Biomedical subjects
Publications and source records attributed to I Eltorai.
Autonomic dysreflexia is the most important specific complication of high level spinal cord injury both in tetraplegic and in paraplegic patients above the midthoracic neural segment. It is a life threatening emergency that may lead to apoplexy. We present a case of fatal cerebral hemorrhage due to autonomic dysreflexia in order to demonstrate the gravity of this particular syndrome.
Pressure ulcer is a common occurrence in spinal cord injured (SCI) patients and can lead to serious complications. With proper management, some patients exhibit satisfactory healing whereas others show slow or nonhealing ulcers. Fibronectin has been shown to accumulate in wound, opsonize macroaggregate debris for phagocytosis, promote revascularization, and facilitate fibroblast migration and proliferation. We explored the relationship of plasma fibronectin with healing potential in 21 SCI men with pressure ulcer. They received standard wound care and were observed for eight weeks. Ten otherwise healthy SCI men without pressure ulcer (SCI-controls) and 32 able-bodied normal individuals (normal controls) were also studied. Plasma fibronectin and related proteins, ie, fibrinogen, plasminogen, alpha 2-antiplasmin and Factor XIII, were measured. Ten of 21 SCI patients with pressure ulcer showed rapid healing within four weeks and had significantly higher fibronectin levels as compared with the 11 patients with poor healing ulcers, SCI controls, and normal controls. Factor XIII and alpha 2-antiplasmin were mildly reduced and fibrinogen values were significantly increased in all SCI groups. Plasminogen concentrations were comparable in all groups studied. It thus appears that plasma fibronectin rises in patients with fast healing ulcers but fails to do so in those with poor healing ulcers and as such may be predictive of the course of pressure ulcers.
Muscle spasticity and contractures in the spinal cord injured are a big problem interfering with rehabilitation, leading to inconveniences and complications in these patients. Management is based on pharmacotherapy, physiotherapy and surgeries. The authors are against central neurosurgery except on rare occasions. They have been practicing peripheral surgeries chiefly on muscles and tendons with satisfactory results in selected cases. The guidelines and procedures are presented.
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Patients with chronic spinal cord injury (SCI) and end-stage renal disease (ESRD) exhibit antithrombin III deficiency and several other coagulation abnormalities. In view of increasing recognition of protein C (PC) as an important, naturally occurring anticoagulant and fibrinolytic factor, we studied plasma PC in this population. PC antigen concentration and its anticoagulant activity were measured in nine SCI men with ESRD maintained on hemodialysis and in a control group of ten normal able-bodied men. The results showed a significant increase in PC anticoagulant activity in the SCI group. Consequently, the ratio of the PC activity to its concentration, which is a measure of the functional integrity of PC molecule, was markedly depressed. These findings are indicative of the presence of inactive or abnormal PC in SCI-ESRD patients and may suggest its in vivo activation. The combination of impaired PC activity shown in this study, with previously demonstrated antithrombin III deficiency and other coagulation abnormalities, is suggestive of a hypercoagulable state.
Data on the effects of combined long-standing spinal cord injury (SCI) and end-stage renal disease (ESRD) on blood coagulation system are limited. We studied the extrinsic and common pathways of blood coagulation system in 9 men with SCI-ESRD treated with maintenance hemodialysis. Plasma procoagulant activities of factors (F)VII, X and II were measured in a clotting assay using appropriate deficient plasmas as substrate. In addition, the antigen concentration of FII was measured using monospecific antibodies against human FII raised in goat in a gradient plate immunodiffusion system. Also measured were plasma fibrinogen concentration and platelet count. The results were compared with those obtained in a group of 10 ambulatory ESRD patients and 8 normal control volunteers. Plasma coagulant activity of FVII was markedly elevated and plasma fibrinogen concentration was moderately increased in SCI-ESRD patients. In contrast, plasma FII was mildly depressed while platelet count was within normal limits in SCI-ESRD patients. The data indicate that the combination of SCI and ESRD can lead to the alteration of the extrinsic and common coagulation pathways. Further studies are needed to elucidate the precise mechanism and the clinical significance of the observed abnormalities.
External fixation was used to treat femoral shaft fractures in nine spinal cord injury (SCI) patients. One patient died of unrelated causes during fracture treatment. Of the remaining eight patients, seven healed their fractures. Two complications, one superficial pin-track drainage and one fracture comminution, occurred in the nine patients. Neither complication adversely affected the patient's final result. In patients with acute spinal cord injury, external fixation should be considered for the treatment of closed femoral shaft fractures with marked comminution, and for open femoral shaft fractures with significant contamination or soft tissue loss. In the chronic SCI patient, external fixation of a femoral shaft fracture may increase the patient's level of independence and mobility during fracture healing, and may permit a more rapid return to the patient's pre-fracture functional level.
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Median nerve compression at the wrist (Carpal Tunnel Syndrome) is commonly associated with local trauma around the flexor retinaculum. Repeated manual activity also exacerbates the disease severity. We undertook a prospective study of the incidence of Carpal Tunnel Syndrome (CTS) in 47 paraplegic patients who have used their hands extensively for daily activity. Since surgical decompression generally provides excellent relief of symptoms, early detection of CTS will be particularly important in these patients. Of the 47 patients studied, 19 had clinical CTS (40%). A total of 91 hands (nerves) were tested with motor and sensory nerve conduction of the median and ulnar nerves. Electrophysiological evidence of CTS was noted in 57 hands (63%). The incidence of CTS appears to be related to the duration of Spinal Cord Injury. Concurrent ulnar neuropathy at the elbow was noted in 19 patients (40%). There was no predisposing factor such as diabetes mellitus in any of these patients, and the compressive neuropathy appears to be purely mechanical.
In the early fifties, total ischiectomy was in vogue as a procedure in the surgical treatment of ischial pressure sores. The immediate results by various authors were impressive. One of us, however (A.E.C.), reported the later development of urethral fistulae and the high incidence of perineal urethral diverticulae. The procedure has been abandoned and few surgeons recommend less radical ischiectomy supplemented by muscle transplantation.
Plasma procoagulant activities of factors XII, XI, IX, and VIII and plasma concentrations of factor XII antigen and high molecular weight kininogen (HMK) were determined in nine men with chronic renal failure (CRF) associated with long-standing spinal cord injury (SCI) treated with hemodialysis. The results were compared with those obtained in a group of 10 ambulatory CRF patients and 8 normal volunteers (control group). Congenitally deficient plasmas were used as the substrate for the measurement of procoagulant activities in a one-stage clotting assay. Monospecific antibodies were employed in the measurement of factor XII antigen and HMK using gradient plate immunodiffusion and rocket immunoelectrophoresis. Factor XII coagulant activity and antigen concentration were significantly increased in the SCI group. The mean values for plasma factor XI and IX activities in the SCI group were comparable with those observed in the ambulatory patients and normal control group. However, marked variations in factor XI and IX levels were noted among the SCI patients with a few instances of mild to moderate factor deficiencies and several cases of markedly elevated levels. Factor VIII activity was markedly increased, with only two of the nine patients exhibiting normal values. HMK concentration in the SCI group was comparable with values obtained for the other groups. Following dialysis, factor XII antigen concentration rose and factor XI activity fell slightly but significantly. The results indicate that the combination of CRF and long-standing SCI is associated with marked aberrations of intrinsic coagulation pathway. The underlying mechanisms and the clinical consequences of these abnormalities are not known and require further investigation.
Plasma antithrombin III activity and concentration were determined in nine men with end-stage renal disease (ESRD) associated with spinal cord injury (SCI). To determine the possible effects of hemodialysis measurements were repeated following dialysis. Values obtained in the SCI-ESRD group were compared with those obtained in a group of healthy volunteers and a group of 10 ambulatory men with ESRD. A normal pooled plasma was used as the internal standard for all assays. While antithrombin deficiency was observed in both uremic groups it was most severe in the group with SCI. Results demonstrated the association of antithrombin deficiency with ESRD and its potentiation in the presence of SCI. The mechanisms by which SCI compounds the uremia-induced antithrombin deficiency were not known. A mild increase in antithrombin level was noted following dialysis and was thought to be in part due to fluid removal by dialysis.
Avicenna's views on cancer are presented from his Medical Canon. A literal translation from Arabic has been undertaken by the author. The clinical diagnosis, the prognosis as well as the therapeutic measures according to Avicenna are interesting to know and compare with our views one thousand years later.
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The use of CO2 Laser in surgery for decubitus ulcers was assessed in 139 spinal cord injury patients. This technique is valuable for debridement and or excision of the ulcers as well as repair. It accomplishes hemostasis and wound sterility. It was found very helpful in patients with ill health, bleeding tendencies and active infections. It helped avoid amputation in a few paraplegics whose joints were involved or peripheral vessels compromised. Although the apparatus is expensive, its use on a large scale in specialized centers can be a good investment since it saves blood loss, transfusions, antibiotics, and hospital stay, the later so important with the current health care system in the USA known as DRG. However, operators should be very knowledgeable in the basic science of laser, the mechanics of the apparatus and its control for the most efficient, effective and safe utilization.