Ronald S. Taylor

Osteoporotic stress fractures in anorexia nervosa: Etiology, diagnosis, and review of four cases

Anorexia nervosa (AN) is a chronic eating disorder characterized by self-imposed semi-starvation that affects 1% of adolescent females. AN predisposes to osteoporosis through hypothalamic dysfunction, which may lead to elevated cortisol as well as diminished estrogen and progesterone. The osteoporosis associated with AN affects both trabecular and cortical bone and increases the risk of osseous fracture. Fractures in this population may go unrecognized, because planar X-rays may be nondiagnostic for 6 weeks or more. Four women with AN ranging in ages from 22 to 34 with skeletal pain and nondiagnostic roentgenographs are described. Stress fractures in these patients were subsequently identified by bone scan. Although moderate exercise in patients with AN-associated osteoporosis may be beneficial, strenuous exercise can be detrimental, with its potential risk of stress fractures and exacerbation of the underlying neurohormonal abnormalities. This risk for fracture may persist well after improvement in the patients AN.

Bilateral adrenal hemorrhage after anticoagulation prophylaxis for bilateral knee arthroplasty.

After joint arthroplasty, the risk of deep vein thrombosis and pulmonary embolism increases exponentially. Inadequate anticoagulation prophylaxis may not sufficiently reduce the risk of thrombosis, whereas excessive anticoagulation therapy may predispose the patient to a bleed. Bilateral adrenal hemorrhage is a relatively rare but potentially catastrophic life-threatening event. An 82-yr-old woman is described who was rehospitalized from a subacute rehabilitation facility complaining of epigastric pain radiating into her flank. Eight days previously, she had undergone an uncomplicated bilateral total knee arthroplasty and was subsequently administered subcutaneous heparin and warfarin. An abdominal computed tomographic scan subsequently demonstrated bilateral small adrenal hemorrhages. Acute adrenal insufficiency (Addisons disease) caused by hemorrhage within the adrenal cortices, although still uncommon, can be expected to increase as anticoagulation prophylaxis after joint arthroplasty becomes routine.

Varicosities of the paravertebral plexus of veins associated with nocturnal spinal pain as imaged by magnetic resonance venography : A brief report

LaBan MM, Wang A-M, Shetty A, Sessa GR, Taylor RS: Varicosities of the paravertebral plexus of veins associated with nocturnal spinal pain as imaged by magnetic resonance venography.

Occult radiographic fractures of the chest wall identified by nuclear scan imaging: Report of seven cases

Between 1985 and 1990 the enactment of state mandatory seat belt laws has reduced the risk of death from auto accident by at least 40% and the risk of moderate to severe injury by 45%. Although head and facial trauma has also been significantly reduced, there has not been a decrease in injuries to other parts of the body. We evaluated seven restrained drivers who complained of persistent anterior and/or lateral chest wall pain after being in motor vehicle accidents. All had normal x-rays of the osseous thorax. Nuclear scan imaging subsequently revealed that all seven had a healing fracture of either the sternum or ribs. In each instance, direct trauma to the sternum and ribs anteriorly by the chest strap itself and/or laterally displaced bending forces transmitted to the postero lateral rib margins was sufficient to produce x-ray occult fractures.

Spinal stenosis presenting as "the postpolio syndrome". Review of four cases.

The diagnosis of postpolio syndrome is based primarily on a thorough history supported by both clinical and laboratory examination. Similarly, the presence of an occult spinal stenosis may be suspected initially by a history of progressive lumbar or cervical radicular pain, as well as concomitant extremity weakness and/or myelopathic signs. Appropriate electrodiagnostic examinations, including somatosensory spinal-evoked potentials and electroneuromyography, as well as imaging studies, computer-assisted tomography scan, magnetic resonance imaging and/or myelography are all useful in confirming the clinical diagnosis of either cervical spinal stenosis or lumbar spinal stenosis in patients who also may have had a history of poliomyelitis. Four patients (three men and one woman) previously diagnosed as having postpolio syndrome were referred with predominate complaints of spinal and extremity pain as well as associated motor weakness. It was subsequently recognized that these patients, ranging in age from 45-65 yr, were actually presenting with symptomatic spinal stenosis. It was discovered that two patients had cervical spinal stenosis; the other two had lumbar spinal stenosis.

Self-assessment examination: 1987 pretest on electrodiagnosis

1. When doing an electromyogram (EMG) on the left lower extremity and its related paraspinals, you find diphasic potentials with a large initial positive deflection spontaneously firing irregularly and confined to the lumbar paraspinal, extensor hallucis longus. and flexor digitorum longus muscles. EMG testing in other muscles in this extremity is normal. The left peroneal nerve conduction velocity is 46 misec below the fibular head and 48 misec across the fibular head. The most likely diagnosis is ( 1) S 1 radiculopathy (2) L4 radiculopathy (3) L5 radiculopathy (4) upper motor neuron disease (5) peroneal palsy

Poster 50 Progressive Lower Extremity Weakness Due to Nitrous Oxide Induced Myelopathy: A Case Report

Participants: OEF/OIF Veterans with mTBI (N1⁄457). The majority of participants were male (89.5%) with a mean age of 32.5 and two combat deployments. Interventions: Not applicable Main Outcome Measures: Clinical interviews were used to assess lifetime history of mTBI and PTSD. Questionnaires included the Moral Injury Events Scale (MIES), Spiritual Health and Life-Orientation Measure (SHALOM), and Brief Multidimensional Measure of Religiousness/ Spirituality (BMMRS). Results or Clinical Course: Participants reported high levels of perceived moral transgressions (M1⁄420.8, SD1⁄48.1) and perceived moral betrayals (M1⁄411.1, SD1⁄44.5), as well as high rates of PTSD diagnoses (86%). Discrepancies were found between ideal (M1⁄416.2) and current (M1⁄412.5) levels of spiritual health. Preliminary results suggest a preference for individuals to identify as spiritual rather than religious (M1⁄4 2.5, 3.1, respectively, SD1⁄41). Further, 33.4% of the sample identified as atheist, agnostic, or as having no religion, while 50.8% identified as Christian. Conclusion: Preliminary data reveal rates of moral injury, spiritual health, and post-traumatic stress disorder. Veterans with mTBI reported greater moral injury than has been previously reported in other military samples. Discrepancies found between ideal and current states of spiritual health highlight unsatisfactory spiritual well-being. Religious preferences (or rejection thereof) were noteworthy. These findings call attention to potential factors associated with PCS maintenance, and reinforce the need for continued exploration of moral injury and spirituality.

Poster 77 Pulmonary Rehabilitation: Its Role in Decreasing Length of Stay, Cost of Hospitalization, and 30-day Readmission Rates for Chronic Obstructive Pulmonary Disease

ed. Acute care length of stay (LOS), IRU LOS and discharge disposition, along with IRU FIM scores at admission and discharge were analyzed. Main Outcome Measures: Primary outcome measures were change in functional status (as measured by the FIM), IRU LOS, FIM efficiency (FIM gain/LOS), and discharge setting. Results: Mean IRU LOS was 17.5 days (SD 8.9). Mean FIM gain was statistically significant at 28.6 (SD 10.2, 95% CI 21.7-35.4, P .0001), and compared favorably to benchmarks for mean FIM gain (22.5 regionally and 23 nationally) for patients admitted to inpatient rehabilitation facilities with a cardiac diagnosis. Mean FIM efficiency (FIM gain/IRU LOS) was 1.97 (SD 1.1), compared with the regional mean of 2.27 and national mean of 2.28. Seven of the 11 patients were discharged directly home following inpatient rehabilitation, and three others returned home after an additional acute hospital stay. One subject expired after transfer back to the acute hospital service. Conclusions: The patients with LVADs in this study achieved clinically meaningful functional gains from inpatient rehabilitation that compare favorably to national benchmarks for patients with cardiac diagnoses. The majority of subjects were successfully discharged home. Inpatient rehabilitation facilities should consider implementing rehabilitation programs for this growing patient population. Poster 80 Early Outpatient Rehabilitation Following Lung Transplantation. Gerold Ebenbichler, MD (Vienna Medical University, Vienna, Austria); Victoria Augustin, MD; Peter Jaksch, MD; Ursula Maier, PT; Barbara Zweytick, MD. Disclosures: G. Ebenbichler, No Disclosures. Objective: To set up an early outpatient rehabilitation program immediately following lung transplantation (LuTX) with limited sources for supervised training, and to follow longitudinal changes of patients’ lung function and physical performance as at the end of rehabilitation. Design: Observation of a series of cases. Setting: Outpatient department of PMR. Participants: A total of 7 non-Austrian, non-German speaking patients (5 females), who 1) underwent single (n 1) or double LuTX (n 6) at the department of thoracic surgery, Vienna Medical University; 2) were not eligible for inpatient rehabilitation due to reimbursement issues, and received outpatient rehabilitation in 2011. Interventions: The program consisted of 2 to 3 weekly 30-minute sessions of supervised therapeutic and breathing exercises, regular consultations by a psychologist and dietic consultations by a physician. Patients were regularly encouraged to perform daily muscle S216 PRESENTATIONS

Cardioembolic Stroke with Visual Deficit in a Patient who is a Bilateral Hand Amputee: A Case Report

addition to PO Baclofen to treat spasticity, the patient was also fitted with a dynamic left-upper-extremity splint to gradually stretch the arm and relieve the elbow contracture. Modifying, bilateral ankle-foot orthoses were used for 2 hours a day during bed rest to maintain range of motion and prevent contractures. Discussion: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC Virus (JCV), activated during immunosuppression. It is characterized by subacute neurological decline that typically results in progressive weakness, sensory loss, dysarthria, ataxia, hemianopsia, and cognitive impairment. Despite the progression of this disease, rehabilitation therapy with our patient shows the possibility of improved function after certain decline. After approximately 4 weeks of acute inpatient rehabilitation, our patient showed improvements with dynamic sitting, bed mobility, feeding, transferring, ambulation across level surfaces, wheelchair propulsion, and static standing balance. Conclusions: While likely under-reported, to the best of the authors’ knowledge, we describe the first case of functional improvement in a patient with PML after inpatient rehabilitation. This case also highlights the importance of how increased functional ability can increase patient safety and decrease caretaker burden.

Poster 412 Paraneoplastic Syndrome Masked by a History of Chronic Alcoholic Neuropathy: A Case Report

Disclosures: K. E. Ramos-Vargas, none. Program Description: A 46-year-old Puerto Rican man with a history of diabetes mellitus type 2, and a family history of neuroacanthocytosis (brother), who, in July 2005, presented with left hemiparesis. Imaging studies, at that time, revealed right basal ganglia ischemic infarction. On September 2007, he presented with new onset seizures that required hospitalization due to status epilepticus for which antiepileptic treatment was given. Soon after, the patient developed progressive choreoathetoid movements in his trunk, with associated poor neck and trunk control. In September 2008, he was admitted to an inpatient rehabilitation center with the diagnosis of neuroacanthocytosis. Setting: Inpatient rehabilitation facility. Results: The patient’s clinical improvement after receiving therapies in an inpatient rehabilitation facility was assessed. The Functional Independence Measurement (FIM) scores on admission and discharge were compared. On admission, the patient was totally dependent in activities of daily living and was not able to ambulate or to use a wheelchair to move across areas. FIM assessment upon discharge (change in FIM scores from admission to discharge date) showed progress in wheelchair mobility (FIM change, 2-5), transfers (FIM change, 3-4), toileting (FIM change, 2-5), eating (FIM change, 2-3), grooming (FIM change, 3-4), dressing (FIM change, 4-5), and bladder control (FIM change, 3-4). Discussion: A description of a specific regimen of therapies in a patient with neuroacanthocytosis has not been made. After receiving a combination of physical, occupational, and speech therapies in an inpatient setting, this patient was able to improve toward his independence in some areas and to maintain a steady state in others. Conclusions: Little is known about neuroacanthocytosis treatment and its rehabilitation process. New studies are still needed to continue expanding our knowledge in neuroacanthocytosis pathophysiology, treatment, and rehabilitation process.