The shoulder-hand syndrome occurrs in about twenty per cent of patients following hemiplegia, being not a rare complication of cerebrovascular disease and often interfering with stroke rehabilitation process. This syndrome is considered as reflex neurovascular conditions involving the shoulder and hand, but its pathophysiological mechanism is not definitely proved. In early phase of this syndrome the vasomotor changes may be the most characteristic and important phenomenon. The skin temperature and plethysmographic pulse wave height of the paralysed hand is significantly higher in hemiplegics with this syndrome than that in those without it. In most cases with this syndrome the first symptom may develop within three months after onset of hemiplegia, when some suggestive findings of a significant increase of blood flow in the paralysed hand are observed. The increase of peripheral blood flow in the affected upper extremity of hemiplegic patients is sometimes observed prior to such other symptoms as pain and loss of range of motion in the shoulder and the hand. The reduction of blood flow due to reflex vasoconstriction is observed during local body cooling, which is one of somatosympathetic reflexes. Such a reflex activity is decreased in hemiplegic patients with this syndrome. There seems to be a disturbance of autonomic vasomotor regulation mechanism in peripheral circulation in the affected extremity with the shoulder-hand syndrome. The most important mechanism in pathogenesis of this syndrome following hemiplegia is considered to be associated with vaso motor paralysis due to damage of the central nervous systemabove the spinal cord, especially in the cerebrum.
The shoulder-hand syndrome has been recognized as a reflex neurovascular condition, since Steinbr ocker reviewed the literatures and described it in detail, in 1948 As this condition progresses, marked dystrophic changes will be observed in the skin, the hand muscles and the bone of the affected upper extremity. However, the pathogenetic mechanism of this fairly common syndrome is still unknown. This paper describes seven autopsied cases with this syndrome, included four with cerebral infarction, one with cerebral hemorrhage and two with intracranial tumor. Six cases except the cerebral hemorrhage case havethe common pathological extent in and round thepremotor region in the territory of the middle cerebral artery adjacent to that of the anterior cerebral artery. In addition to these autopsied cases, two of three other intracranial tumor cases are confirmed in craniotomy that they have the same region as the common pathological extent. This syndrome is not associated with cerebral lesions but also a number of medical and surgical conditions in adults such as trauma, myocardial infarction, cervical spondylosis and so on. Although the pathogenetic mechanism in various forms of this syndrome is not completely clear, the above clinicopathological findings may suggest that the cessation of cortical autonomic regulation associated with the damage of the premotor and surrounding areas in the territory of the middle cerebral artery gives rise to the disturbances of the normal reflex vasomotor mechanism in the spinal internuncial pool, which leads to the chain reactions along the transmission pathways as far peripherally as to the shoulder and the hand. This syndrome may be caused by multiple and complex pathogenetic factors. Howhver, among the other possiblefactors, such a cerebral lesion should be considered to play the most important role in the pathogenesis of this syndrome following hemiplegia.
The present study was designed to evaluate the influence of age on the cardiovascular response during postural change. Ninety-one healthy male subjects with age from nineteen to eighty-three years were divided into three age groups: young (19-39 yrs.), middle (40-59 yrs.), old (60-83 yrs.). Circulatory function was examined by noninvasive method before, during and after five minutes of 70°head-up tilt. Hemodynamic parameters observed were heart rate, blood pressure (BP), cardiac output by impedance cardiograph and systolic time intervals (STI) which included total electromechanical systole (QS2), left ventricular ejection time (LVET), pre-ejection period (PEP) and the ratio of pre-ejection period to left ventricular ejection time (PEP/LVET). QS2 and LVET were corrected for heart rate according to the following regression equations obtained in thirty young healthy men. QS2=-1.5 HR+482, LVET=-1.1 HR+360. Stroke volume (SV), cardiac output (CO) and total peripheral vascular resistance (TPR) were calculated in their relative changes with tilt. After one minute of tilt in the young group, there were increases in heart rate (11beats/min.), diastolic BP (4.9mmHg) and TPR (47%) and decreases in SV (39%) and CO (29%). AS to STI, QS2 and ETI shortened, PEP lengthened and PEP/LVET ratio increased with tilt. Analyzing these changes in hemodynamic parameters with aging, following results were obtained. 1) Heart rate was little influenced by aging both in the supine and head-up tilt position. 2) Significant reversed correlation between the rise in diastolic BP and age was observed both after one minute and five minutes of tilt. The old group showed less rise in diastolic BP and greater fall in systolic BP than the young group. 3) The changes in TPR, CO and SV decreased in the old group. Reversed correlation between the changes in these hemodynamic parameters and age was observed. 4) In the resting supine position, QS2I and PEP lengthened and PEP/LVET ratio increased with aging, but ETI was little influenced. In the head-up tilt position, there was no significant difference of STI among the three groups. 5) With regards to the change in STI to tilting, increase in PEP and in PEP/LVET ratio diminished with aging. In the old group increase in PEP and in PEP/LVET ratio was significantly lower than in the young group.
In this paper, hemodynamic changes in the presence of high blood pressure were investigated using 70° head-up tilt. One hundred and two hypertensive subjects divided into three age groups were compared with normotensive subjects reported in a previous paper. All the hypertensives were clinically free of renal disease, diabetes mellitus and other diseases affecting the cardiovascular system. The young hypertensives were subdivided into the borderline and the established hypertensives. The middle-aged and the old hypertensives were subdivided into two groups according to ECG critera; the hypertensives without LVH and with LVH. Hemodynamic parameters were observed in the same way as previously reported. Following results were obtained. 1) In the supine position, heart rate in the borderline hypertensives was significantly higher than in the normotensives but there was little difference among the other groups. The increase in heart rate after one minute of tilt in the middle-aged and the old hypertensives with LVH was significantly less than in the normotensives. This was also observed in the old group after five minutes of tilt. The border line hypertensives showed greater increase in heart rate with tilt than the established hypertensives but not than the normotensives. 2) With regards to the response of blood pressure during postural change, the old hypertensives showed significant change. In the old hypertensives with LVH there was significant decrease in the response of diastolic BP and greater fall in systolic BP compared with the normotensives. As to the response of mean BP, the old hypertensives without LVH also showed decreased response. In the young and middle-aged group there was little difference between the normotensives and the hypertensives. 3) With tilt, the hypertensives showed less change in TPR and CO compared with the normotensives. The increase in TPR to tilting tended to decline with aging both in the hypertensives and the normotensives. 4) STI in the supine position showed significant difference between the hypertensives and the normotensives in the young age group. Shortened ETI, lengthened PEP and higher PEP/LVET ratio were significantly observed in the established hypertensives. In the borderline hypertensives shortened ETI and higher PEP/LVET ratio were significant. 5) With regards to the change in STI with tilt, increase in PEP and in PEP/LVET ratio after one minute of tilt in the young established hypertensives were smaller than in the normotensives. The middle-aged hypertensives with LVH showed smaller increase in PEP/LVET ratio than the normotensives.
The hemodynamic effects of sublingual nitroglycerin were examined at rest and during 70° head-up tilt. The twenty-eight healthy male normotensives and the fifty-one male hypertensives were investigated for evaluating the cardiovascular regulation in the presence of high blood pressure and aging. Both the normotensives and the hypertensives were divided into three age groups as the previous report. The hypertensives in the young group were subdivided into the borderline and the established hypertensives. 70° head-up tilt test was made before and after administration of nitroglycerin. Each subject was first tilted for five minutes and returned to the supine position for five minutes. A fresh 0.3mg nitroglycerin tablet was then administered sublingually and 70° head-up tilt test was repeated after five minutes. Hemodynamic parameters were measured in the same way as previously reported. The effects of nitroglycerin were examined in the supine position five minutes after administration and in the first minute of tilted position. Compared with the state before nitroglycerin, following results were obtained. A) Hemodynamic changes in the supine position five minutes after nitroglycerin. 1) Heart rate increased in almost all the cases and especially in the borderline hypertensives. 2) As to blood pressure, systolic BP tended to fall and there was slight increase of diastolic BP. The old hypertensives showed significantly greater fall in systolic BP than the normotensives. 3) There was tendency to increase in TPR and to decrease in SV and CO. 4) Abbreviation of QS2-I and ETI, lengthened PEP, and heightened PEP/LVET ratio were observed. B) Hemodynamic changes in the first minute of tilted position five minutes after nitroglycerin. 1) The increase in heart rate was greater than the state before administration and there was significant correlation between before and after nitroglycerin. The borderline hypertensives showed greater increase in heart rate than the normotensives. 2) After nitroglycerin, systolic and mean BP tended to fall but nitroglycerin had various effect on diastolic BP. Significant correlation was observed between the fall in systolic BP and age. In the old hypertensives, this fall in systolic BP was significantly greater than in the normotensives. 3) Compared with the state before administration, TPR tended to decrease, CO changed a little and SV decreased. 4) As to STI compared with the period before nitroglycerin, QS2-I and ETI tended to shorten. In the young and the middle-aged normotensives, PEP tended to shorten but changed a little in the other groups. PEP/LVET ratio tended to increase except in the young normotensives.
Serum Vitamin E was determined quickly and simply by the fluorometric method modiefied by ABE and KATSUI in recent years. It is used to examine what relationship serum vitamin E has with various diseases. Serum E concentration of young healthy persons are usually 1.01±0.23mg/dl and show a slightly increase with advancing age. Those diseases which give low serum E values are absorption deficiences such as malabsorption syndrom, diseases thought to reduce the synthesis of carrier protein of vitamin E such as liver malfunction, diseases though to cosume vitamin E such as stroke or myocardial infarction on early stage of attack. High serum vitamin E values are associated with diabetes mellitus, hyperlipemia, nephrosis and pregnancy. However, since most investigators have given their major attention to vitamin E deficiency, there is littel known about high vitamin E syndrom. We have examined the change of serum vitamin E in hyperlipemic subjects. There was a correlation in serum lipids and serum vitamin E in both clinically healthy persons and hyperlipemic subjects, and particulary, serum E had a highly significant correlation to cholesterol levels. The lipoprotein vitamin E profiels were shown. It was found that healthy adults had a great deal of vitamin E in HDL fraction, but with hyperlipemic subjects, a number of peculiarities were seen according to type. Type IIa hyperlipoproteinemia had a great deal of vitamin E in LDL fiaction, type IIb had in VLDL and LDL fraction and type IV in VLDL fraction. With a dosage of 300mg per day of natural vitamin E (d-alpha-tocophryel acetate) there was no change in serum lipids of healthy adults. However, with hyperlipemic subjects given the same dosage, there was low natural fat after 4 weeks of use. After two weeks of dosage, serum E value declined with both type of people by more than twice, but afterwards there was no marked change. However, hyperlipemic subjects after two and four weeks of dosage always had a significantly higher serum E value than healthy persons. Measurement of serum vitamin E fluorometric method is though to be very inportant in clinical use as well.
This paper reviews the clinical microbiological study on microorganisms isolated from decubitus ulcers of 403 mean aged 75 yr. bedridden patients. Skin lesions were classified into following 3 groups according to the morphological evolution of decubitus: Grade I; redness, Grade II; erosion and Grade III; ulcer or fistula formation. Results were as follows. 1. Comparing the number of isolated strains among the skin lesions, buttocks had 7 times more than the upper schoulder or legs. 2. Number of isolates from the lesion (buttocks) was in decreasing order of groups: Grade I<Grade II<Grade III. In Grade I, predominant organisms were Staph. aureus, Corynebacterium and Staph. epidermidis which were consistent with the normal skin flora. While, in Grade III, Proteus mirabilis, Staph. aureus, Strepto. faecalis, Ps. aeruginosa, Klebsiella, E. coli, Other Gram-negative bacilli and Bacteroides were predominant. Frequency of Staph. aureus isolation had a tendency to increase during the past 5 years. Otherwise, E. coli, St. faecalis, Proteus and Bacteroides which belong to normal intestinal flora showed a marked decrease in number. The reason was thought to be the effect of good cares of nursing. 3. In annual changes of susceptibilities against commonly used antibiotics to the predominant isolates, the increase of Chloramphenicol sensitivity to various organisms were worth of notice. This was probably caused by having recovery of sensitivity to the strains due to the recent notable limitation of the daily use by its side effects. 4. The cases with severe decubitus ulcers had significant bacteriuria in frequency and in such cases there was a tendency of isolation of the same organisms such as Pr. mirabilis and Klebsiella from urine and ulcers. In severe cases anaerobic bacteria such as Bacteroides and Peptococcus were also isolated so often from the lesions. These results suggested that the taint with urine or faeces on the lesions due to incontinentia of bladder and colon of the patients exerts a serious influence upon the developement of the decubitus ulcers. Good nursing care, nutrition and maintanance of skin hygine are most important measures for prevention and treatment of this disease.