garches (France).

METHOD

Current medical literature includes reports of only 14 spinal cord injured patients with SMA syndrome. This syndrome has been often described in anorexia nervosa, burns or other causes of cachexia, following correction of spinal deformities or after application of body casts.

RESULTS

In spinal cord injured patients SMA usually occurs in tetraplegic patients during the first weeks after injury. Only four cases of SMA syndrome in paraplegic patients have been described. Late forms are less common than acute ones: only three cases among 14. SMA syndrome consists of a vascular compression of the third part of the duodenum between the ventrally oriented SMA and the aorta. The normal aorto-mesenteric angle ranges between 38 degrees and 65 degrees and can be as low as 6 degrees in patients with SMA syndrome. The diagnosis is usually based on upper gastro-intestinal contrast X-ray study, which shows abrupt vertical compression of the third part of the duodenum. CT scan with angiography is useful in some difficult cases. Conservative management includes early correction of dehydration and electrolyte imbalance, insertion of a nasojejunal tube beyond the obstruction and renutrition. Duodenojejunostomy may be necessary in case of failure of conservative treatment.

CONCLUSION

SMA syndrome is an unusual gastro-intestinal complication that may occur in paraplegic patients, even late after injury.

[Intracavernous injections in the treatment of erectile dysfunction in spinal cord injured patients: experience with 36 patients]

OBJECTIVES

To confirm the efficiency of intracavernous injections in the treatment of erectile dysfunction in spinal cord injured (SCI) patients and to determine the mean necessary dose to obtain functional erection.

MATERIALS

This prospective study concerns 36 spinal cord injured men. None of them had erectile dysfunction before the neurologic impairement. Sixty four intracavernous injections were performed.

METHOD

The first injection was done with the usually recommended starting dose. The injections were then repeated with increasing dosage to archive a rigid erection. The erection was evaluated with Schramek grading. A grade 4 or 5 erection was considered as functional.

RESULTS

Nine tetraplegics and 27 paraplegics were included. Twenty two were grade A in ASIA classification. The mean age was 31 years. Twenty for patients had a level above T10, 11 between T11 and L2, one below L2. Twenty seven patients obtained an erection of grade 4 or 5. Alprostadil was used 51 times, moxisylite nine times and papaverine four times. The average dose necessary to obtain a grade 4 or 5 functional erection adequate for coitus was 12.3 +/- 4.8 microgram with alprostadil and 14 +/- 5.4 mg with moxisylite. No side effects were noted. The nine left patients did not archive satisfying erection during this study. No clinical differences were noted in this population, compared with the 27 other patients.

CONCLUSION

The findings confirm the efficiency of intracavernous injections in the management of erectile dysfunction in SCI. The average doses required to obtain a functional erection was 12.3 (+/- 4.8) microgram with alprostadil and 14 (+/- 5.4) mg with moxisylyte.

Results of excision of heterotopic new bone around the elbow in patients with head injuries. A series of 25 cases

Twenty patients were operated upon for heterotopic ossification around the elbow of neurogenic origin following intra-cranial trauma between 1993 and 1997. They did not receive any diphosphonates or radiotherapy. Pre-operative evaluation included a CT scan with enhancement using a dye injected intravenously and 3D reconstruction. Surgery was indicated in the presence of a clinical deficit in mobility or signs (clinical or electrical) of nerve compression. The average delay between the accident and the surgery was 34 months (5 months to 9 years). Associated procedure included lengthening of the brachialis (4 cases), lengthening of the triceps tendon (4 cases) and an anterior capsulotomy in 3 cases. 24 elbows were reviewed with an average follow-up period of 18 months (6 months to 4 years). In 58% of the cases, the result was very good (gain in mobility > 70%) while in the remaining 42% of cases, the improvement was between 40% and 70%. This study confirms the possibility of obtaining good results by excision of the masses of heterotopic ossification of neurogenic origin around the elbow before 1 year after the accident without the necessity of complementary treatment.

Kinematics of prehension and pointing movements in C6 quadriplegic patients

AIMS

C6 quadriplegic patients lack voluntary control of their triceps muscle but can still perform reaching movements to grasp objects or point to targets. The present study documents the kinematic properties of reaching in these patients.

MATERIALS AND METHODS

We investigated the kinematics of prehension and pointing movements in four quadriplegic patients and five control subjects. Prehension and pointing movements were recorded for each subject using various object positions (ie different directions and distances from the subject). The 3D motion was analyzed with Fastrack Polhemus sensors.

RESULTS

During prehension tasks the velocity profile of control subjects showed two peaks (go and return); the first velocity peak was scaled to the distance of the object. In quadriplegic patients there was a third intermediary peak corresponding to the grasping of the object. The amplitude of the first peak was slightly smaller than in control subjects. Velocity was scaled to the distance of the object, but with a greater dispersion than in control subjects. Total movement time was longer in quadriplegics because of the prolonged grasping phase. There were few differences in the pointing movements of normal and quadriplegic subjects. The scapula contributed more to the reaching phase of both movements in quadriplegic patients.

CONCLUSION

In spite of some quantitative differences, the kinematics of the hand during reaching and pointing in quadriplegic patients are surprisingly similar to those of control subjects. Spinal Cord (2000) 38, 354 - 362.

Contribution of D-Dimer determination in the exclusion of deep venous thrombosis in spinal cord injury patients

Deep vein thrombosis (DVT) is a common complication of paraplegia despite prophylactic anticoagulant therapy. The diagnosis relies primarily on ultrasonography or phlebography; these investigations are difficult, expensive and can be time-consuming in paraplegic patients.

STUDY DESIGN

To evaluate the usefulness of coagulation activation markers in excluding a diagnosis of DVT, D-Dimers, thrombin-antithrombin complexes, prothrombin fragments (F1+2) and activated factor VIIa.

OBJECTIVES

To improve the diagnosis of deep venous thrombosis in paraplegic patients.

SETTING

This collaborative work was done at Raymond Poincaré Hospital, Garches, France.

METHODS

To evaluate the usefulness of coagulation activation markers in excluding a diagnosis of DVT, D-Dimers (D-Di), thrombin-antithrombin (TAT) complexes, prothrombin fragments (F1+2) and activated factor VIIa (FVIIa), were determined in a prospective study of 67 consecutive patients with paraplegia or tetraplegia. Doppler ultrasonography and/or phlebography of the lower limbs and D-Di, TAT, F1+2 level determination were systematically done in each patient at admission to our rehabilitation unit.

RESULTS

Despite prophylactic low molecular weight heparin therapy, six of the 67 patients developed DVT diagnosed by radiologic explorations. D-Di levels measured by a reference ELISA (Asserachrom D-Di, Diagnostica Stago) or a new rapid automated turbidimetric test (STA-Liatest D-Di) were greater than 500 ng/ml in all DVT patients and in 40 non-DVT patients, of whom most had urinary tract infections, osteomas, or pressure sores. D-Di values were normal in only 21/67 patients (31%). The negative predictive value of D-Di in our study was 100% since all DVT patients had D-Di values greater than 500 ng/ml. TAT and F1+2 levels were not correlated with D-Di levels but also had a negative predictive value of 100%. Comparison of D-Di levels obtained using the two tests showed that results of the reference ELISA were closely correlated to those of the new rapid automated turbidimetric. TAT, F1+2, and factor VIIa are not useful for measuring hypercoagulability in paraplegic or tetraplegic patients since no rapid tests for determining these parameters are available.

CONCLUSION

D-Di levels determined using an ELISA or a new rapid automated turbidimetric test have a good negative predictive value for DVT in paraplegic or tetraplegic patients and may reduce the need for Doppler ultrasonography and/or phlebography by 31%.

Endothelial fibrinolytic reactivity and the risk of deep venous thrombosis after spinal cord injury

Deep vein thrombosis (DVT) is a frequent event in patients with spinal cord injury, even with prophylactic anticoagulant therapy. Lower limb paralysis is a known major risk factor for venous thrombosis, supposedly due to the venostasis in relation with total immobility. The main goal of this study was to evaluate the endothelial response to anoxia to determine whether recovery of fibrinolytic potential occurs in patients subjected to forced bedrest because of a spinal cord injury and whether this recovery is related to the incidence and/or evolution of DVT. We evaluated vascular endothelium reactivity in the lower limbs no longer submitted to the hydrostatic pressure of the erected position in 15 patients with paraplegia or tetraplegia and in 10 normal volunteers after venous occlusion produced by the application of 10 cm Hg pressure to the lower limb for 15 min comparatively to the upper limb used as reference. Among the 15 patients, 10 whose spinal cord injury had occurred 1 to 6 months earlier were still receiving prophylactic anticoagulant therapy, whereas the five other patients were not receiving prophylactic anticoagulants because the injury dated back 6 months or more. After venostasis, tissue plasminogen activator (tPA) increased significantly in both patients and controls in the upper limb (tPA levels twofold and threefold respectively in controls and patients) but showed no significant changes in the lower limb; prolonged immobility did not allow recovery in the lower limbs of a level of fibrinolytic responsiveness identical to that in the upper limbs. The plasminogen activator inhibitor (PAI1) remained unchanged after anoxia, although wide interindividual variations were seen. Natural coagulation inhibitors and circulating blood stigmates of hypercoagulability were measured. None of the patients had abnormally low levels of coagulation inhibitors (ie, antithrombin III, protein C and protein S levels were normal). Seventy-five per cent of patients (prophylactically anticoagulated or not) had very high levels of fibrin degradation products (D. Dimer levels sevenfold to eightfold those of the controls), but all patients had normal levels of thrombin-antithrombin complexes and prothrombin fragments 1 + 2. The permanence of the thrombotic process characterized by an increase in D. Dimer levels without recovery of fibrinolytic potential suggests a proposal for the patients an indefinite antithrombotic treatment at curative doses.

[Visual, auditory and somatosensory potentials in the diagnosis of vitamin B12 deficiency]

We describe visual, brain stem auditory, and somatosensory evoked (VEP, BAEP, SEP) in a 49-year old male patient presenting with subacute degeneration of the spinal cord due to vitamin B12 deficiency. Neurological signs included tetraplegia with a C4-C5 spinal cord compression that was unchanged after surgical decompression. Before treatment, the duration of the bilateral VEP was slightly increased, though their amplitude and morphology were not modified. BAEP were normal. However, abnormalities of SEP with loss of cortical potentials were noticed. Two months after initiation of the treatment, both VEP and SEP recorded in response to median nerve stimulation had improved, but there was still no cortical response to tibial nerve stimulation. Eighteen months later, VEP were normal and recovery of SEP in response to tibial nerve stimulation was observed; however, alterations of peripheral sensory and motor action potentials were still present. These findings are in good agreement with previously reported pathological changes in patients presenting with subacute combined degeneration. Similar abnormalities have been described in patients with multiple sclerosis. Evoked potentials in this case proved to be useful for the diagnosis and the evaluation of the efficacy of the treatment. These findings also suggest that demyelination of the posterior part of the spinal cord and peripheral axonal degeneration might be the main pathological changes related to vitamin B12 deficiency. The former, but not like the latter, were clearly responsive to the treatment.

[Neuro-orthopedic and muscle tonus disorders in patients with spinal cord injuries]

Heterotropic ossifications and contractures are frequent during evolution of spinal cord injury. Heterotopic ossifications occur in the first months following the acute state. Hip is the most common localisation. No preventive or curative treatment is available. At an early stage, clinical or instrumental (sonographic) diagnosis may prevent functional consequences. Muscular disbalance, incomplete physiotherapy, tonus disorders lead to contractures of limbs or trunk. They may have severe consequences on activities of dairy living. Surgical procedures may be necessary. Tonus disorders may resist to usual drugs. In this cases, intrathecal infusion of baclofen, injection of botulinus toxin, neurosurgery of orthopedic surgery may be useful.

Two cases of spondylometaphyseal dysplasia. Literature review and discussion of the genetic inheritance of the disease

We describe 2 cases of spondylometaphyseal dysplasia: in a 33-year-old woman and her 42-year-old stepsister. The usual pattern of inheritance is autosomal dominant. As this was not so in our cases, we offer another explanation.

Systematic lower limb phlebography in acute spinal cord injury in 147 patients

This study was concluded on paraplegic and tetraplegic patients of all aetiologies except neoplasic, where paralysis developed within 48 hours. All patients were admitted to the rehabilitation department within 90 days after the onset of paralysis. In a preliminary review of 328 files, there were 27 cases of clinical deep vein thrombosis (DVT) and 10 with pulmonary embolism (PE), 6 of which were fatal. A prospective study was conducted, based on systematic detection of asymptomatic DVT with phlebography. Among the 147 patients, 20 previously presented with DVT. The 127 others underwent phlebography which showed 39 DVT in 29 patients. Eighty seven patients with negative phlebography underwent a second study a month later which showed 14 DVT in 12 patients. Only one minor pulmonary embolism occurred in these 147 patients. The incidence of DVT after acute spinal cord injury and the frequent absence of clinical manifestations were confirmed. Prophylactic anticoagulant therapy is useful but insufficient. This study demonstrates that systematic and repeated detection of DVT by phlebography may reduce the incidence of PE.

Variations of prothrombin time, factor VII and protein C with a single daily dose of acenocoumarol. Preliminary results

In 11 patients on steady anticoagulation with a daily dose of acenocoumarol, prothrombin time, factor VII and protein C were measured 2 and 16 h after the daily intake of acenoumarol. Prothrombin time (expressed as International Normalised Ratio) increases significantly, factor VII and protein C decrease between the two samples. These results suggest that a daily dose of acenoumarol is associated with fluctuation of the anticoagulant effect.