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Objective: To determine the effect of exercise with the wheelchair aerobic fitness trainer (WAFT) on anthropometric indices, conditioning, and endocrine and metabolic parameters in persons with lower extremity disability. Design: Exercise sessions with the WAFT lasted 20 to 30 minutes for two to three sessions. Setting: Tertiary-care Veterans Administration medical center. Participants: Twelve subjects (3 with quadriplegia, 7 with paraplegia, 1 with cerebrovascular accident, 1 with bilateral above-knee amputation). Main Outcome Measures: Anthropometric indices (heart rate, blood pressure, weight, oxygen utilization, body mass index, upper arm and abdominal circumference, arm power) and endocrine and metabolic parameters (fasting serum glucose, lipids, and thyroid function) were determined before and after 10 weeks of exercise with the WAFT. Results: All patients noted improved feelings of well-being after training. Mean resting heart rate, upper arm fat area, and fasting serum cholesterol level decreased significantly. Peak oxygen consumption, midarm circumference, and free thyroxine index increased significantly with training. Conclusions: WAFT improves quality of life, conditioning, and endocrine-metabolic parameters in disabled persons.

We present the case of a 60 year old C6 complete tetraplegic patient who developed profound hypotension following initiation of the angiotensin-converting enzyme inhibitor lisinopril to control blood pressure. Other causes of hypotension, such as myocardial infarction and sepsis was ruled out. Inhibition of the renin-angiotensin-aldosterone system was the probable cause of hypotension. This case demonstrates the critical importance of the renin-angiotensin-aldosterone axis in the maintenance of blood pressure in tetraplegic patients, who may lack input from the brain to sympathetic neurons, and therefore have increased reliance on the renin-angiotensin-aldosterone axis for the maintenance of blood pressure. Angiotensin-converting enzyme inhibitors should be avoided in tetraplegic patients, unless other treatment modalities are ineffective.

Purpose This study measured the accuracy of two impression techniques recommended by Noblepharma to be used with their CeraOne single tooth implant restoration. The first technique was to lute the impression transfer coping to the impression tray with autopolymerizing acrylic resin. The second was to leave the transfer coping free-standing in the impression material. Materials and Methods Thirty-five samples were made of a polyvinyl impression of the CeraOne transfer coping free-standing in the set impression material. Thirty-five samples were made of a polyvinyl impression of the CeraOne transfer coping luted to the impression tray with autopolymerizing acrylic resin. A jig was fabricated and used to record the spatial relations of the impressions and the transfer copings in reference to the jig. A light microscope was used to measure the distance between fixed markings on pressure sensitive paper, representing impression variations. Results The mean discrepancy in the horizontal plane for nonluted impressions was 0.094 mm, and for luted impressions, it was 0.275 mm. The mean discrepancy in the vertical plane for nonluted impressions was 0.154 mm, and for luted impressions, it was 0.192 mm. The differences found between the group with the luted impression tray and the group with the nonluted impression tray were found to be statistically significant. Conclusions The more accurate of the two techniques is to transfer the impression coping without luting it to the impression tray.

Spinal cord injury increases the risk of many life-threatening medical problems, including respiratory failure, pulmonary embolism, and renal failure. Respiratory failure results from paralysis of muscles of inspiration (which impairs oxygen transport to alveoli) and of expiration (which impairs cough and predisposes to pneumonia and atelectasis). Respiratory failure in patients with spinal cord injury can be prevented by proper positioning of the patient, training of ventilatory muscles, pulmonary toilet, and aggressive use of antibiotics and bronchodilators. When respiratory failure occurs, it can be managed by administration of oxygen, intubation, and mechanical ventilation, and in instances of paralysis of the diaphragm, by diaphragmatic pacing. The risk of deep vein thrombosis and pulmonary embolism in acute spinal cord disease is increased by the immobilization of the patient and abnormalities in clotting factors. Thrombotic disease in spinal cord disease can be prevented by intermittent calf compression and heparinization. If pulmonary embolism develops, the patient should be started on a regimen of warfarin for at least 3 months. If anticoagulation is contraindicated, a Greenfield filter can be placed. However, concurrent use of quad cough places the patient at increased risk for complications from the Greenfield filter. Chronic pyelonephritis and systemic amyloidosis are the most common causes of renal failure in the patient with spinal cord disease. Renal failure can be prevented by maintaining a low postvoid residual volume, avoidance of indwelling catheters, use of medications that are not nephrotoxic, and rapid treatment of infection. Hemodialysis and peritoneal dialysis can extend the life of the patient with spinal cord disease in whom renal failure develops, and successful use of renal transplantation has recently been reported.

The insufflator-exsufflator has been shown to be effective in assisting cough in individuals with spinal cord injury. However, many institutions do not use this device. The study was performed to assess use of the device and attitudes among health care providers.We developed a questionnaire with 4 categories of questions: knowledge of the device, type of facility, clinical practice with the device, and patient and provider satisfaction. The questionnaire was mailed to members of the American Paraplegia Society.Eighty-six questionnaires (16%) were returned. The device was being used in 49% of the institutions. The device was most commonly used with a tracheostomy; use did not correlate with size or type of facility. Patient and provider satisfaction with the insufflator-exsufflator was high.The insufflator-exsufflator is used as a means of removal of secretions in approximately one half of institutions polled. Satisfaction with the device is high.

Epidural spinal cord stimulation has been used to decrease spasticity and spasms in spinal cord injury patients. However, the long-term benefits of this procedure have not been determined. We therefore conducted a retrospective study of the possible long-term efficacy of the epidural spinal cord stimulator for the relief of symptoms. Seventeen patients were identified who had undergone implantation of an epidural spinal stimulator. The total number of implantations in these seventeen patients was 24, (seven patients had undergone a second implantation) costing a total of $566,400. In only one of the patients was the epidural stimulator providing symptomatic relief. The epidural spinal cord stimulator lacks long-term efficacy for the relief of spasticity and pain and is not cost effective.

Background It has been hypothesized that certain Mycoplasma species may cause Gulf War veterans' illnesses (GWVIs), chronic diseases characterized by pain, fatigue, and cognitive symptoms, and that affected patients may benefit from doxycycline treatment. Objective To determine whether a 12-month course of doxycycline improves functional status in Gulf War veterans with GWVIs. Design A randomized, double-blind, placebo-controlled clinical trial with 12 months of treatment and 6 additional months of follow-up. Setting 26 U.S. Department of Veterans Affairs and 2 U.S. Department of Defense medical centers. Participants 491 deployed Gulf War veterans with GWVIs and detectable Mycoplasma DNA in the blood. Intervention Doxycycline, 200 mg, or matching placebo daily for 12 months. Measurements The primary outcome was the proportion of participants who improved more than 7 units on the Physical Component Summary score of the Veterans Short Form-36 General Health Survey 12 months after randomization. Secondary outcomes were measures of pain, fatigue, and cognitive function and change in positivity for Mycoplasma species at 6, 12, and 18 months after randomization. Results No statistically significant differences were found between the doxycycline and placebo groups for the primary outcome measure (43 of 238 participants [18.1%] vs. 42 of 243 participants [17.3%]; difference, 0.8 percentage point [95% CI, -6.5 to 8.0 percentage points]; P > 0.2) or for secondary outcome measures at 1 year. In addition, possible differences in outcomes at 3 and 6 months were not apparent at 9 or 18 months. Participants in the doxycycline group had a higher incidence of nausea and photosensitivity. Limitations Adherence to treatment after 6 months was poor. Conclusion Long-term treatment with doxycycline did not improve outcomes of GWVIs at 1 year.

Impaired gastrointestinal motility as a result of interruption of sympathetic outflow is a common occurrence in the spinal cord injury (SCI) population. In addition, frequent use of medications with anticholinergic properties in this population results in further impairment of peristalsis resulting in gastrointestinal stasis. Since SCI patients often lack sensation below the level of injury, they may present with vague symptoms, which complicates the diagnosis of intestinal obstruction. We report the first case of gastric phytobezoar in a patient with T4 ASIA A paraplegia who presented with vague upper abdominal discomfort, anorexia, weight loss, and vomiting. Because mortality rates can be as high as 30% if phytobezoars remain untreated, gastrointestinal phytobezoars should be considered in the differential diagnosis of abdominal discomfort in SCI patients. Etiologic factors for phytobezoars are discussed for the general population and in particular, for patients with SCI.

In a retrospective study we investigated the effects of altering treatment of type II diabetes mellitus from insulin to tolazamide on weight and blood pressure. In 17 patients, weight decreased from 136 +/- 6 to 131 +/- 6% of ideal body weight (P = .01). Even though weight loss occurred, mean systolic blood pressure increased from 133 +/- 3 mm Hg to 142 +/- 4 mm Hg (P = .025). There was no difference in diastolic blood pressure on the two treatments (79 +/- 3 v 78 +/- 4 mm Hg). In an additional 10 patients whose treatment was changed from tolazamide to insulin, mean systolic blood pressure decreased from 136 +/- 1 to 124 +/- 2 mm Hg (P.01). In spite of the potential benefits of reversal of insulin resistance and weight reduction, altering therapy of type II diabetes mellitus from insulin to tolazamide may increase blood pressure, thereby increasing cardiovascular risk.

In eight healthy volunteers, basal and arginine-stimulated plasma glucose and growth hormone levels were determined during administration of a placebo and after 3 days of ibuprofen (800 mg four times daily). Ibuprofen had no significant effect on basal or stimulated plasma glucose or growth hormone levels. As is not the case with indomethacin, ibuprofen fails to increase basal and arginine-stimulated plasma growth hormone levels. This suggests that the effect of indomethacin on growth hormone secretion is due to a mechanism unrelated to inhibition of prostaglandin synthesis.

In seven normal volunteers, the basal and arginine-stimulated levels of plasma growth hormone, glucose, glucagon, and free fatty acids and serum insulin was determined during placebo and during indomethacin 25 mg four times daily. Basal plasma growth hormone was higher during indomethacin (5.4 +/- 1 vs 1.7 +/- 2 ng/ml, p less than 0.005), as was the mean integrated response to intravenous arginine (40 +/- 14 vs 6 +/- 4 ng.min/ml, p less than 0.05). Despite lack of effect on plasma glucagon, indomethacin decreased the insulin response to arginine. The fall in free fatty acids during arginine infusion was decreased by indomethacin, which may in part be due to increased plasma growth hormone levels. In view of the many patients treated with indomethacin, the effect on growth hormone may be of clinical importance.

ContextGulf War veterans' illnesses (GWVI), multisymptom illnesses characterized by persistent pain, fatigue, and cognitive symptoms, have been reported by many Gulf War veterans. There are currently no effective therapies available to treat GWVI.ObjectiveTo compare the effectiveness of cognitive behavioral therapy (CBT), exercise, and the combination of both for improving physical functioning and reducing the symptoms of GWVI.Design, Setting, and PatientsRandomized controlled 2 × 2 factorial trial conducted from April 1999 to September 2001 among 1092 Gulf War veterans who reported at least 2 of 3 symptom types (fatigue, pain, and cognitive) for more than 6 months and at the time of screening. Treatment assignment was unmasked except for a masked assessor of study outcomes at each clinical site (18 Department of Veterans Affairs [VA] and 2 Department of Defense [DOD] medical centers).InterventionsVeterans were randomly assigned to receive usual care (n = 271), consisting of any and all care received from inside or outside the VA or DOD health care systems; CBT plus usual care (n = 286); exercise plus usual care (n = 269); or CBT plus exercise plus usual care (n = 266). Exercise sessions were 60 minutes and CBT sessions were 60 to 90 minutes; both met weekly for 12 weeks.Main Outcome MeasuresThe primary end point was a 7-point or greater increase (improvement) on the Physical Component Summary scale of the Veterans Short Form 36-Item Health Survey at 12 months. Secondary outcomes were standardized measures of pain, fatigue, cognitive symptoms, distress, and mental health functioning. Participants were evaluated at baseline and at 3, 6, and 12 months.ResultsThe percentage of veterans with improvement in physical function at 1 year was 11.5% for usual care, 11.7% for exercise alone, 18.4% for CBT plus exercise, and 18.5% for CBT alone. The adjusted odds ratios (OR) for improvement in exercise, CBT, and exercise plus CBT vs usual care were 1.07 (95% confidence interval [CI], 0.63-1.82), 1.72 (95% CI, 0.91-3.23), and 1.84 (95% CI, 0.95-3.55), respectively. The OR for the overall (marginal) effect of receiving CBT (n = 552) vs no CBT (n = 535) was 1.71 (95% CI, 1.15-2.53) and for exercise (n = 531) vs no exercise (n = 556) was 1.07 (95% CI, 0.76-1.50). For secondary outcomes, exercise alone or in combination with CBT significantly improved fatigue, distress, cognitive symptoms, and mental health functioning, while CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant impact on pain.ConclusionOur results suggest that CBT and/or exercise can provide modest relief for some of the symptoms of chronic multisymptom illnesses such as GWVI.

The inhibition by somatostatin (SRIF) of basal and arginine-stimulated glucagon, insulin, and glucose levels was compared with that obtained when SRIF was preceded by alpha-adrenergic blockade with phentolamine. No noteworthy differences were observed, except that the characteristic rebound of insulin upon discontinuation of SRIF was significantly lower with phentolamine (P less than 0.01). These results indicate that inhibition of basal and arginine-stimulated glucagon and insulin secretion by SRIF in man is not mediated through activation by alpha-adrenergic receptors.

SummaryWe investigated the effect of indomethacin on the glucagon, glucose, and insulin responses to arginine in eight normal subjects. Glucagon secretion was not affected, but glucose and insulin responses were significantly decreased. Although inhibition of hepatic glycogenolysis is a possible reason for this effect, hepatic glycogen depletion and augmented peripheral glucose utilization are other explanations to be considered.Supported in part by Grant AM-12763(09) from the National Institutes of Health and by the Levi J. and Mary Skaggs Foundation of Oakland, California, and the Susan Greenwall Foundation of New York City.

Because cardiovascular risk correlates with serum low density lipoprotein (LDL) cholesterol and is inverse with high density lipoprotein (HDL) cholesterol, the LDL-HDL cholesterol ratio has been advocated as a sensitive index of relative cardiovascular risk. In 50 normal weight insulin-treated Type II diabetic subjects, mean LDL-HDL ratios were significantly higher than for controls. In diabetic women, the LDL-HDL cholesterol ratio correlated with hemoglobin A1 better than any of the lipids or lipoprotein cholesterol fractions. When 8 poorly controlled diabetics were treated with insulin, the LDL-HDL ratio changed more significantly than did its component fractions, and the fall in LDL-HDL ratio parelled the fall in hemoglobin A 1 .

In 27 patients with non-insulin-dependent diabetes mellitus, we determined fasting serum glucose, hemoglobin A,, body weight, serum triglycerides, cholesterol, low-density lipoprotein cholesterol (LDL-chol), high-density lipoprotein cholesterol (HDL-chol), and very-low-density lipoprotein cholesterol during treatment with insulin and several months after changing treatment to chlorpropamide. In five patients, diabetic control deteriorated to the point where insulin was reinitiated. In the remaining 22 patients, despite a significant decrease in weight (122 ± 5 vs. 114 ± 5% ideal body wt; P < .025) on chlorpropamide, HDL-chol fell from 49 ± 4 to 40 ± 4 mg/dl (P < .01) when therapy was modified from insulin to the sulfonylurea. There was a concomitant increase in LDL-chol:HDL-chol from 3.6 ± 0.3 to 4.4 ± 0.5 (P < .05). In the 5 patients in whom insulin was reinstituted, HDL-chol increased to its previous level on insulin (P < .05). Changing antidiabetic medication from insulin to sulfonylureas may alter the lipoproteins in a manner that increases cardiovascular risk.

SummaryIn 7 obese subjects treated with phenformin, serum insulin and plasma glucose responses to oral glucose were significantly reduced, but serum gastric inhibitory polypeptide (GIP) levels were not significantly changed. These results indicate that the insulin-lowering effect of phenformin on glucose-induced insulin release is not mediated by alterations in GIP levels.

Excerpt To the editor: A recent report has noted that a high-dose (8 mg) overnight dexamethasone suppression test is helpful in separating patients with hypercortisolism due to Cushing's disease fr...