Utilization of somatosensory evoked cortical potentials in spinal cord injury. Prognostic limitations

The prognostic value of somatosensory evoked cortical potentials (SECP) for clinical recovery was studied in 71 patients with complete (28) and incomplete (43) spinal injuries. While the absence of an SECP was associated with no clinical recovery, the presence of an SECP was of little value in predicting the clinical state at the time of examination or the potential for recovery.     

Predictive value of immature reticulocyte and platelet fractions in hematopoietic recovery of allograft patients

Hematopoietic progenitor cell transplantation is the treatment of choice for patients with malignant hematologic diseases. Neutrophil (NEUT) and platelet (PLT) counts are used to evaluate hematologic engraftment of transplanted patients. Recent-generation hematology analyzers offer an alternative way to evaluate immature peripheral blood (PB) cell fractions, which may also give an indication of hematopoietic recovery. The immature reticulocyte fraction (IRF) and immature platelet fraction (IPF) in PB samples may provide early indicators of transplant success. We evaluated the predictive value of IRF and IPF for the hematologic recovery of 46 adult patients undergoing allogeneic PB progenitor cell transplantation. We observed that IRF recovery anticipated by 4 days compared with NEUT recovery (11 vs 15 d) and IPF by 2 days compared with PLT (10 vs 12 d). The recovery was different for patients undergoing a nonmyeloablative regimen (NMA); we observed an early IRF recovery by 5 days compared with NEUT (10 vs 15 d) and a IPF compared with PLT recovery by 2 days (9 vs 11 d). We also observed significant correlations between NEUT and PLT recovery with recoveries of the new parameters IRF and IPF. We concluded that IRF and IPF predicted hematopoietic recovery. For allografted patients after NMA regimens, prediction was even more clinically relevant. These immature fractions open new perspectives for monitoring patient transfusion support through the posttransplantation recovery.     

The nature of spontaneous recovery from mivacurium-induced neuromuscular block

The hypothesis of this study was that, in a given patient, recovery from a tracheal intubating dose of mivacurium would indicate the time course of spontaneous recovery after discontinuation of an infusion of mivacurium. Thirty-eight male patients consented to participate in the study. After induction of anesthesia and endotracheal intubation, the ulnar nerve was stimulated with train-of-four (TOF) stimuli at 12-s intervals. Patients received 0.3 mg/kg mivacurium in two evenly divided doses of 0.15 mg/kg each, separated by 30 s. Complete ablation of TOF responses occurred in most patients. Once the first twitch in the TOF (T ) had recovered to 25% of its baseline height, a mivacurium infusion was begun to maintain 95% suppression of T1. As surgery was nearing completion, the infusion was discontinued, and neuromuscular function was allowed to recover spontaneously. Data were analyzed for recovery intervals after the administration of the initial doses of mivacurium and after discontinuation of the infusion. Analysis of variance was used to determine the strength of correlation between the time from administration of the initial 0.3 mg/kg dose to 5% recovery of T1 and the times to recovery of TOF ratios of 70% and 90%. The 25%-75% recovery interval after discontinuation of the infusion ranged from 2.8 to 11.3 min. The time interval after administration of mivacurium 0.3 mg/kg to 5% recovery of T1 correlated with both the time to recovery of a TOF ratio of 70% and 90%. Recovery to a TOF of 90% after discontinuation of the infusion required approximately the same amount of time as recovery to 5% T1 after the administration of 0.3 mg/kg mivacurium. Each patient's recovery of neuromuscular function after discontinuation of a mivacurium infusion was related to his recovery after the administration of 0.3 mg/kg mivacurium. Therefore, the need for pharmacologic antagonism of block can be anticipated well before the end of an anesthetic. IMPLICATIONS: Mivacurium (0.3 mg/kg) was administered to 38 patients. As they began to recover muscle strength, a mivacurium infusion was begun and later discontinued as surgery was nearing completion. Each patient's early recovery (administration to 5% recovery of T1) after the initial dose of mivacurium correlated well with more complete recovery of muscle strength after discontinuation of an infusion. This relationship enables early prediction of recovery speed after a mivacurium infusion.     

How is recovery from low back pain measured? A systematic review of the literature

Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of ‘completely recovered’. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.     

Recovery from neuromuscular blockade after either bolus and prolonged infusions of cisatracurium or rocuronium using either isoflurane or propofol-based anesthetics

We examined the recovery characteristics of cisatracurium or rocuronium after bolus or prolonged infusion under either isoflurane or propofol anesthesia. Sixty patients undergoing neurosurgical procedures of at least 5 h were randomized to receive either isoflurane with fentanyl (Groups 1 and 2) or propofol and fentanyl (Groups 3 and 4) as their anesthetic. Groups 1 and 3 received cisatracurium 0.2 mg/kg IV bolus, spontaneously recovered, after which time an infusion was begun. Groups 2 and 4 received rocuronium 0.6 mg/kg IV, spontaneously recovered, and an infusion was begun. Before the end of surgery, the infusion was stopped and recovery of first twitch (T(1)), recovery index, clinical duration, and train-of-four (TOF) recovery was recorded and compared among groups by using appropriate statistical methods. Clinical duration was shorter for rocuronium compared with cisatracurium using either anesthetic. Cisatracurium T(1) 75% recovery after the infusion was shorter with propofol compared with isoflurane. Cisatracurium TOF 75% recovery was similar after either bolus or infusion, but rocuronium TOF 75% recovery after the infusion was delayed. Infusion rates decreased for cisatracurium but remained relatively constant for rocuronium regardless of the anesthetic used. Isoflurane enhances the effect of both muscle relaxants but prolonged cisatracurium recovery more than rocuronium. Of the two muscle relaxants studied, rocuronium's recovery was most affected by length of the infusion. Cisatracurium may be a more desired muscle relaxant for prolonged procedures because recovery was least affected by prolonged infusion. Implications: This study describes the effect of different anesthetic techniques on the recovery of two different muscle relaxants, cisatracurium and rocuronium, when administered as either a single bolus or prolonged infusion during neurosurgery. This study demonstrates the feasibility of using these relaxants for these prolonged procedures.     

Recovery cycle of the cerebral neocortex: preliminary observations in epileptic patients.

The recovery cycle of the amplitude of the potential evoked in the cerebral neocortex by paired electrical stimuli of the underlying white matter was studied in 5 epileptic patients with intracerebral electrodes chronically implanted stereotactically. A reproducible pattern was apparent for the late components of the potential (i.e., the peak-to-peak amplitude between the second and the third peak, with an average peak latency of 14 and 35 ms, respectively). There was an early period of facilitation (5-10 ms interstimulus interval) followed by a period of relative or absolute depression (20-100 ms) with recovery at an interstimulus interval of about 150 ms. The recovery function of the early components of the potential (i.e., the peak-to-peak amplitude between the first and the second peak, with an average peak latency of 6 and 14 ms, respectively) was variable; recovery was reached at about 150 ms. The responsiveness seemed less in the most epileptogenic cortical areas.     

Rate of third nerve palsy recovery following endovascular management of cerebral aneurysms

Endovascular management of cerebral aneurysms resulting in third nerve palsies has been proposed as an alternative to microsurgical clip ligation. Third nerve function recovery following endovascular treatment in a large patient population has not been evaluated. A literature search of MEDLINE, PubMed, and Cochrane databases for third nerve palsies and endovascular management of cerebral aneurysms was performed. All reported patients in these studies were systematically compiled. Fifty-two patients with third nerve palsies secondary to cerebral aneurysms underwent endovascular treatment. Endovascular management resulted in some degree of third nerve recovery in 65% of patients. The extent of recovery was reported in 21 patients. Of these, 71% had complete recovery. At least two procedure-related third nerve palsies are reported in the literature. One was permanent. One case of recurrent painful palsy is also reported. Microsurgical clip ligation of cerebral aneurysms has a 93% rate of third nerve palsy recovery and a 43% rate of complete third nerve recovery. Endovascular management of cerebral aneurysms can alleviate third nerve palsies in some patients. In reviewing the world literature, however, microsurgical clip ligation is associated with a higher rate of third nerve recovery. Endovascular management, in the subset of patients in whom extent of recovery was documented, demonstrated a higher rate of complete recovery.     

Dosage of neostigmine for reversal of rocuronium block from two levels of spontaneous recovery

Spontaneous recovery, and recovery following neostigmine 20, 35 or 50 microgram.kg-1 administered at 10 or 25% of recovery of the first twitch of the train-of-four, was assessed in 80 patients after rocuronium administration under continued isoflurane anaesthesia. In an additional 40 patients, isoflurane administration was discontinued and neostigmine 35 or 50 microgram.kg-1 was given at 10 or 25% recovery. The administration of neostigmine reduced the recovery times significantly. A neostigmine dose of 20 microgram.kg-1 resulted in slower recovery compared with the higher doses, particularly when reversal was attempted at a first twitch height of 10%. Higher doses of neostigmine given at a first twitch height of 25% resulted in rapid reversal of block [mean (SD) times of 7.0 (4.8) and 6.4 (1.9) min with the 35 and 50 microgram.kg-1 doses, respectively, for attaining a train-of-four ratio of 0.8]. Discontinuing isoflurane did not alter recovery times. The incidence of emetic symptoms did not differ between groups, including one group that received atropine instead of glycopyrronium in combination with neostigmine. We conclude that rocuronium block can be antagonised safely using a neostigmine dose of 35 microgram.kg-1, although recovery may be slightly slower if administered at a first twitch of 10% of control.     

Radiostereometric analysis of early implant migration – a valuable tool to ensure proper introduction of new implants

1 reviewed 24 patients after decompression for peroneal entrapment neuropathy; in 3 cases the lesion was bilateral. There were 15 males and 9 females; mean age 44 (12–72) years. The etiology was an operation around the knee in 12, a tibial fracture in 2, a slight compression in 1, an ankle sprain in 2, excessive climbing in 2, sitting in a cross-legged position in 4, and in 4 cases no reason was found. There was foot drop in 15 and ankle instability in 12 cases. The nerve was decompressed after an average period of 17 months (4 days–8 years). Immediate relief of symptoms was achieved in 14 cases, slower relief in 10, and in 3 cases there was no recovery, In peroneal neuropathy, decompression should be considered after 2 months without recovery and after 4 months when recovery is slow.     

A novel system of assessing myocardial recovery during left ventricular support: Report of a case

The criteria for device removal and prediction of sustained recovery are still unclear in the bridge to myocardial recovery strategy using the left ventricular assist system (LVAS). We report the case of an 11-year-old boy with dilated cardiomyopathy, who was successfully weaned off LVAS after 4 months of support. Although the recovery of his left ventricular function was marginal, with a left ventricular ejection fraction of 40%, and a left ventricular end-diastolic diameter of 53 mm, we decided on its removal because an LVAS-off test showed well-maintained diastolic function. No signs of deterioration in LV function have been seen in the 4 months since removal of the device.     

Pharmacodynamics of vecuronium and atracurium in the obese surgical patient

The effect of obesity on the duration of action of the nondepolarizing muscle relaxants atracurium and vecuronium was studied in 28 neurosurgical patients. In obese patients given vecuronium (0.1 mg/kg), the time to go from 5 to 25% of recovery of twitch response was statistically significantly longer (14.6 +/- 7 minutes, mean +/- SD) than it was in nonobese control patients (6.9 +/- 2 minutes). Similarly, with vecuronium times for recovery from 25 to 75% were longer (33 +/- 15 minutes) in obese patients than in control patients (13.2 +/- 2 minutes), as was time to 75% recovery, 82 +/- 30 minutes in obese patients, 50 +/- 9 minutes in controls. In contrast, obese patients given atracurium (0.5 mg/kg) exhibited no difference in recovery indexes or recovery times when compared to control patients of normal weight. The prolonged duration of action of vecuronium in obese patients is most likely related to impaired hepatic clearance and/or an overdose effect with recovery occurring during the distribution phase. That the duration of action of atracurium is not prolonged in the obese is believed due to this relaxant's not depending on organ function for elimination.     

应用自体静脉套和脑细胞生长肽对面神经损伤恢复影响的临床研究

目的研究采用自体静脉管套入吻合口并注入脑细胞生长肽的方法,对面神经损伤后功能恢复的影响.方法吻合神经断端后用自体静脉管套入吻合口并注入脑细胞生长肽.分析肌电图和观察表情肌功能恢复,比较两种方法对损伤的面神经功能恢复的影响.结果自体静脉管套入吻合口并注入脑细胞生长肽的方法,比传统方法表情肌功能恢复时间明显缩短,且一期修复比二期修复功能恢复时间明显缩短,差异具有非常显著性意义(P＜0.01).两种方法修复面神经损伤,表情肌功能恢复后检测面神经传导速度差异无显著性意义(P＞0.05).结论自体静脉管套入吻合口并注入脑细胞生长肽的方法是一种比较有前途的面神经修复方法.     

Biomechanics of increased exposure to lumbar injury caused by cyclic loading. Part 2. Recovery of reflexive muscular stability with rest

STUDY DESIGN: Electromyographic responses from the lumbar multifidus muscle of the cat were recorded in vivo during 50 minutes of cyclic loading followed by 2 hours of rest. OBJECTIVE: To determine the rate of recovery of reflexive muscular stabilizing activity resulting from rest after viscoelastic laxity induced by 50 minutes of cyclic loading. SUMMARY OF BACKGROUND DATA: Muscular forces from agonists and antagonists were repeatedly shown to be the most significant stabilizing structures of the lumbar spine. Reflexive muscular coactivation force from the multifidus muscle elicited by mechanoreceptors in the spinal viscoelastic structures were, however, shown to diminish drastically with the onset of laxity in the viscoelastic structures. Data describing the rate of recovery of reflexive muscular coactivation forces resulting from rest after cyclic loading were not found. METHODS: Cyclic loading of the lumbar spine at 0.25 Hz was applied to L4-L5 for 50 minutes while electromyograms from the multifidus muscles of L1-L2 to L6-L7 were recorded. A rest period of up to 2 hours was given, during which electromyographic responses and load were measured every 10 minutes to sample recovery of laxity and reflexive muscular activity. RESULTS: Load and electromyographic response demonstrated an exponential decrease during the 50 minutes of cyclic loading. The first 10 minutes of rest allowed a significant recovery in laxity and muscle activity, with additional slow recovery over the next 20 to 30 minutes. The electromyographic response and load were increasing at an extremely slow rate thereafter. Overall, 2 hours of rest yielded only a 20% to 30% recovery in electromyographic response. Full recovery was never observed. A biexponential model was developed to predict loss and recovery of reflexive muscular activity and viscoelastic tension with laxity. CONCLUSIONS: Laxity in the viscoelastic structures of the lumbar spine desensitizes the mechanoreceptors within and causes loss of reflexive stabilizing forces from the multifidus muscles. The first 10 minutes of rest after cyclic loading results in fast partial recovery of muscular activity. However, full recovery is not possible even with rest periods twice as long as the loading period, placing the spine at an increased risk of instability, injury, and pain.     

Evaluation of a clinical recovery score after general anesthesia.

A clinical recovery score (CRS) assessing recovery after general anesthesia was compared with the Digit-Symbol Substitution Test (DSST), Trieger Test (TT), a patient-completed visual analogue scale for alertness (VAS), and an independent observer's evaluation of recovery. The CRS included ratings of the following parameters: activity, respiration, circulation, consciousness, ambulation, color, and nausea and vomiting. Forty patients requiring the removal of three or four third molars participated in the study. All patients received the same general anesthetic technique. Each patient was evaluated by the five methods preoperatively, on admission to the recovery room, and at 15-min intervals until discharge. The four recovery tests (CRS, DSST, TT, VAS) were evaluated using chi 2 analysis to determine if there was any overall difference among the tests using the observer's determination of home readiness as the standard for discharge. The CRS was significantly more in agreement with the observer's determination than were the paper and pencil tests. The recovery tests were also evaluated with regard to instances of early dismissal or prolonged retention of the patient, again using the observer's determination as the "gold standard." The CRS was the only recovery test devoid of early dismissals. We conclude that the CRS provides a valid, simple measure of recovery that can be readily used in offices providing outpatient anesthesia and in studies measuring clinical recovery from anesthesia or sedation.     

Association of fasting plasma glucose with heart rate recovery in healthy adults: a population-based study

Diabetes is associated with abnormal autonomic function and increased mortality. Abnormal heart rate recovery after exercise, a measure of autonomic dysfunction, is also associated with increased mortality. The objective of this study was to determine the association of fasting plasma glucose with abnormal heart rate recovery and its prognostic importance in healthy adults. We studied 5,190 healthy adults who did not have medically treated diabetes (mean age 45 years, 39% women), were enrolled in the Lipid Research Clinics' Prevalence Study, and underwent exercise testing. Heart rate recovery was defined as the change from peak heart rate to that after 2 min of recovery; an abnormal value was < or = 42 bpm. All-cause mortality was assessed over 12 years. A total of 504 participants (10%) had impaired fasting glucose, and 131 (3%) had untreated diabetes. An abnormal heart rate recovery was found in 1,699 (33%). Compared with participants who had normal fasting plasma glucose, abnormal heart rate recovery was more common among those with impaired fasting glucose (42 vs. 31%; relative risk, 1.34; 95% confidence interval [CI], 1.20--1.50; P < 0.0001) and those with diabetes (50 vs. 31%; relative risk, 1.61; 95% CI, 1.35--1.92; P < 0.0001). Fasting plasma glucose remained an independent predictor of abnormal heart rate recovery even after adjustment for age, sex, and other confounders (P = 0.0003). An abnormal heart rate recovery added to impaired fasting plasma glucose for the prediction of death. Fasting plasma glucose is strongly and independently associated with abnormal heart rate recovery, even at nondiabetic levels.     

Recovery of the electrocorticogram after incomplete and complete ischaemia of the brain

Summary Incomplete cerebral ischaemia of 10 to 60 minutes duration was performed by reducing the perfusion pressure of completely isolated canine heads at brain temperatures of 37 and 32 °C. Complete cerebral ischaemia of the same duration was performed by complete stopping of the perfusion. The latency of recovery of the electrocorticogram,i.e. the time interval from the end of the cerebral ischaemia until reappearance of the first spontaneous cortical potentials, was shorter after incomplete ischaemia than after complete ischaemia. At 37 °C brain temperature the latency of recovery of the electrocorticogram was zero after a perfusion of the brain with a perfusion pressure of 22 mm Hg for 1 hour. After an incomplete ischaemia of 1 hour produced by a perfusion pressure of 20 mm Hg the latency of recovery was 0 to 4 minutes. Lower perfusion pressures increased the latency of recovery considerably. Reduction of brain temperature to 32 °C decreased the latency of recovery. At perfusion pressures of 22 mm or more there was no difference in the latency of recovery between 37 and 32 °C brain temperature.     

Longitudinal quantitative measures of the natural course of low back pain recovery

STUDY DESIGN: A prospective study was developed to quantify acute low back pain recovery. OBJECTIVE: To compare traditional self-report measures of low back pain recovery with a quantitative measure of recovery. SUMMARY OF BACKGROUND DATA: The magnitude of low back disorders in society continues to be a problem. To prevent secondary injuries, an understanding of recovery must be gained by comparing the natural course of recovery using several outcome measures. METHODS: For this study, 16 occupational and 16 nonoccupational patients with low back pain were recruited. Recovery was monitored prospectively every 2 weeks for 3 to 6 months, using subjective work status, pain symptoms, activities of daily living, and objective functional performance probability (trunk kinematics). RESULTS: Return to work underestimated the percentage of subjects impaired, as compared with all other outcome measures. Symptoms, activities of daily living, and functional performance probability all showed similar patterns of recovery for 0 to 12 weeks. At 14 weeks, there was a lag in functional performance recovery. Both symptoms and activities of daily living indicated that 80% of the population was recovered, whereas functional performance indicated the figure to be 68%. CONCLUSION: This prospective study demonstrates the natural course of recovery using several outcome measures. The objective kinematic functional performance measure of recovery quantifies a different aspect of impairment not evaluated by traditional subjective measures. Use of several outcome measures may lead to a better understanding of low back pain recovery or residual impairment, which may minimize the risk of recurrent injury.     

Early recovery of urinary continence after radical prostatectomy: Correlation with vesico‐urethral anastomosis location in the pelvic cavity measured by postoperative cystography

Objectives: To determine the association of vesico‐urethral anastomosis location (VUAL) with early recovery of urinary continence (UC) after radical prostatectomy (RP). Methods: A retrospective analysis of 678 patients who underwent RP was carried out. Patients were divided into three groups based on the VUAL as determined by postoperative cystography: group I – VUAL above the upper margin of the symphysis pubis (SP), group II – between the upper margin and the middle of the SP, and group III – below the middle of the SP. Early recovery of UC was defined as using no pads or an occasional security pad within 3 months. Recovery rates were compared between the groups and factors predicting an early recovery of UC were investigated. Results: Among all patients, 62.2% achieved an early recovery of UC. Patients in group I were younger, with a longer membranous urethra, greater percent of nerve sparing and shorter time to continence than those in groups II or III. Early recovery rates were 89.5%, 69.8% and 40.7% in group I, II and III, respectively (P < 0.001). VUAL remained an independent predictor of early recovery of UC (OR 3.2 for group I vs II and 10.8 for group I vs III [P < 0.001]) when adjusted for age, operative time, membranous urethral length and operation by surgeon with high surgical volume. Conclusion: VUAL represents an independent predictor of recovery of UC after RP. A higher VUAL is associated with a higher rate of early recovery of UC.     

Length of Stay: An Inappropriate Readout of the Success of Enhanced Recovery Programs

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are designed to reduce hospital length of stay by shortening the postoperative recovery period. The intended effect of an accelerated recovery on the length of stay may be frustrated by a delayed discharge. This study was designed to assess the influence of an ERAS program on the proportion, appropriateness, and extent of delay in discharge. METHODS: Patients who enrolled in the ERAS program (n = 121) between 2003 and 2006 were compared with 52 patients who were managed traditionally in 2001. RESULTS: Ninety percent of the pre-ERAS patients and 87% of the ERAS patients were not discharged on the day that discharge criteria were fulfilled. The additional stay of 59% of the pre-ERAS patients and 69% of the ERAS patients was inappropriate. Wound care (15% in the pre-ERAS and 3% of the ERAS group) and observation of any symptoms pointing to an anastomotic leakage (10% in both groups) were the most important reasons for a medical appropriate delay of discharge. The extent of delay in discharge decreased significantly from a median of two days in the pre-ERAS group to a median of 1 day in the ERAS group (p = 0.004). CONCLUSIONS: Reductions in length of stay up to a median of 2 days after start of an enhanced recovery program may relate to changes in organization of care and not to a shorter recovery period. Recovery statistics should replace or at least be added to the length of stay as outcome of enhanced recovery programs.