The prevalence of chest compression leaning during in-hospital cardiopulmonary resuscitation

Objective

Successful resuscitation from cardiac arrest requires the delivery of high-quality chest compressions, encompassing parameters such as adequate rate, depth, and full recoil between compressions. The lack of compression recoil (“leaning” or “incomplete recoil”) has been shown to adversely affect hemodynamics in experimental arrest models, but the prevalence of leaning during actual resuscitation is poorly understood. We hypothesized that leaning varies across resuscitation events, possibly due to rescuer and/or patient characteristics and may worsen over time from rescuer fatigue during continuous chest compressions.

Methods

This was an observational clinical cohort study at one academic medical center. Data were collected from adult in-hospital and Emergency Department arrest events using monitor/defibrillators that record chest compression characteristics and provide real-time feedback.

Results

We analyzed 112,569 chest compressions from 108 arrest episodes from 5/2007 to 2/2009. Leaning was present in 98/108 (91%) cases; 12% of all compressions exhibited leaning. Leaning varied widely across cases: 41/108 (38%) of arrest episodes exhibited <5% leaning yet 20/108 (19%) demonstrated >20% compression leaning. When evaluating blocks of continuous compressions (>120 s), only 4/33 (12%) had an increase in leaning over time and 29/33 (88%) showed a decrease (p < 0.001).

Conclusions

Chest compression leaning was common during resuscitation care and exhibited a wide distribution, with most leaning within a subset of resuscitations. Leaning decreased over time during continuous chest compression blocks, suggesting that either leaning may not be a function of rescuer fatiguing, or that it may have been mitigated by automated feedback provided during resuscitation episodes.     

Family witnessed resuscitation: The views and preferences of recently resuscitated hospital inpatients, compared to matched controls without the experience of resuscitation survival

Aim of the study

To compare the preferences of patients who survived resuscitation with those admitted as emergency cases about whether family members should be present during resuscitation.

Methods

We used a case control design and recruited, from four large hospitals, 21 survivors of resuscitation and 40 patients admitted as emergency cases without the experience of resuscitation (control group) who were matched by age and gender at a ratio of 1:2. Data collection involved face-to-face interviews using a standardised 22 item questionnaire. Data analysis sought to identify differences between the two groups.

Results

Both groups were broadly supportive of the practice, however resuscitated patients were more likely to favour witnessing the resuscitation of a family member (72% versus 58%), preferred to have a relative present in the event they required resuscitation (67% versus 50%) and believed that relatives benefited from such an experience (67% versus 48%). Additionally, both groups indicated that staff should seek patient preferences about family witnessed resuscitation following hospital admission, and stated that they were unconcerned about confidential matters being discussed with family members present during resuscitation (91% and 75%, respectively). However none of these differences between the two groups achieved statistical significance.

Conclusion

Hospitalised patients report a favourable disposition towards family witnessed resuscitation, and this view appears to be strengthened by successfully surviving a resuscitation episode. Practitioners should strive to facilitate family witnessed resuscitation by establishing, documenting and enacting patient preferences. Research exploring the perceptions of the wider public would help further inform this debate.     

Paediatric resuscitation training--do medical students believe it should be a mandatory component of the curriculum?

Background

Resuscitation outcomes are related to care delivered by ‘first responders’, even for hospitalized patients. Third year medical students (clinical clerks) at McGill University are trained and certified in Advanced Cardiac Life Support (ACLS) for critically ill adult patients, but receive only minimal instruction, in the form of a brief introductory lecture, on paediatric life support.

Methods

We developed an interactive, case-based 4-h Paediatric Resuscitation Course based on the objectives and teaching methods of the Pediatric Advanced Life Support (PALS) course. Objectives were tailored to an appropriate level for medical students through the consensus of the two content-expert authors and two external expert physician-educators.Students completed equivalent pre and post course multiple-choice exams, using questions selected from the PALS course. In order to minimize ‘guessing’, subjects were penalized for incorrect answers. Upon completion of the course, students were anonymously surveyed on the perceived educational value of the resuscitation course.

Results

49 subjects voluntarily participated, in groups of 6-8 at a time, with 47 subjects completing the study protocol. Students’ test scores significantly increased from the pre to post test (12.65/22 vs. 17.70/22; p < 0.001). All students believed the course was delivered at an appropriate level for them, that it was a worthwhile use of their time, and that it should be a mandatory course in their clinical clerkship.

Conclusion

Medical students can learn from appropriately designed paediatric resuscitation courses and believe it should be mandatory in their training.     

The LA story: What happened after a new policy allowing paramedics to forgo resuscitation attempts in prehospital cardiac arrest

Background

Despite potential harm to patients, families, and emergency personnel, a low survival rate, and high costs and intensity of care, attempting resuscitation after prehospital cardiac arrest is the norm, unless there are signs of irreversible death or the presence of a valid, state-issued DNR.

Objective

To determine whether there was a change in the rate of forgoing resuscitation attempts in prehospital cardiac arrest after implementation of a new policy allowing paramedics to forgo resuscitation based on a verbal family request or the presence of certain arrest characteristics.

Methods and results

All prehospital run sheets for cardiac arrest in Los Angeles County were reviewed for the first seven days of each month August 2006-January 2007 (pre-policy) and January-June 2008 (post-policy). Paramedics were more likely to forgo resuscitation attempts after the policy change (13.3% vs. 8.5%, p < 0.01). In addition, the percentage of patients with documented signs of irreversible death decreased post-policy, from 50.4% to 35.8%, p < 0.01. After adjustment for potential confounders (patient demographics, clinical characteristics and EMS factors), as well as exclusion of patients with signs of irreversible death, paramedics are significantly more likely to forgo a resuscitation, and less likely to attempt resuscitation, after the policy change (OR 1.67 [95% CI 1.07, 2.61], p = 0.024).

Conclusions

Paramedics are more likely to forgo, and less likely to attempt, resuscitation in victims of cardiac arrest after implementation of a new policy. There was also an associated decrease in the percentage of patients who had signs of irreversible death, which might reflect a change in paramedic behavior.     

Examining the contextual effects of neighborhood on out-of-hospital cardiac arrest and the provision of bystander cardiopulmonary resuscitation

Objective

To understand the association between neighborhood and individual characteristics in determining whether or not bystanders perform cardiopulmonary resuscitation (CPR) in cases of out-of-hospital cardiac arrest (OHCA).

Methods

Between October 1, 2005 to November 30, 2008, 1108 OHCA cases from Fulton County (Atlanta), GA, were eligible for bystander CPR. We conducted multi-level non-linear regression analysis and derived Empirical Bayes estimates for bystander CPR by census tract.

Results

279 (25%) cardiac arrest victims received bystander CPR. Provision of bystander CPR was significantly more common in witnessed events (odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21-2.22, p < 0.001) and those that occurred in public locations (OR 1.67; 95% CI 1.16-2.40, p < 0.001). Other individual-level characteristics were not significantly associated with bystander CPR. Cardiac arrests in the census tracts that rank in the highest income quintile, as compared to the lowest income quintile were much more likely (OR 4.98; 95% CI 1.65-15.04) to receive bystander CPR.

Conclusion

Cardiac arrest victims in the highest income census tracts were much more likely to receive bystander CPR than in the lowest income census tracts, even after controlling for individual and arrest characteristics. Low-income neighborhoods may be particularly appropriate targets for community-based CPR training and awareness efforts.     

Assessing the impact of immersive simulation on clinical performance during actual in-hospital cardiac arrest with CPR-sensing technology: A randomized feasibility study

Aim

Advanced simulation tools are increasingly being incorporated into cardiopulmonary resuscitation (CPR) training. These educational methods have been shown to improve trainee performance in simulated settings, but translation into clinical practice remains unknown for many aspects of CPR quality. This study attempts to measure the impact of simulation-based training for resuscitation team leaders on some measures of CPR quality during actual in-hospital resuscitation attempts.

Methods

In this prospective, randomized interventional cluster trial, internal medicine resident physicians (post-graduate year 2) were randomized using a random number generator to participate in a 4-h, immersive simulation course in cardiopulmonary resuscitation leadership using a high-fidelity simulator with video debriefing prior to serving as resuscitation team leaders at an academic medical center. Objective metrics of actual resuscitation performance were obtained from a CPR-sensing monitor/defibrillator.

Results

Thirty-two residents were randomized to receive simulation training or no additional training between April and July 2007 and data were collected following 98 actual resuscitations between July 2007 and June 2008. CPR quality from resuscitations led by 14 simulation-trained and 16 control group residents was similar in terms of mean compression depth (48 vs 49 mm; p = 0.53); compression rate (107 vs 104 min⁻¹; p = 0.30); ventilation rate (12 vs 12 min⁻¹; p = 0.45) and no-flow fraction (0.08 vs 0.07; p = 0.34).

Conclusions

Although we failed to detect any significant differences in objective measures of CPR quality, we have demonstrated that CPR-sensing technology has the potential for use in assessing the impact of a simulation curriculum on some aspects of actual resuscitation performance. A larger study, performed in a setting with lower baseline performance, would be required to assess the specific simulation curriculum.     

Parents’ and health professionals’ perceptions of family centred care for children in hospital, in developed and developing countries: A review of the literature

Background

In paediatrics family centred care (FCC) is a widely used model of care that is believed to help meet the emotional, psychological and developmental needs of the hospitalized child. However, perceptions of the effectiveness of the operationalization of FCC in terms of meeting family needs are varied.

Objectives

The aim of this review was to explore the attitudes towards and experiences of FCC by healthcare professionals and parents during the hospitalization of a child.

Design

A comprehensive search of the literature was undertaken drawing principally on key electronic databases of the health literature, augmented with reference list searching.

Data sources

: English language publications indexed in CINAHL, EMBASE, The Cochrane Database of Systematic Reviews, AMED, MEDLINE and PsycINFO published from 1997 to 2009.

Review methods

: Two review authors independently undertook the searches and two to three authors independently assessed trial quality, family centeredness, data extraction and thematic synthesis. Fifteen studies were reviewed.

Results

Four themes emerged from the literature on communication, healthcare professional and parent relationships, caring for parents and available resources. The differences, similarities and interpretation between healthcare professionals’ and parents’ perspectives on these themes are reported.

Conclusion

The effectiveness of FCC can often depend on individual demographic characteristics of the child, parent and healthcare professional. A broad spectrum of variability exists in the perceptions of healthcare professionals and parents on parental needs and FCC within a hospital context.     

Sex differences in cardiac injury after severe haemorrhage and ventricular fibrillation in pigs

Aim of the study

Experimental studies have shown sex differences in haemodynamic response and outcome after trauma and haemorrhagic shock. We recently reported that female sex protects against cerebral injury after exsanguination cardiac arrest (CA), independent of sexual effects of hormones. The current study examines if female sex is also cardioprotective.

Methods

In this study 21 sexually immature piglets (12 males and 9 females) were subjected to 5 min of haemorrhagic shock followed by 2 min of ventricular fibrillation and 8 min of cardiopulmonary resuscitation (CPR). Volume resuscitation was started during CPR with intravenous administration of 3 ml kg⁻¹ hypertonic saline-dextran (HSD) solution for 20 min. Sexually immature animals were used to differentiate innate sex differences from the effects of sexual hormones. Sex differences in haemodynamics, myocardial injury (troponin I), and short-term survival (3-h) were evaluated.

Results

After resuscitation female animals had a higher blood pressure, lower heart rate, lower troponin I concentrations, and higher survival rate (100% and 63% in 3 h) despite comparable sex hormone levels.

Conclusions

After resuscitation from haemorrhage and circulatory arrest, haemodynamic parameters are better preserved and myocardial injury is smaller in female piglets. This difference in outcome is independent of sexual hormones.     

Educational impact of a hospital-based neonatal resuscitation program in Ghana

Aim of the study

To assess midwives’ baseline cognitive knowledge of evidence-based neonatal resuscitation practices, and short- and long-term educational effects of teaching a neonatal resuscitation program in a hospital setting in West Africa.

Methods

All midwives (n = 14) on the labor ward at Ridge Hospital in Ghana were trained using materials modified from the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP). This training program included didactic and practical teaching and was assessed by direct observation within delivery rooms and written pre- and post-test evaluations. Written and practical modules 9-12 months after the initial training session were also conducted to assess retention of NRP knowledge and skills.

Results

Fourteen midwives received NRP training on the labor ward. Both written and practical evaluation of neonatal resuscitation skills increased after training. The percentage of items answered correctly on the written examination increased from 56% pre-training to 71% post-training (p < 0.01). The percentage of items performed correctly on the practical evaluation of skills increased from 58% pre-training to 81% (p < 0.01). These results were sustained 9-12 months after the initial training session.

Conclusion

After receiving NRP training, neonatal resuscitation knowledge and skills increased among midwives in a hospital in West Africa and were sustained over a 9-month period. This finding demonstrates the sustained effectiveness of a modified neonatal resuscitation training program in a resource constrained setting.     

A narrative review of interventions to support family carers who provide physical care to family members with cancer

Objectives

Most reports of cancer caregivers’ needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer.

Design

Narrative review.

Data sources

Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews.

Review methods

All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied.

Results

In total, 19 studies were included in the review. Interventions focused on skills development (n = 1), managing symptoms (n = 9), problem solving (n = 5) and learning (n = 4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer.

Conclusions

Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.     

Quality of closed chest compression on a manikin in ambulance vehicles and flying helicopters with a real time automated feedback

Context

Automated verbal and visual feedback improves quality of resuscitation in out-of-hospital cardiac arrest and was proven to increase short-term survival. Quality of resuscitation may be hampered in more difficult situations like emergency transportation. Currently there is no evidence if feedback devices can improve resuscitation quality during different modes of transportation.

Objective

To assess the effect of real time automated feedback on the quality of resuscitation in an emergency transportation setting.

Design

Randomised cross-over trial.

Setting

Medical University of Vienna, Vienna Municipal Ambulance Service and Helicopter Emergency Medical Service Unit (Christophorus Flugrettungsverein) in September 2007.

Participants

European Resuscitation Council (ERC) certified health care professionals performing CPR in a flying helicopter and in a moving ambulance vehicle on a manikin with human-like chest properties.

Interventions

CPR sessions, with real time automated feedback as the intervention and standard CPR without feedback as control.

Main outcome measures

Quality of chest compression during resuscitation.

Results

Feedback resulted in less deviation from ideal compression rate 100 min⁻¹ (9 ± 9 min⁻¹, p < 0.0001) with this effect becoming steadily larger over time. Applied work was less in the feedback group compared to controls (373 ± 448 cm × compression; p < 0.001). Feedback did not influence ideal compression depth significantly. There was some indication of a learning effect of the feedback device.

Conclusions

Real time automated feedback improves certain aspects of CPR quality in flying helicopters and moving ambulance vehicles. The effect of feedback guidance was most pronounced for chest compression rate.     

Monitoring in resuscitation: Comparison of cardiac output measurement between pulmonary artery catheter and NICO

Aim

The cardiac output and coronary perfusion pressure generated from chest compressions during resuscitation manoeuvres can predict effectiveness and successful outcome. Until now, there is no good method for haemodynamic monitoring during resuscitation. Noninvasive partial carbon dioxide rebreathing system (NICO, Novametrix Medical Systems, Inc., Wallingford, CT, USA) is a relatively new non-invasive alternative to thermodilution for measuring cardiac output. The accuracy of the NICO system has not been evaluated during resuscitation. The aim of this study is to compare thermodilution cardiac output method with NICO system and to assess the utility of NICO during resuscitation.

Methods and design

Experimental study in 24 Yorkshire pigs.Paired measurements of cardiac output were determined during resuscitation (before ventricular fibrillation and after 5, 15, 30 and 45 min of resuscitation) in the supine position. The average of 3 consecutive thermodilution cardiac output measurements (10 ml 20 °C saline) was compared with the corresponding NICO measurement.

Results

Bland and Altman plot and Lin's concordance coefficient showed a high correlation between NICO and thermodilution cardiac output measurements although NICO has a tendency to underestimate cardiac output when compared to thermodilution at normal values of cardiac output.

Conclusions

There is a high degree of agreement between cardiac output measurements obtained with NICO and thermodilution cardiac output during resuscitation.The present study suggests that the NICO system may be useful to measure cardiac output generated during cardiopulmonary resuscitation.     

The effect of basic life support education on laypersons’ willingness in performing bystander hands only cardiopulmonary resuscitation

Background

Recently, hands only CPR (cardiopulmonary resuscitation) has been proposed as an alternative to standard CPR for bystanders. The present study was performed to identify the effect of basic life support (BLS) training on laypersons’ willingness in performing standard CPR and hands only CPR.

Methods

The participants for this study were non-medical personnel who applied for BLS training program that took place in 7 university hospitals in and around Korea for 6 months. Before and after BLS training, all the participants were given questionnaires for bystander CPR, and 890 respondents were included in the final analyses.

Results

Self-assessed confidence score for bystander CPR, using a visual analogue scale from 0 to 100, increased from 51.5 ± 30.0 before BLS training to 87.0 ± 13.7 after the training with statistical significance (p 0.001). Before the training, 19% of respondents reported willingness to perform standard CPR on a stranger, and 30.1% to perform hands only CPR. After the training, this increased to 56.7% of respondents reporting willingness to perform standard CPR, and 71.9%, hands only CPR, on strangers. Before and after BLS training, the odds ratio of willingness to perform hands only CPR versus standard CPR were 1.8 (95% CI 1.5-2.3) and 2.0 (95% CI 1.7-2.6) for a stranger, respectively. Most of the respondents, who reported they would decline to perform standard CPR, stated that fear of liability and fear of disease transmission were deciding factors after the BLS training.

Conclusions

The BLS training increases laypersons’ confidence and willingness to perform bystander CPR on a stranger. However, laypersons are more willing to perform hands only CPR rather than to perform standard CPR on a stranger regardless of the BLS training.     

Differential effects of ageing and BLS training experience on attitude towards basic life support

Purpose of study

To determine the effects of ageing and training experience on attitude towards performing basic life support (BLS).

Methods

We gave a questionnaire to attendants of the courses for BLS or safe driving in authorised driving schools. The questionnaire included questions about participants’ backgrounds. The questionnaire explored the participant's willingness to perform BLS in four hypothetical scenarios related to early emergency call, cardiopulmonary resuscitation (CPR) under their own initiative, telephone-assisted compression-only CPR and use of an automated external defibrillator (AED), respectively.

Results

There were significant differences in gender, occupation, residential area, experience of BLS training, and knowledge of AED use among the young (17-29 y, N = 6122), middle-aged (30-59 y, N = 827) and elderly (>59 y, N = 15,743) groups. In all four scenarios, the proportion of respondents willing to perform BLS was lowest in the elderly group. More respondents in the elderly group were willing to follow the telephone-assisted instruction rather than performing CPR under their own initiative. Multiple logistic regression analysis confirmed ageing as an independent factor related to negative attitude in all scenarios. Gender, occupation, resident area, experience with BLS training and knowledge about AED use were other independent factors. Prior BLS training did not increase willingness to make an emergency call.

Conclusion

The aged population has a more negative attitude towards performing BLS. BLS training should be modified to help the elderly gain confidence with the essential elements of BLS, including making early emergency calls.     

Good outcome in every fourth resuscitation attempt is achievable--an Utstein template report from the Stavanger region

Aim of the study

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the western world. We wanted to study changes in survival over time and factors linked to this in a region which have already reported high survival rates.

Methods

We used a prospectively collected Utstein template database to identify all resuscitation attempts in adult patients with OHCA of presumed cardiac origin. We included 846 resuscitation attempts and compared survival to discharge with good outcome in two time periods (2001-2005 vs. 2006-2008).

Results

We found no significant differences between the two time periods for mean age (71 and 70 years (p = 0.309)), sex distribution (males 70% and 71% (p = 0.708)), location of the OHCA (home 64% and 63% (p = 0.732)), proportion of shockable rhythms (44% and 47% (p = 0.261)) and rate of return of spontaneous circulation (38% and 43% (p = 0.136)), respectively. Bystander cardiopulmonary resuscitation (CPR), however, increased significantly from 60% to 73% (p < 0.0001), as did the overall rate of survival to discharge from 18% to 25% (p = 0.018). In patients with a shockable first rhythm, rate of survival to discharge increased significantly from 37% to 48% (p = 0.036). In witnessed arrest with shockable rhythm survival to discharge increased from 37% to 52% (p = 0.0105).

Conclusion

Overall, good outcome is now achievable in every fourth resuscitation attempt and in every second resuscitation attempt when patients have a shockable rhythm. The reason for the better outcomes is most likely multi-factorial and linked to improvements in the local chain of survival.     

Comparison of the efficacy of nifekalant and amiodarone in a porcine model of cardiac arrest

Objective

To compare the efficacy of nifekalant and amiodarone in the treatment of cardiac arrest in a porcine model.

Methods

After 4 min of untreated ventricular fibrillation, animals were randomly treated with nifekalant (2 mg kg⁻¹), amiodarone (5 mg kg⁻¹) or saline placebo (n = 12 pigs per group). Precordial compression and ventilation were initiated after drug administration and defibrillation was attempted 2 min later. Hemodynamics were continuously measured for 6 h after successful resuscitation.

Results

Compared with saline, nifekalant and amiodarone equally decreased the number of electric shocks, defibrillation energy, epinephrine dose, and duration of cardiopulmonary resuscitation required for successful resuscitation (P < 0.01). The incidence of restoration of spontaneous circulation (ROSC) and the 24-h survival rate were higher in both antiarrhythmic drug groups (P < 0.05) vs. the saline group. Furthermore, post-resuscitation myocardial dysfunction at 4-6 h after successful resuscitation was improved in animals given antiarrhythmic drugs as compared with the saline group (P < 0.05). There were no differences between nifekalant and amiodarone for any of these parameters.

Conclusion

The effect of nifekalant was similar to that of amiodarone for improving defibrillation efficacy and for the treatment of cardiac arrest. Administration of either nifekalant or amiodarone before defibrillation increased the ROSC and 24-h survival rates and improved post-resuscitation cardiac function in this porcine model.     

Comparative impact of 2 botulinum toxin injection techniques for elbow flexor hypertonia

Mayer NH, Whyte J, Wannstedt G, Ellis CA. Comparative impact of 2 botulinum toxin injection techniques for elbow flexor hypertonia.

Objective

To compare 2 techniques of botulinum toxin injection for elbow flexor hypertonia.

Design

Parallel-group, randomized, controlled trial with blinded outcome assessment.

Setting

Laboratory, tertiary rehabilitation hospital.

Participants

Adults (N=31) with acquired brain injury (21 with traumatic brain injury, 8 with stroke, 2 with hypoxic encephalopathy) provided 36 sets of elbow flexors with Ashworth Scale scores equal to 3.

Intervention

Botulinum toxin type A (BTX-A) was injected with a motor point or a multisite injection technique after obtaining 2 baseline evaluations of the main outcome measures. Motor point technique involved decremental electric stimulation with delivery of 60U of BTX-A (Botox) in 2.4mL or 30U BTX-A in 1.2mL of preservative-free saline at single biceps and brachioradialis motor points, respectively. Distributed injection was performed using electromyographic feedback. Fifteen units in 0.6mL were delivered to each of 4 biceps sites and 2 brachioradialis sites. Total dose (90U) and total injection volume (3.6mL) were identical across groups. Only sites and injection techniques varied. The brachialis was not injected in either group.

Main Outcome Measures

Ashworth Scale, Tardieu catch angle, and root mean square surface electromyographic activity of the biceps, brachialis, and brachioradialis.

Results

Postintervention testing at 3 weeks showed no significant differences between groups (P range, .31-.82 across 3 outcome measures). However, within each group, significant treatment effects were observed on all outcome measures (all P<.01). For the uninjected brachialis muscle, electromyographic reduction was greater for the distributed group.

Conclusions

In 31 adults with acquired brain injury, single motor point and multisite distributed injections of low-dose, high-volume BTX-A had similar impact. Findings suggest that low-dose, high-volume strategies may have a potential role in reducing drug cost and helping clinicians stay within accepted limits for total body dose in patients with upper motoneuron syndrome requiring many injections.