Interaction between valproic acid and aspirin in epileptic children: serum protein binding and metabolic effects.

In five of six epileptic children who were taking 18 to 49 mg/kg/day valproic acid (VPA), the steady-state serum free fractions of VPA rose from 12% to 43% when antipyretic doses of aspirin were also taken. Mean total VPA half-life (t1/2) rose from 10.4 +/- 2.7 to 12.9 +/- 1.8 hr and mean free VPA t1/2 rose from 6.7 +/- to 2.1 to 8.9 +2- 3.0 hr when salicylate was present in the serum. The in vitro albumin binding association constant (ka) for VPA was decreased by salicylate, but the in vivo ka value was not affected. The 12-hr (trough) concentrations of both free and total VPA were higher in the presence of serum salicylate in five of six patients. Renal excretion of unchanged VPA decreased in five of six patients, but the VPA carboxyl conjugate metabolite-excretion patterns were not consistently affected. Salicylate appeared to displace VPA from serum albumin in vivo, but the increased VPA t1/2 and changes in VPA elimination patterns suggest that serum salicylate also altered VPA metabolism.

Differential effect of cimetidine on serum concentrations of carbamazepine and phenytoin.

Cimetidine is an inhibitor of drug metabolism. We studied the effects of cimetidine (1,200 mg/d) on steady-state serum concentrations of carbamazepine and phenytoin in 11 epileptic volunteers. The mean serum carbamazepine concentration was unchanged after 7 days of cimetidine treatment. Five subjects were taking phenytoin concurrently; their mean serum phenytoin concentration was significantly increased after 7 and 10 days of cimetidine treatment and returned to baseline 2 weeks after cimetidine was discontinued. Cimetidine apparently inhibits the clearance of phenytoin but not of carbamazepine in adults on chronic therapy.

Organization of day-case adenoidectomy in the management of chronic otitis media with effusion--preliminary results.

We report our initial findings of adenoidectomy performed in Leicester as a day case on 149 children between the ages of 3 and 9 years, who have been assessed for suitability for day-case surgery according to specific medical and social criteria. The selection a paediatric community nurse. All of the surgical procedures have been performed by experienced medical staff and the various anaesthetic techniques used by consultants or senior registrars have been documented. Six children were admitted postoperatively for overnight observation, three of whom had suffered a primary haemorrhage. No patients have been returned to theatre because of haemorrhage and there have been no re-admissions after discharge. A strict entry protocol has been observed to ensure the safety of this type of surgery and to date the acceptability of such a scheme and its organization has been widespread amongst those children and their parents who have participated.

Laryngeal squamous cell carcinoma presenting as a prelaryngeal, air-filled structure (pseudolaryngocoele).

OBJECTIVE: We report a unique case of a squamous cell carcinoma of the larynx presenting as a large pseudolaryngocoele, arising through a thyroid cartilage defect. METHOD: Case report and review of the literature. CASE REPORT: A 47-year-old man presented with a two-month history of hoarseness and a large, midline neck swelling. Endoscopic examination revealed a transglottic carcinoma involving the anterior commissure. Fine needle aspiration of the neck mass showed it to be an air-filled structure which transiently collapsed but refilled within minutes. Subsequent computed tomography scanning and histopathological examination revealed that the air-filled mass was created by a defect in the thyroid cartilage, with formation of a pseudolaryngocoele. CONCLUSIONS: The anatomy of the anterior commissure region and its effect on the spread of laryngeal carcinoma is reviewed in order to explain the pathophysiology of this unusual presentation. We highlight the need for a high index of suspicion of malignancy if a laryngocoele or pseudolaryngocoele is detected clinically.

Characteristics of temporomandibular joint problems.

A review of the characteristics of 145 patients with temporomandibular joint and myofascial pain-dysfunction syndrome is presented. The material includes both temporomandibular and myofascial involvements. The evidence supports the psychophysiologic etiology theory for most patients. This does not exclude anatomic abnormalities which may be present in such patients nor anatomic abnormalities which may be present without psychogenic causes. The lack of awareness of the range of condylar movement is contributory to iatrogenic trauma. A classification of etiologic factors is proposed. The superimposition of one upon another can create a severe problem. The superimposition of two upon a third can create an unusually severe problem.

Vertical dimension measurements.

Changes in the vertical dimension of mandibular rest position for 50 subjects wearing complete dentures were measured on cephalometric radiographs between lead markers attached to the face and between skeletal landmarks. Measurements between the landmarks were compared on radiographs made without (edentulous) and with (edentoprosthetic) the dentures in the mouth. The findings support the following statements. The facial structures tended to mask the positional changes of the mandible. The rest position of the edentulous mandible tended to vary within the time frame of the cephalometric examination. The range of measurements of the skeletal rest position appeared greater with greater denture age and experience of the subjects. The rest position of the edentoprosthetic mandible (with dentures in the mouth) was more frequently constant when measured skeletally than when measured facially and more frequently constant than the edentulous mandibular rest position. The edentulous mandibular rest position of most subjects was increased upon insertion of dentures. The rest position was decreased for the remainder of the subjects. As a group, those subjects whose mandibular rest position decreased (up-shifted) with insertion of dentures had older dentures and more years of denture-wearing experience than subjects whose mandibular rest position increased (down-shifted) with insertion of dentures. The edentulous mandibular rest position does not seem particularly suitable for determination of the vertical dimension of occlusion and appears somewhat less suitable when facial measurements are used.

The relationship of vertical dimension of atypical swallowing with complete dentures.

A number of subjects were studied cineflourographically during swallowing, and their vertical dimensions of occlusion were clinically evaluated. The subjects who had reduced vertical dimensions of occlusion were older than those with normal vertical dimensions, their dentures were older, their total years with complete dentures were more, and the tendency to swallow without opposing tooth contact was greater. The cumulative evidence indicates that such aberrant muscle activity might contribute to the regressive changes found in complete denture wearers.

Subluxation of the temporomandibular joint.

The temporomandibular joint in actual function does not resemble other joints in the body in that the condyles leave their fossae with maximal opening and in some subjects with only a 35 mm. opening. The term subluxation, with its implication of abnormality, does not seem applicable to a normal movement. While significant problems, such as dislocation, locking, and loud clicking, can occur with such anterior-to-the-fossae movements, they are relatively rare. Most temporomandibular problems are associated with confinment of the condyles to their fossae with limited or no translatory condylar movement. A recognition of the normal range of condylar movement would lessen iatrogenic abuse of this area.

Airway obstruction by a child's pacifier--could flange design be safer?

UNLABELLED: The use of pacifiers (dummies or soothers) for infants is prevalent. Rare episodes of an adverse consequence must be taken seriously. We report a case of aspiration of a pacifier by a 6-month-old baby. Nine similar cases were found in the literature since 1966. The details of these cases are outlined and changes to flange design proposed ahead of a new European Union Standard document. CONCLUSION: Pacifier ventilation holes are essential, flanges should have a minimum horizontal and vertical diameter of 43 mm. Rings should be attached to the flange to facilitate removal if aspirated.

MRI in the detection of acoustic neuromas--a suggested protocol for screening.

Magnetic resonance imaging (MRI) is the definitive investigation in the detection of an acoustic neuroma and its use is becoming increasingly widespread for this purpose. In the Oxford region, this facility has been available for 3 years, resulting in the scanning of the internal auditory meati and cerebellopontine angles of 892 patients and the detection of 38 acoustic neuromas. Based on our use of this investigation over this time period, we have attempted to rationalize our entry protocol for screening by limiting the availability of the test to those patients up to 70 years of age presenting with unilateral audiovestibular symptoms in the absence of significant neurological symptoms or signs, with an average difference in hearing threshold of 15 dB between normal and symptomatic ears or unilateral tinnitus with normal hearing. By following these entry criteria, we would hope to maximize the available resources.

A prospective study of day case adenoidectomy.

Adenoidectomy in this country is typically performed as an in-patient procedure requiring an overnight stay in hospital but experience from other countries shows that adenoidectomy can be safely performed as a day case procedure. In Leicester, a prospective study of day case adenoidectomy was initiated in 1991 under carefully monitored conditions. We report on 721 patients entered in the first 3 years. We have so far found day case adenoidectomy to be a safe procedure.

Is emergency laryngectomy a waste of time?

INTRODUCTION: Patients who present with airway obstruction due to carcinoma of the larynx may be managed by tracheotomy followed by definitive tumor surgery at a later date. An alternative is emergency laryngectomy, defined as total laryngectomy performed within 24 hours, for a previously untreated and undiagnosed malignancy. In this study, we compare and contrast the outcome of 13 patients managed by tracheotomy and delayed laryngectomy to another group of patients, previously reported, managed by emergency laryngectomy. MATERIALS AND METHODS: Stridor due to malignant laryngeal neoplasm was treated by tracheotomy and delayed definitive laryngectomy in 13 patients. In every case, the tracheostomy site was removed with a surgical specimen. A comparison of the survival data was performed with earlier reported series of 13 emergency laryngectomies using the Wilcoxon log rank method. RESULTS: All patients were followed for a minimum of 24 months. Seven patients underwent postoperative radiotherapy. Two of these patients (15%) developed peristomal recurrence at 6 and 22 months respectively. Both died of disease. Six patients from each group survived disease free for a minimum of 24 months. No significant correlation was found between the time delay of definitive surgery and survival (P > .5). DISCUSSION: This series suggests that emergency laryngectomy offers patients no survival advantage. Emergency laryngectomy does, however, have several disadvantages. These include the necessity to rely on frozen section analysis, the difficulty in obtaining expert anesthetic support, and the inability to provide thorough and complete nutritional and metabolic work up before major surgery. Finally, the psychologic aspects of radical surgery for patient and family cannot be adequately addressed. We conclude that stomal recurrence is as much a function of extensive disease at presentation as of preliminary tracheotomy. Emergency laryngectomy is not a superior treatment modality and offers no particular survival advantage.

Initial management of open fractures sustained in the M1 aircraft disaster. Nottingham, Leicester, Derby and Belfast (NLDB) Study Group.

There were 83 survivors of the M1 aircrash admitted to hospital; of these, 28 patients sustained a total of 40 open fractures. These open fractures were classified as 19 grade 3, 16 grade 2 and five grade 1. There were six upper limb fractures and 34 lower limb fractures. A high proportion of grade 3 open fractures were identified in this series (47 per cent) and one-half of these occurred at or below the ankle. This reflected the high energy and direction of the forces involved in the aircrash. The early results in terms of the incidence of wound infection (15 per cent), delayed wound healing (7.5 per cent) and skin flap necrosis (7.5 per cent) were similar to other series. The controversy over whether to leave grade 3 wounds open or closed was not clarified by this study, but the closure of grade 3 wounds after internal fixation is to be avoided. This study emphasizes the need for provision of adequate specialist manpower, equipment and resources to manage the unexpected major disaster successfully.