The late sequelae of poliomyelitis

Progressive functional deterioration following poliomyelitis has been reported after a prolonged period of stability. We present follow up data on 209 patients; the period from the original illness to December 1985 or death was between two and 73 years (mean 33.9). One hundred and sixty-three (78 per cent) patients developed late functional deterioration. This was due to purely respiratory factors in 99 cases, new neurological signs in 20 cases, and orthopaedic problems in 17 cases; 31 patients deteriorated due to a combination of factors. The commonest cause of respiratory deterioration was the development of nocturnal alveolar hypoventilation, sometimes associated with late progressive scoliosis. Eighty-six patients needed respiratory support beginning between one year and 66 years (mean 28.5) after the acute illness. New neurological signs had a clearly defined cause in each of 20 patients. No cases of motor neurone disease or post-poliomyelitis muscular atrophy (PPMA) were identified. This series shows that late sequelae following poliomyelitis are common. There were no patients with functional deterioration after poliomyelitis in whom a clear underlying cause could not be shown. The major causes of deterioration may be treatable or avoidable, and in particular, those who develop chest infections or new respiratory symptoms should be treated with caution as respiratory failure may rapidly supervene.     

The Late Sequelae of Poliomyelitis

SUMMARY Progressive functional deterioration following poliomyelitishas been reported after a prolonged period of stability. Wepresent follow up data on 209 patients; the period from theoriginal illness to December 1985 or death was between two and73 years (mean 33.9). One hundred and sixty-three (78 per cent) patients developedlate functional deterioration. This was due to purely respiratoryfactors in 99 cases, new neurological signs in 20 cases, andorthopaedic problems in 17 cases; 31 patients deteriorated dueto a combination of factors. The commonest cause of respiratorydeterioration was the development of nocturnal alveolar hypo-ventilation,sometimes associated with late progressive scoliosis. Eighty-sixpatients needed respiratory support beginning between one yearand 66 years (mean 28.5) after the acute illness. New neurologicalsigns had a clearly defined cause in each of 20 patients. Nocases of motor neurone disease or post-poliomyelitis muscularatrophy (PPMA) were identified. This series shows that late sequelae following poliomyelitisare common. There were no patients with functional deteriorationafter poliomyelitis in whom a clear underlying cause could notbe shown. The major causes of deterioration may be treatableor avoidable, and in particular, those who develop chest infectionsor new respiratory symptoms should be treated with caution asrespiratory failure may rapidly supervene.     

Life-long morbidity among Danes with poliomyelitis

OBJECTIVE: To estimate long-term morbidity in a cohort of Danish poliomyelitis patients. DESIGN: A historical prospective cohort study of 27,047 persons. SETTING: Denmark. PARTICIPANTS: A total of 5421 persons hospitalized for poliomyelitis between 1919 to 1954 in Copenhagen, Denmark, and 21,626 age- and gender-matched Danes. Participants were followed up on average for 20.6 years, yielding a total of 555,884 person-years of follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The exposed (poliomyelitis) cohort and the unexposed (control) cohort were followed up for somatic hospitalization from 1977 to 1999 in the Danish Hospital Discharge Register. The incidence rate ratio (IRR) was calculated as the ratio between the incidence rate of disease in the exposed and unexposed cohorts. RESULTS: Overall, polio patients had a 1.2- to 1.3-fold increased risk of being hospitalized with pulmonary diseases, heart diseases, gastrointestinal disorders, or diseases of the locomotive apparatus. Among paralytic polio patients, long-term morbidity seems to be associated with the acute severity of poliomyelitis, as well as young age at infection. Paralytic patients, who contracted respiratory polio under the age of 5, had the highest risk of being hospitalized with lung diseases (IRR=7.26; 95% confidence interval [CI], 3.06-18.33), diseases of the locomotive apparatus (IRR=4.05; 95% CI, 1.66-9.86), heart diseases (IRR=1.70; 95% CI, 0.65-3.98), and diseases of the digestive system (IRR= 2.23; 95% CI, 1.03-4.62). Surprisingly, patients without paralyses, especially women, also had an increased morbidity. CONCLUSIONS: Overall, a history of poliomyelitis was associated with a slightly increased morbidity measured by hospitalizations. Long-term morbidity was highest among respiratory polio patients; however, patients presumably left without any residual symptoms also had an increased morbidity.     

Children with paralytic poliomyelitis: Utilization of physiotherapy services in Zamfara State,Nigeria

Physiotherapy is usually indicated for health promotion and the rehabilitation of individuals with paralytic poliomyelitis. The endemic nature of this condition in children in Zamfara State, Nigeria necessitated investigation into the utilization of physiotherapy services by parents or primary caregivers of children affected with polio in this sub-region. Parents and primary caregivers of children with paralytic poliomyelitis were recruited using a purposive multi-stage sampling procedure in a cross-sectional survey. Factors associated with the utilization of physiotherapy services were assessed based on questions extracted from a 4-part, 52-item structured questionnaire originally designed for a study which investigated knowledge, attitude, and beliefs of parents of children with paralytic poliomyelitis. A total of 217 participants were included in this study. The mean age was 32.29?±?9.89 years and the mean knowledge of polio score was 62.0?±?17.3%. The mean age of the children with paralytic poliomyelitis was 6.41?±?2.50 years. Only 27.2% of the parents or primary caregivers had utilized physiotherapy service for their children at some point. No association existed between utilization of physiotherapy service and ‘knowledge of paralytic poliomyelitis’, ‘employment status’, and ‘family income’ of respondents. Explanations for low utilization of physiotherapy services for children with paralytic poliomyelitis by parents or primary caregivers are discussed.     

Use of the rocking bed in the treatment of neurogenic respiratory insufficiency

We describe 53 patients who received ventilatory support witha rocking bed. Diagnoses included previous poliomyelitis (30),muscular dystrophy (12), motor neurone disease (4), adult-onsetacid maltose deficiency (4) and a miscellaneous group (3). Patientspresented with respiratory insufficiency characterized by diaphragmweakness, progressive nocturnal hypoventilation and/or acuteor chronic respiratory failure. Domiciliary rocking beds wereused by 43 patients for a mean of 16.0 years (range 1 monthto 35 years). Most patients were able to breathe adequatelyby day when sitting or standing, but needed assistance by rockingbed for 6–11 h when lying down for sleep. The rockingbed was well-tolerated, and associated with both symptomaticrelief and amelioration of arterial blood gas abnormalities.Seventeen of these 43 patients discontinued its use, eitherbecause of discomfort (9) or increasing respiratory insufficiency(8). The rocking bed is a valuable adjunct in the managementof the respiratory insufficiency associated with neuro-musculardisease.     

Upper-limb pain in long-term poliomyelitis

BACKGROUND: Late functional deterioration is common in long-term poliomyelitis patients. While upper-limb pain in individual functional regions is common, its overall prevalence and pattern in long-term poliomyelitis is poorly documented. Aim: To assess the nature of upper-limb pain in these patients and examine its association with dependence on mobility aids (and therefore upper limb 'overuse'). DESIGN: Questionnaire-based survey of patients attending a specialist unit. METHODS: Questionnaires were sent to 139 patients with known long-term poliomyelitis (mean 49.8 years post polio), attending the Lane Fox Unit out-patient clinic at St Thomas' Hospital between January 1998 and December 1998. There were questions on the nature of the patient's acute illness, limb involvement at initial infection ('polio-affected' limbs), the site and onset of upper-limb pain, hand dominance, previous injuries and surgery, and the use of mobility aids. Limbs that had sustained an injury or undergone surgery, at or preceding onset of upper-limb pain, were excluded from analysis. RESULTS: Among 103 valid replies, the prevalence of upper limb pain was 64%. Mobility aids were used by 74%, and were associated with an increased risk of upper-limb pain, while 'polio-affected' limbs were at reduced risk. DISCUSSION: These data support 'overuse' due to greater mobility aid dependence as a cause of increasing upper-limb pain in long-term poliomyelitis.     

Influence of the prospective payment system on speech-language pathology services

OBJECTIVE: The present study was performed to determine the clinical effects of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) on speech and language intervention services and to examine the feasibility of using the federally mandated FIM instrument to establish resource allocation to patients with cognitive, communication, and swallowing disorders. DESIGN: A pre-IRF PPS and post-IRF PPS comparative study was conducted over a 1-yr time interval using data from the American Speech-Language-Hearing Association's National Outcomes Measurement System. Toward this end, the National Outcomes Measurement System's Functional Communication Measures were used to obtain data from 2,631 patients residing in 96 freestanding rehabilitation hospitals or hospitals with rehabilitation units implementing the prospective payment system on or after January 1, 2002. To ensure reliable retrospective and prospective data comparisons, all sites were active participants within the National Outcomes Measurement System program before the introduction of IRF PPS within their facilities. RESULTS: Findings revealed changes in both the utilization of speech-language pathologists and patient outcomes. Under the IRF PPS, there was a clear decline in speech- and language-related lengths of stay. However, clinicians attempted to compensate for these decrements in lengths of stay by increasing the intensity and frequency of their speech and language services. Despite these compensatory efforts, further analyses of the data revealed that under the IRF PPS, fewer patients achieved multiple levels of functional progress in speech and language abilities than before this payment system was implemented. This trend was most noteworthy in the treatment areas of swallowing, motor speech, and memory. In addition, this study revealed that, compared with the National Outcomes Measurement System's Functional Communication Measures, the FIM instrument significantly under-represented and undervalued the extent of a patient's overall progress in recovering from their cognitive, communication, or swallowing disabilities. CONCLUSION: These findings support the notion that the introduction of the IRF PPS has, perhaps unintentionally, caused more patients with cognitive, communication, and swallowing disorders to be discharged from inpatient rehabilitative care with less than adequate functional skill levels. The discouraging results in speech-language pathology utilization and patient outcomes will be useful for clinicians in the future when facing the ongoing challenges of maintaining quality care while streamlining services under the prospective payment system.     

Paralytic poliomyelitis: Quality of life of adolescent survivors

Polio survivors are prone to secondary health problems that may negatively affect their quality of life (QoL), but the impact of paralytic poliomyelitis on QoL of its Nigerian survivors has not been reported in literature. We investigated and compared the QoL of Nigerian paralytic polio survivors (PPS) and age- and sex-matched apparently healthy controls (AHC). Seventy-three (45 males and 28 female) consecutive adolescent PPS and an equal number of AHC participated in the cross-sectional survey. Participants' QoL was assessed using the Comprehensive Quality of Life Scale—Adolescent. Data were analyzed with Mann-Whitney U-test and two-sample t-test at the 0.05 alpha level. There were no significant differences between the ages of PPS (14.16 ± 2.01 years) and AHC (14.18 ± 2.02 years), and between the ages of male (13.93 ± 2.16 years) and female PPS (14.30 ± 2.02 years). Polio survivors scored significantly lower than AHC in health, productivity, community, emotion and spiritual domains, and overall QoL. The PPS scored significantly higher (p < 0.001) on the subjective than objective axis in five of the seven domains of Comprehensive Quality of Life Scale—Adolescent. Paralytic polio has a significant impact on health, productivity, community, and emotion domains of QoL, hence the need for interventions targeting identified affected domains to enhance polio survivors' QoL.     

The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes

OBJECTIVE: To examine the impact of the Medicare inpatient rehabilitation facility (IRF) prospective payment system (PPS) on outcomes in a stroke rehabilitation program. DESIGN: An analysis was performed on a database including 945 stroke patients admitted to an inpatient stroke rehabilitation program 5 yrs before implementation of the IRF PPS and 3.5 yrs after implementation. Patients were classified with regard to stroke location (left vs. right), level of cognitive impairment, presence/absence of unilateral neglect, and level of depressive symptomatology. Functional status was evaluated at time of admission and discharge by functional independence measure (FIM). Other outcome measures included length of stay (LOS) and discharge destination. The impact of IRF PPS on LOS, progress in rehabilitation, and discharge destination was examined via univariate analyses of covariance and logistic regression. RESULTS: Patients admitted after implementation of the IRF PPS had shorter LOS but made less progress, had lower functional levels at discharge, and had higher rates of institutional discharge. CONCLUSIONS: Although associated with decreased LOS, implementation of the IRF PPS was associated with decreased functional gains, lower discharge FIM levels, and higher rates of institutional discharge. Cost savings associated with the PPS must be considered in light of these untoward outcomes.     

Carbapenemase-producing Enterobacteriaceae in an inpatient post-acute care facility: Impact on time to functional recovery

BackgroundThe carriage of carbapenemase-producing Enterobacteriaceae (CPE) might lengthen the time to functional recovery (TTFR) for inpatients in post-acute care (PAC) units.ObjectiveWe aimed to assess the impact of CPE carriage on TTFR in a PAC facility.MethodsThis 2-year retrospective cohort study included 20 CPE-positive patients and 54 CPE-negative patients admitted to 3 PAC units (general, orthopaedic and neurological rehabilitation units) in a teaching hospital from January 2017 to December 2019. Potential risk factors and demographic data were collected from patients’ medical records, the French national hospital discharge database, and the hospital's CPE surveillance database. Functional recovery was defined as the median difference in functional independence measure (FIM) between admission and discharge from each unit. Survival analysis and multiple Cox regression models were used to predict the TTFR and identify factors associated with functional recovery.ResultsThe overall median [interquartile range] TTFR was 50 days [36–66]. Longer median TTFR was associated with CPE carriage (63 vs 47 days in the CPE-negative group; adjusted hazard ratio (aHR) 0.35, 95% CI 0.13–0.97) and presence of a peripheral venous catheter (aHR 3.51, 1.45–8.46); shorter TTFR was associated with admission to an orthopaedic versus general rehabilitation unit (aHR 3.11, 1.24–7.82).ConclusionsCPE carriage in inpatient PAC facilities was associated with long TTFR. Further studies are needed to explore the mechanisms involved in these adverse events and to identify possible preventive measures.     

Long-standing poliomyelitis and psychological health

Abstract

Objective: To compare the psychological health of the individuals with long-standing poliomyelitis, with or without post-polio syndrome (PPS), to the general population and to identify the role of work as well as other variables with regard to their psychological health. Design: A cross-sectional study. Subjects: One hundred and ninety-five polio patients attending postpolio clinic in Jerusalem. Methods: Emotional distress (ED) was measured using the general health questionnaire (GHQ-12). Demographic, medical, social and functional data were recorded using a specific structured questionnaire. Each polio patient was compared to four age- and sex-matched controls. Results: ED was higher in the polio population as compared to the general population. Within the polio population ED was inversely correlated with work status. No correlation was found between ED and the functional level of polio participants and no difference was found in GHQ score between polio participants with or without post-polio. In addition, ED was less affected by subjective perception of physical health among polio patients as compared to the general population. Conclusions: Long-standing poliomyelitis is associated with decreased psychological health as compared to the general population. Yet, the resilience of polio survivors is manifested by their ability to block further decline of their psychological health in spite of deterioration in their physical health. Work appears as a significant source of resilience in the polio population.

• Implications for Rehabilitation

• Individuals with long-standing poliomyelitis often suffer from high emotional distress and may benefit from psychotherapy aimed at reducing distress.

• As active employment status is associated with increased mental health among polio survivors, encouraging participation at work needs to be a significant component of psychotherapeutic programs.

• Polio survivors, although physically disabled, may be relatively resilient, as their mental health is less affected by their negative health perception. This and other expressions of resilience may serve as a platform for increasing personal growth among them by implementing hope-oriented psychotherapy.

     

An epidemic of paralytic poliomyelitis characterized by dual infections with poliomyelitis and Coxsackie viruses

The first known epidemic of poliomyelitis in Easton, Pennsylvania, occurred in 1949, and was unusual in the high proportion of paralytic to non-paralytic cases. Both poliomyelitis and Cosxackie, or C, viruses were isolated from more than half the patients studied during the acute stage of the disease. One month later C virus was only occasionally recovered. Classification of the 28 strains of C virus which were isolated revealed that 24 belonged to one antigenic type, Easton-2 (related to Albany type 1 virus). Patients from whom C virus was isolated showed a rise during convalescence to the Easton-2 or homologous type antibody. Two patients with paralytic poliomyelitis were studied for the quantitative development of antibodies to the poliomyelitis virus and to the C virus found in their stools. Using the neutralization test in monkeys and in newborn mice, respectively, a simultaneous rise in antibodies to both agents was observed. The situation at present can be summarized as follows:—Poliomyelitis virus or C virus may produce infection in man, with a specific antibody response. Both agents may be carried, particularly in the intestines, without causing any serious illness and healthy carrier states have been observed for each. Both viruses can be found in nature in flies and in sewage. However there has been no evidence to suggest that these two viruses bear a relationship to each other, even when isolated from the same patient. Thus, when both viruses are found in a patient with paralysis, it is not yet possible to say with any degree of accuracy to what extent each is responsible in the over-all pattern of the disease. How frequently dual infections of this nature may occur remains for future investigations to determine. Certainly all cases of poliomyelitis are not complicated by a superimposed infection with a C virus. However, this will have to be one more item to consider in epidemic poliomyelitis.     

Early prediction of functional outcome one year after initial unilateral hemispheric stroke]

BACKGROUND AND PURPOSE: Several prognostic factors have been identified for outcome after stroke. We conducted a study to determine early predictive factors of functional outcome one year after stroke and to evaluate which factors are independent predictors, with an aim of specifying the role of age, aphasia, unilateral neglect, cognitive impairment and family social support. METHODS: Observational cohort study of 156 patients. All patients admitted to the university hospital for initial unilateral hemispheric stroke were included. The study duration was two years (inclusion, one year, and follow-up, one year) .The initial evaluation of stroke was conducted at day 2 and day 15 and included the Motricity Index and Trunk Control Test, New Functional Ambulation Classification, Frenchay arm test, Mini-Mental State Examination, Boston Diagnostic Aphasia Examination, unilateral neglect evaluation, and depression. Data on functional recovery (Barthel Index) were collected at day 360. RESULTS: The average age of patients was 72 years. Age was correlated to social situation (P<0.01) and previous neurological impairment (P<0.01). A multiple regression analysis, including 14 initial clinical factors correlated with the Barthel Index score at day 360, revealed 4 independent early predictive factors of outcome: initial score of Barthel Index at day 2 and its progression from day 2 to day 15, disorders of the executive functions and previous neurological impairment. CONCLUSION: In our cohort, in accordance with previous studies, age, cognitive impairment, unilateral neglect, aphasia, depression and social situation are not independent factors of poor outcome after stroke as evaluated by the Barthel Index.     

Microsurgery for glioblastoma preserves short-term quality of life both in functionally impaired and independent patients

OBJECTIVE: Considering the short remaining life expectancy with glioblastoma multiforme, numerous patients and their referring physicians are hesitant to use aggressive surgical treatment for fear of greater risk of neurological deterioration. The aim of our study was to determine whether surgical treatment of glioblastoma, utilizing modern microsurgical dissection techniques and tools, interferes with short-term quality of life. METHODS: The functional status before and after 67 microsurgical operations in 65 patients with glioblastomas was studied retrospectively. To evaluate the patients' quality of life, their functional neurological status was correlated with the Karnofsky performance scale (KPS). Post-operative evaluation was done within 7 days of surgery. RESULTS: No significant difference was found between the preoperative and the early postoperative functional status. Neither patient age nor the preoperative functional status determined a significant risk for postoperative functional deterioration. Patients with tumors involving so-called eloquent brain areas statistically worsened (p = 0.018); however, they showed only mild clinical impairment that was represented by a mean KPS status decline of less than -10. After total tumor resection, patients showed functional improvement. CONCLUSION: Microsurgery is safe and effective in order to improve or preserve short-term quality of life in glioblastoma patients. Total tumor resection is not associated with a significantly greater risk for neurological deterioration, either in patients with preoperative functional impairment, or in functionally independent patients.     

POLIOMYELITIS IN THE CYNOMOLGUS MONKEY : I. COMPARISON OF THE UPPER PORTION OF THE ALIMENTARY TRACT WITH ITS LOWER,GASTROINTESTINAL PORTION AS A PORTAL OF ENTRY,WITH SPECIAL REFERENCE TO THE PERIPHERAL GANGLIA

1. Cynomolgus monkeys were subjected to a series of non-traumatic exposures of the mucous membranes of the alimentary tract, designed to test the relative permeability to poliomyelitis virus of its upper and lower portions. 2. In the first stage, dried poliomyelitis virus of tested potency was administered in fat-covered capsules to 26 monkeys in such a way as to avoid contamination of the oropharynx but to permit thorough exposure of the gastro-intestinal mucosae. No clinical evidence of poliomyelitic infection appeared. 3. Subsequent application of small amounts of virus to the tongues of 18 of the same monkeys caused paralytic poliomyelitis in one of them. 4. Virus given subsequently by enema to 11 of the monkeys caused no clinical manifestations of poliomyelitis. 5. Of 7 monkeys later treated with virus by oronasal spraying, one developed typical preparalytic signs of infection, and the distribution of lesions indicated that entry had occurred through the afferent nerves of the oropharynx and, possibly, the esophagus. 6. The 6 surviving monkeys were exposed to virus by inhalation. One of them developed paralytic poliomyelitis by olfactory entry. The others appeared to have acquired some resistance to infection. 7. The 5 surviving monkeys were inoculated intracerebrally, as a test of immunity. One of them developed paralytic poliomyelitis. The other 4 showed no clinical signs of infection, but all had typical lesions of varying extent and intensity in the central nervous system. 8. A histological examination of the peripheral nervous ganglia in 12 of the exposed monkeys sacrificed at various stages of the experiments revealed lesions compatible with poliomyelitis in all. Ganglia connected with the head alone (Gasserian, cervical sympathetic) were more constantly and, on the average, more severely involved than the celiac, which is connected only with the intestine. 9. While the celiac ganglion was involved in 7 cases, no evidence was found of the spread of infection from it to the spinal cord.     

Management of a patient with post-polio syndrome

PURPOSE: To describe the current understanding of the management of patients with post-polio syndrome (PPS) and relate the research to a case study. DATA SOURCES: Standard neurology textbooks, current review and research articles, and a case study. CONCLUSIONS: More than 15 years following a diagnosis of poliomyelitis, a new onset of weakness, fatigue, joint pain, decreased endurance, muscle atrophy, gait disturbance, respiratory and swallowing problems, cold intolerance, and difficulties with activities of daily living might indicate a neurologic disorder called PPS. IMPLICATIONS FOR PRACTICE: Non-post-polio causes of weakness, fatigue or pain must be excluded before making a diagnosis of PPS. Approaches to management vary depending on the symptoms and level of disability. Reducing physical and emotional stress, energy conservation, adequate rest, modification of work and home environments, joint protection, and the use of orthoses, adaptive equipment, or mobility aids can reduce fatigue and preserve function.     

胫骨延长述对跟行足矫治作用分析

目的 分析胫骨延长术跟行足畸形的矫治作用。方法 将１７例小儿麻痹后遗跟行足畸形患的胫骨延长２．３￣３．９ｃｍ并经２年￣６年８月随访。结果 跟行足畸形基本纠正，踝、膝关节稳定性增加。结论 胫骨延长术是纠正跟形足畸形的一种方法。     

Impact of age and co-morbidity on the functioning of patients with sequelae of poliomyelitis: a cross-sectional study.

OBJECTIVE: To investigate the impact of age and co-morbidity on the functional independence and perceived physical functioning of patients with sequelae of poliomyelitis. DESIGN: Cross sectional study. SUBJECTS: A convenience sample of 168 patients with sequelae of poliomyelitis, aged 45-85 years, recruited from 2 university hospitals. METHODS: Outcome measures were Functional Independence Measure (FIMTM) for functional independence, Short Form-36 (SF-36) for physical functioning and general mental health, Cumulative Illness Rating Scale (CIRS) for co-morbidity. RESULTS: FIMTM scores were significantly lower for the 65-85 year age group than for the 45-54 year age group. No differences in the SF-36 were found between the age groups, except that the SF-36 general mental health sub-scale score was significantly better in the 65-85 year age group than in the 45-54 year age group. The CIRS score increased significantly with age. Linear regression showed that age, gender, polio severity, and 4 co-morbidity scores ("cardiac", "vascular", "endocrine, metabolic"and "muscle, bone, skin") were significantly and inversely associated with functional independence and physical functioning. CONCLUSION: The level of functional independence of elderly former poliomyelitis patients is lower than that of younger patients. Specific attention should be paid to co-morbidity and ageing in this increasingly older population of polio survivors, since they negatively affect functional independence and perceived functioning.     

Prognose des Erfolges von Operationen an der Bandscheibe

The outcome of disk surgery in 40 consecutive patients was predicted by pre-treatment assessments of sociodemographic and psychological variables and findings in a standardised orthopaedic and neurological examination. The pre-surgery variables that proved to be associated with outcome criteria six months post surgery by means of a multiple stepwise regression procedure were selected for discriminant analyses, using three outcome criteria: functional status, patient evaluation of the outcome, and vocational rehabilitation. The correct classification rate was 85%, 77.5%, and 90%, respectively. No prediction was possible for postoperative pain behaviour and postoperative orthopaedic and neurological status. Significant predictors were time off work before surgery, active search for information about disease and surgery, presence of conditions that reinforce pain behaviour, and cognitive variables indicating helplessness.     

THE NATURAL HISTORY OF HUMAN POLIOMYELITIS : II. ELIMINATION OF THE VIRUS

Studies on the elimination of virus in human paralytic poliomyelitis during the first 2 weeks of the disease, revealed the following:— 1. The nasal (not nasopharyngeal) secretions collected from 22 patients on cotton plugs over a period of 3 days and the saliva and oral secretions expectorated during a similar period by 20 patients failed to yield virus. 2. In 10 of the patients whose secretions (nasal, oral, or both) were investigated, virus was isolated from single specimens of the lower intestinal contents. 3. No virus was found in large amounts of urine (up to 200 cc.) obtained from 12 patients, 6 of whom had paralysis of the bladder. 4. In the present tests virus was found 4 times more often in the stools of patients under 8 years of age (64 per cent of 11 cases) than in older individuals (17 per cent of 12 cases). This difference was found to obtain when our data were combined with those which could justifiably be selected from the literature, the total figures indicating that virus has been isolated from 50 per cent of 58 children under 8 years of age and from 12 per cent of 60 older individuals. 5. No support was found for the hypothesis that poliomyelitis virus in the stools originates from swallowed nasal secretions and saliva or oral secretions.