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. Acute hypothalamic instability occurs in patients with traumatic brain injury (TBI). It usually occurs in the form of autonomic dysfunction syndrome (also known as diencephalic seizures or paroxysmal sympathetic storms); however, there are other causes of acute hypothalamic instability of which the clinician must be aware. Neuroleptic malignant syndrome, malignant hyperthermia, autonomic dysfunction syndrome, and lethal catatonia are all syndromes that clinically present as signs and symptoms of acute hypothalamic instability. Because of the lethal potential of these syndromes, clinicians who care for patients with TBI must be aware of the various syndromes, their clinical presentation, and their treatment. We present a case of life-threatening acute hypothalamic instability in a patient with TBI.

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The process of selecting residents is an important issue in medical training. In an attempt to quantify and thereby objectify this process, a model for selection was developed. The model, using scaled scores reflective of each of the applicants' characteristics, was used to rank applicants in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, Milwaukee. Data derived from the selection process were analyzed over a three-year period, 1986-1989. Statistical analysis of the data showed that as few as three experienced faculty members were needed to interview reliably. The statistically significant correlation (p less than .01) between those who interviewed and those who did not interview was necessarily influenced by the fact that those who did not interview had access to the narrative descriptors of those who did. These findings suggest that the use of this recruitment model would permit a more cost-effective approach to the selection of residents.

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It has become an accepted practice to perform endotracheal intubation on patients who are comatose as a result of traumatic brain injury; and if the comatose state persists, a surgical tracheotomy is performed. There are inherent risks associated with both of these procedures. Of 44 patients with traumatic brain injury admitted to the author's rehabilitation unit, ten required endotracheal intubation only; in 32, endotracheal intubation was followed by tracheotomy; and two required immediate tracheotomies. Clinically detectable laryngotracheal pathology developed in five patients; four patients did not tolerate decannulation and were discharged with tracheotomies; and two patients required reintubation because of recurrent pneumonias. Surgical intervention was necessary in three patients; one patient was extubated two years after injury; and seven remain with tracheotomy. The management of these complications and principles of tracheotomy care are discussed. The literature is reviewed to gain a better understanding of these problems. Anticipation of these complications should prevent possible life-threatening consequences.

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Recent changes in health care mandate innovative approaches to teaching. Rehabilitation as part of the continuum of disability motivated the "continuity of care model." This model permits the presentation of rehabilitation in its global sense: from onset of injury through re-integration into the community. This report describes a curriculum for physical medicine and rehabilitation residents that comprises a three-phase approach to rehabilitation: acute care, inpatient rehabilitation and community re-entry. The curriculum is adaptable for medical students. A secondary benefit of the project for the resident is a better understanding of relevant cost benefit/cost effective concepts in the delivery of quality services. The close interaction of residents with community agencies permits these agencies to gain a better understanding of the medical needs of disabled people.

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This article reports a technique for determining new standard values for median sensory nerve latencies, amplitudes, and durations. Use of these values should significantly improve the ability to diagnose carpal tunnel syndrome and to reduce the number of false negative results. Forty-five median sensory nerves of 30 neurologically healthy subjects were evaluated with rigid techniques and temperature control at stimulation and recording points. Latencies for antidromic and orthodromic conduction from wrist-to-thumb, wrist-to-index finger, wrist-to-middle finger, and wrist-to-ring finger (all 14 cm distances) are reported. Conduction time for nerve impulses through the transcarpal segment via ulnar and radial nerves was also measured for comparison with median nerve latencies. In addition to latency measurements, characteristics of electrical responses evoked by stimulation were described. These include amplitude of the recorded response measured from baseline to negative peak and from negative peak to positive peak, duration of the negative response wave (from baseline to return to baseline) and duration measured from onset of the negative wave to the positive peak. According to our data, a distal median nerve sensory latency of more than 3.3 ms (the mean of 2.9 ms plus two standard deviation values of 0.18 ms) when measured to the peak of the negative wave is indicative of abnormality.

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Anterior pituitary insufficiency in patients with traumatic brain injury is rare. Only sporadic cases have been reported in the literature. The authors report a case of panhypopituitarism that developed in a 19-year-old man and was diagnosed six months after the patient sustained severe craniocerebral trauma in a motor vehicle accident. After an initial slow improvement in neurologic function he very gradually retrogressed in physical and mental capacities. An acute adrenal crisis led to the diagnosis of hypopituitarism. Institution of appropriate hormone therapy resulted in steady improvement in motor and cognitive functioning. The authors reviewed the literature and discuss the possible pathophysiology. They exhort physiatrists to be aware of this rare but potentially fatal consequence of craniocerebral trauma.

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A study was undertaken to critically observe electrophysiologic findings in patients with end-stage renal disease (ESRD) secondary to primary renal disease (PRD) and to compare these with data recorded from patients with ESRD secondary to diabetes mellitus. Motor and sensory nerve conduction velocity studies were performed on 56 patients; 16 parameters were investigated and laboratory data recorded. Our findings reveal that diabetic uremics have more severe peripheral neuropathy electrophysiologically than nondiabetics, indicating that the diabetic component of neuropathy sustains its influence even in the presence of end-stage renal neuropathy. The sural latency and amplitude, median sensory latency and amplitude, H-reflex and facial latency were significantly involved parameters in nondiabetic and diabetic patients. The facial nerve was found to be a sensitive indicator of uremic neuropathy. In 28 nondiabetic uremic patients the mean facial latency was 3.8 +/- 0.5msec compared to 28 diabetic uremic patients with a mean of 5.0 +/- 0.4msec.

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The objective of this study was to compare two techniques of obtaining median motor and sensory nerve determinants. One method utilized premeasured electrode placement, while the other used anatomic landmarks. It was postulated that increased accuracy could be achieved by more precise measuring techniques. The right median nerve in 50 able-bodied subjects was investigated. Each subject was tested by both anatomic and premeasured methods. Skin temperatures were maintained between 31C and 33C. Latencies were measured to onset and peak, and amplitudes were gauged from baseline to peak. Latency studies were evaluated. Results concluded that mean distal motor latencies, stimulating 8cm from active recording electrode, was 3.1msec +/- 0.4 and amplitude was 11.1mV +/- 3.0. Stimulating at distal wrist crease, mean latency was 2.6msec +/- 0.38 and amplitude was 11.3mV +/- 3.6. Sensory latencies to onset of response when stimulating 14cm from active ring electrode with reference 4cm distally were 2.1msec +/- 0.25. Sensory latency when stimulating at wrist crease and ring electrodes over proximal interphalangeal and distal interphalangeal joints was 2.1msec +/- 0.25 to onset and 2.8msec +/- 0.32 to peak and amplitude was 36.1 +/- 14.6. The authors concluded that there was no statistically significant difference in accuracy between the premeasured and anatomic methods.

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