Paul F. Pasquina

Sensor technology for smart homes

A smart home is a residence equipped with technology that observes the residents and provides proactive services. Most recently, it has been introduced as a potential solution to support independent living of people with disabilities and older adults, as well as to relieve the workload from family caregivers and health providers. One of the key supporting features of a smart home is its ability to monitor the activities of daily living and safety of residents, and in detecting changes in their daily routines. With the availability of inexpensive low-power sensors, radios, and embedded processors, current smart homes are typically equipped with a large amount of networked sensors which collaboratively process and make deductions from the acquired data on the state of the home as well as the activities and behaviors of its residents. This article reviews sensor technology used in smart homes with a focus on direct environment sensing and infrastructure mediated sensing. The article also points out the strengths and limitations of different sensor technologies, as well as discusses challenges and opportunities from clinical, technical, and ethical perspectives. It is recommended that sensor technologies for smart homes address actual needs of all stake holders including end users, their family members and caregivers, and their doctors and therapists. More evidence on the appropriateness, usefulness, and cost benefits analysis of sensor technologies for smart homes is necessary before these sensors should be widely deployed into real-world residential settings and successfully integrated into everyday life and health care services.

Psychosocial impact of participation in the National Veterans Wheelchair Games and Winter Sports Clinic

Purpose. The purpose of this study was to determine the characteristics of individuals who participate in the National Veterans Wheelchair Games (NVWG) and the Winter Sports Clinic (WSC) for veterans with disabilities. In addition, it was of interest to determine how these events had impacted their lives. Method. Participants were recruited at the 20th Winter Sports Clinic, held in Snowmass Colorado and the 26th National Veterans Wheelchair Games held in Anchorage, Alaska. Data of interest included demographic, sport participation information, community integration, self-esteem, and quality of life. A secondary data analysis was completed to determine how comparable individuals who attended the NVWG/WSC were to individuals who did not participate in these events. Results. The 132 participants were a mean age of 47.4 + 13.4 and lived with a disability for an average of 13.4 + 12.1. Participants felt that the NVWG/WSC increased their knowledge of sports equipment (92%), learning sports (89%), mobility skills (84%), and acceptance of disability (84%). The majority of participants stated that the NVWG/WSC improved their life. Of those who participated at the NVWG/WSC, they tended to be more mobile, but have increased physical and cognitive limitations as measured by the CHART when compared to the non-attendees. Conclusions. Recommending veterans participate in events such as the NVWG and WSC can provide psychosocial benefits to veterans with disabilities.

Dismounted complex blast injury report of the army dismounted complex blast injury task force

Abstract : The use of civilian expertise to assist the military medical corps during times of conflict is not a new concept. Perhaps, one of the most noted examples was the service of Edward D. Churchill, MD, who volunteered to serve as the chief surgical consultant in the North African and Mediterranean theaters during World War II. A colonel in the US Army, Dr. Churchill followed his deployed surgical unit from Harvard Medical School into the war zone, making major contributions to the care of the wounded, most notably in advocating for the use of whole blood for resuscitation. In addition to Churchill and DeBakey, other surgical giants who contributed to combat care during World War II included Loyal Davis, Fred Rankin, Isidor Ravdin, Robert Zollinger, Ben Eiseman, and J. Englebert Dunphy (former chief of surgery at the University of California, San Francisco). For a more in-depth review of the contributions of Dr. Churchill and others, interested readers are referred to the excellent article authored by Cannon et al. The war that has engaged US troops for the past 10 years in Iraq and Afghanistan is unique in American history. This prolonged war has been fought with an all-volunteer military service, including the members of the medical corps. A portion of the surgeons in theater are recent residency graduates and thus relatively inexperienced in trauma surgery. Other deployed surgeons may be reservists in the Army, Navy, or Air Force Medical Corps who have been deployed multiple times from their private or academic practices. Modern technology has brought the war into our living rooms and onto our computer screens, giving civilians a unique look at battlefield injuries. These considerations as well as many others culminated in the development of the Senior Visiting Surgeons (SVS) program composed primarily of civilian trauma surgeons.

Quality of medical care provided to service members with combat- related limb amputations: Report of patient satisfaction

A group of 158 service members who sustained major limb amputations during the global war on terrorism were surveyed on their satisfaction with the quality of care received from the Walter Reed Army Medical Center (WRAMC) Amputee Clinic from the time of their injury to their inpatient discharge. Of these participants, 96% were male, 77% were Caucasian, 89% were enlisted personnel, and 68% had sustained lower-limb amputations. WRAMC inpatient therapy, peer visitors, overall medical care, and pain management received particularly high satisfaction ratings. Age, race, rank, and level and side of amputation had little effect on overall satisfaction ratings. Significant differences, however, were found by location of injury (Iraq vs Afghanistan, Cuba, and Africa) regarding satisfaction with care received while in Europe and with the education process at WRAMC. Study findings strongly support the rehabilitation-based, integrative care approach designed by the U.S. military to care for service members with amputations.

Intradermal Botulinum Toxin Type A Injection Effectively Reduces Residual Limb Hyperhidrosis in Amputees: A Case Series

OBJECTIVEnTo study the effectiveness of botulinum toxin type A (BTX-A) therapy for residual limb hyperhidrosis, prosthesis fit and function, and residual and phantom limb pain in patients with limb amputation.nnnDESIGNnConsecutive case series.nnnSETTINGnOutpatient physical medicine and rehabilitation clinic.nnnPARTICIPANTSnWalter Reed Army Medical Center patients (N=8) with unilateral traumatic upper- or lower-limb amputation.nnnINTERVENTIONnBTX-A was injected transdermally in a circumferential pattern around the residual limb by using a 1-cm matrix grid.nnnMAIN OUTCOME MEASUREnA 10-cm continuous Likert visual analog scale was used to assess residual limb sweating and pain and prosthesis fit and function before and 3 weeks after BTX-A injections.nnnRESULTSnPatients reported a significant reduction in sweating and improvement in prosthesis fit and function after treatment. However, residual limb and phantom pain were unaffected by treatment.nnnCONCLUSIONSnBTX-A may be an effective treatment for residual limb hyperhidrosis, resulting in subjective improvement in prosthesis fit and functioning. BTX-A should be considered as a method to manage excessive sweating in the residual limb of traumatic amputees.

Optimizing care for combat amputees: Experiences at Walter Reed Army Medical Center.

Optimizing medical care for the combat amputee is a complex task. To date, Walter Reed Army Medical Center (WRAMC) has cared for more than 100 patients who have sustained a major limb amputation during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Managing these individuals, along with the thousands of other patients, has been challenging for the medical and administrative staff at WRAMC, especially those within the Department of Orthopaedics and Rehabilitation. Technological advances in body armor, along with rapid evacuation and early medical attention, have increased the survival rate of combat amputees. Despite these advances, many members of the armed services continue to return with severe limb wounds. While experienced military physicians and surgeons do everything possible to salvage viable limbs, frequently amputation is necessary. Combat amputees represent a unique patient population, because of the complex nature of their wounds and the extent of their comorbidities. Comorbid conditions—loss of vision, spinal cord injury, traumatic brain injury, fractures, and severe nerve and vascular injures—present significant medical, surgical, and rehabilitative challenges. In addition, an increased risk exists for the development of secondary complications such as infection, heterotopic ossification, and venous thrombus, all of which require close monitoring and attention. Finally, each patient has distinctive psychosocial needs, greatly impacting on issues such as pain management, adjustment to disability, body image issues, movement through the military disability system, and reintegration into the community or back to active-duty service. Providing optimal care requires the development of a well-functioning and coordinated multidisciplinary team, where each member is recognized as having equal importance. Our experience at WRAMC has supported the creation of a dedicated Amputee Inpatient Service as well as a separate Outpatient Amputee Clinic, both under the management of Physical Medicine and Rehabilitation (PM&R). Following a rehabilitation model, the physiatrist functions as the primary care provider for the amputee, coordinating the recommendations and interventions of multiple medical and surgical subspecialists, therapists, nurses,

Developing a Quantitative Measurement System for Assessing Heterotopic Ossification and Monitoring the Bioelectric Metrics from Electrically Induced Osseointegration in the Residual Limb of Service Members

Poor prosthetic fit is often the result of heterotopic ossification (HO), a frequent problem following blast injuries for returning service members. Osseointegration technology offers an advantage for individuals with significant HO and poor socket tolerance by using direct skeletal attachment of a prosthesis to the distal residual limb, but remains limited due to prolonged post-operative rehabilitation regimens. Therefore, electrical stimulation has been proposed as a catalyst for expediting skeletal attachment and the bioelectric effects of HO were evaluated using finite element analysis in 11 servicemen with transfemoral amputations. Retrospective computed tomography (CT) scans provided accurate reconstructions, and volume conductor models demonstrated the variability in residual limb anatomy and necessity for patient-specific modeling to characterize electrical field variance if patients were to undergo a theoretical osseointegration of a prosthesis. In this investigation, the volume of HO was statistically significant when selecting the optimal potential difference for enhanced skeletal fixation, since higher HO volumes required increased voltages at the periprosthetic bone (pxa0=xa00.024, rxa0=xa00.670). Results from Spearman’s rho correlations also indicated that the age of the subject and volume of HO were statistically significant and inversely proportional, in which younger service members had a higher frequency of HO (pxa0=xa00.041, rxa0=xa0−0.622). This study demonstrates that the volume of HO and age may affect the voltage threshold necessary to improve current osseointegration procedures.

Total knee replacement in an amputee patient: A case report ☆ ☆☆ ★ ★★

Osteoarthritis is the most prevalent and more disabling of the rheumatic diseases. One of the most effective forms of treatment of severe osteoarthritis is total joint arthroplasty. Although studies suggest that the incidence of osteoarthritis is higher in prosthetic users, research supporting total joint arthroplasty as an option for treating amputee patients with advanced osteoarthritis is lacking. We report the case of a 76-year-old man with right transtibial amputation who had an excellent outcome after undergoing bilateral total knee replacements for advanced osteoarthritis.

Beta blockade in the treatment of autonomic dysreflexia: A case report and review

Autonomic dysreflexia has long been considered a sympathetically mediated phenomenon. Recent articles have reported the use of alpha blockers as a means of treatment. We report the case of a 20-year-old C5 American Spinal Injury Association A spinal cord injured patient who almost daily experienced symptoms of headache, facial flushing, and hypertension consistent with autonomic dysreflexia. These symptoms caused him frequent discomfort and anxiety. Despite an extensive workup, we were unable to identify a source of his dysreflexic episodes. After starting metoprolol 50 mg every night, however, these episodes stopped and the patient showed no adverse effects from the medication.

DoD Paradigm Shift in Care of Servicemembers with Major Limb Loss

INTRODUCTION Military operations in Iraq and Afghanistan present a multitude of challenges for the U.S. Armed Forces. Whether operating in an urban environment, such as Baghdad, or the rural mountains of Afghanistan, combat military units need to be flexible to adapt to the constant changes on the battlefield. In support of these military operations, the Military Health Care System (MHCS) needs to be equally flexible. Advances in body armor, expertly trained field medics, forward-area surgical support, and modernized evacuation systems greatly increase combat wound survival rates. Despite these advances, to date more than 4,000 servicemembers have died in the line of duty and countless others have been injured. Military professionals continue to serve their country far from their loved ones in hostile environments and treacherous terrain. Many have served on multiple deployments and have witnessed horrific human tragedy. The MHCS remains committed to these heroes and their families, not only to provide the best healthcare that is available today but to continually explore new technology and science to deliver even better care tomorrow. The majority of severe injuries that occur in the combat theater result from a blast. Blast injuries may occur from the primary blast wave or the secondary or tertiary effects caused by flying debris or violent displacement of the individual. Given the relative vulnerability of the servicemembers arms and legs, severe limb trauma is frequently encountered. Although modern surgical reconstructive techniques have contributed to a greater preservation rate of limbs than possible in prior wars, many injured limbs still require amputation. As of January 2010, more than 950 servicemembers sustained one or more major limb amputations from injuries sustained in Iraq or Afghanistan. Servicemembers with traumatic limb loss represent a much different patient demographic than their civilian counterparts. More than 85 percent of the servicemembers who undergo amputation because of combat-related injuries are under the age of 35, whereas in the civilian population more than 81 percent are over the age of 44. Additionally, most amputations in the civilian population occur as a result of diseases such as diabetes or peripheral vascular disease as opposed to the traumatic injuries due to military conflict. Further, while traumatic amputations do occur in civilian settings, the types of trauma and associated injuries are often much different than those experienced by our military servicemembers. EARLY CLINICAL CARE Extremity wounds, especially those occurring as the result of a blast, are extensively contaminated and typically involve massive soft-tissue disruption. Because of the complex nature of these wounds, military surgeons work collaboratively with various subspecialists to perform innovative soft-tissue, bone, nerve, muscle, and vascular grafts to preserve as much of the limb as possible. For injuries that require amputation, the precise level is often not defined until weeks after the injury to allow for adequate wound debridement and ensure tissue vitality. Every effort is made to preserve as much limb length as possible, including saving precious joints such as the elbow and knee to help maximize long-term functional outcomes. Saving a joint may require the amputation to be performed through the zone of injury, potentially complicating soft tissue coverage and creating significant challenges for achieving adequate prosthetic socket fit and comfort. Considerable debate exists as to the optimal level of amputation, particularly for the transtibial versus Symes amputation, or a knee disarticulation versus a transfemoral amputation. Involving rehabilitative experts, prosthetists, and family members in these surgical decisions often benefits the patient, helping to ensure realistic rehabilitation expectations and fully engaging the patient and his/ her family on the road to recovery. …