Iatrogenic lesions of peripheral nerves.

Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.

Inflammatory activation after experimental cardiac tamponade.

BACKGROUND/PURPOSE: Cardiac tamponade is a medical emergency situation associated with a high rate of life-threatening complications, even after immediate interventions. Our aim was to characterize the acute inflammatory consequences of this event in a clinically relevant large animal model. METHODS: Cardiac tamponade was induced for 60 min in anesthetized, ventilated and thoracotomized minipigs by intrapericardial fluid administration, the mean arterial pressure (MAP) being maintained in the interval of 40-45 mm Hg (n = 8). A further group (n = 7) served as sham-operated control. The global macrohemodynamics, including the right- and left-heart end-diastolic volumes (RHEDV and LHEDV), the pulmonary vascular resistance index (PVRI) and the superior mesenteric artery (SMA) flow, were monitored for 240 min, and the intestinal microcirculatory changes (pCO2 gap) were evaluated by indirect tonometry. Blood samples were taken for the determination of cardiac troponin T and vasoactive inflammatory mediators, including histamine, nitrite/nitrate, big-endothelin, superoxide and high-mobility group box protein-1 levels in association with intestinal leukocyte and complement activation. RESULTS: The cardiac tamponade induced significant decreases in MAP, cardiac output, LHEDV and SMA flow, while the PVRI and the pCO2 gap increased significantly. After the removal of fluid from the pericardial sac, the MAP and the LHEDV were decreased, while the PVRI and the pCO2 gap remained elevated when compared with those in the sham-operated group. In the posttamponade period, the abrupt release of inflammatory mediators was accompanied by a significant splanchnic leukocyte accumulation and complement activation. CONCLUSIONS: The macrocirculatory and splanchnic microcirculatory disturbances were accompanied by a significant proinflammatory reaction; endothelin and the complement system may be significant components of the inflammatory cascade that is activated in this porcine model of pericardial tamponade.

Mechanisms of human tumor metastasis studied in patients with peritoneovenous shunts.

The technique of peritoneovenous shunting for the alleviation of abdominal pain and distension in malignant ascites due to inoperable cancer, returns the fluid to the circulation via a one-way, valved, anastomosis between the peritoneum and the jugular vein. Surprisingly, although the patients treated with this technique receive direct infusions of malignant tumor cells into the blood, this study of 29 patients, 15 of whom came to autopsy, shows that they did not all develop metastases, some being completely free of such lesions despite long survival. Even when metastases do form, they are small and clinically asymptomatic, and the technique is therefore not hazardous. In some patients, inert tumor cells identifiable by natural markers were recognized in the tissues, but no growing metastases were observed. In others, the distribution of secondary deposits was unexpected in that metastases did not form in the organ containing the first capillary bed encountered, although hematogenous metastases had formed in other organs. Despite the fact that various factors such as (a) the small numbers of patients treated with the technique; (b) the sensitive nature of studies on terminally ill patients; and (c) the absence of consistency in the sample population with regard to factors such as length of survival and site of neoplasm, combine to reduce the number of suitable cases for study, the approach has unrivaled power and interest for those seeking to understand mechanisms underlying tumor metastasis in humans.

Endogenous fragment of hemoglobin, neokyotorphin, as cell growth factor.

It is shown that neokyotorphin (the alpha-globin fragment 137-141) stimulates proliferation of normal cells (murine embryonic fibroblasts, red bone marrow and spleen cells) and tumor cells (murine melanoma and transformed fibroblasts L929) in the absence or in the presence of fetal bovine serum. In contrast to serum deprivation conditions, the ability to potentiate L929 cell growth in the presence of fetal serum is strongly cell density dependent. The peptide also enhances the viability of L929 cells, murine embryonic fibroblasts and of the primary cultures of murine red bone marrow cells and splenocytes under serum-deprivation conditions for at least 72 h. The results of flow cytometry analysis suggest that the effect of neokyotorphin on survival of L929 cells in serum-free culture medium is due to maintenance of cell proliferation in the absence of growth factors. Along with cell cycle progression the peptide induces reversible reduction of L929 cell size.

Ultrasonography in the diagnosis and monitoring of ascites in acute abdominal attacks of hereditary angioneurotic oedema.

BACKGROUND: Hereditary angioneurotic oedema (HAE) is a rare cause of ascites. As acute abdominal attacks of the disease can mimic surgical emergencies, prompt and accurate diagnosis is essential. This study was undertaken to evaluate the usefulness of serial abdominal ultrasound (US) examinations. PATIENTS AND METHODS: Seventy patients with HAE were followed up for almost a decade. All patients presenting with an acute oedematous attack underwent abdominal US, which was then repeated 24 and 48 h after appropriate therapy. RESULTS: Twenty-two acute oedematous attacks with abdominal complaints severe enough to justify hospital admission occurred in the study population. Abdominal US performed during the attack showed oedematous thickening of the intestinal wall in 80% of cases and invariably demonstrated the presence of free peritoneal fluid in all patients. Rapid symptomatic relief achieved by treatment was accompanied by the significant regression of US abnormalities. CONCLUSIONS: Transitory ascites demonstrated by abdominal US is a clue to the diagnosis of an acute abdominal attack of HAE. The possibility of HAE should always be considered whenever unexplained abdominal pain recurs with or without ascites.

Time since death determinations of human cadavers using soil solution.

This study was conducted to collect data on specific volatile fatty acids (produced from soft tissue decomposition) and various anions and cations (liberated from soft tissue and bone), deposited in soil solution underneath decomposing human cadavers as an aid in determining the "time since death." Seven nude subjects (two black males, a white female and four white males) were placed within a decay research facility at various times of the year and allowed to decompose naturally. Data were amassed every three days in the spring and summer, and weekly in the fall and winter. Analyses of the data reveal distinct patterns in the soil solution for volatile fatty acids during soft tissue decomposition and for specific anions and cations once skeletonized, when based on accumulated degree days. Decompositional rates were also obtained, providing valuable information for estimating the "maximum time since death." Melanin concentrations observed in soil solution during this study also yields information directed at discerning racial affinities. Application of these data can significantly enhance "time since death" determinations currently in use.

People with dementia and their relatives: personal experiences of Alzheimer's and of the provision of care.

Little is known about the experiences of people with dementia, as there has been relatively little research carried out that includes their perspectives. In the past, user perspectives on experiences of dementia and on services have mostly been solicited from family carers, rather than from people with dementia themselves. It has been suggested that these studies may lack information and insight into the experiences of people with dementia. This study aimed at eliciting the views and feelings of people in all stages of dementia, as well as those of their relatives, on care services and on experiences of dementia. Twenty-seven people with dementia from residential and day care settings were interviewed and their daily lives videotaped. Interviews were also conducted with next of kin. This article reports on findings and issues arising from the study.

[Is transposition of the ulnar nerve in ulnar nerve sulcus syndrome really indicated?]. / Ist eine Vorverlagerung des N. ulnaris beim Sulcus nervi ulnaris-Syndrom wirklich indiziert?

Anterior transposition of the ulnar nerve in cubital tunnel syndrome requires ligation of the segmental epineural vessels over 8 to 10 cm in order to free up and mobilize the nerve along its new course. As a result, the blood supply of ulnar nerves already compromised by entrapment is likely to be harmed even more. For the past three years we chose to perform simple decompression of the nerve with or without external/internal neurolysis on 33 patients (34 arms). After a follow-up time of six months to three years (mean 12 months), the outcome was evaluated by complete examination of hand function and by electrophysiologic studies. Four patients were excluded from the analysis due to short follow-up times. Four underwent decompression for mild entrapment symptoms, six for moderate symptoms, and 19 for severe symptoms. The functional outcome was rated as excellent in 26.7% (eight patients) and as good in 33.3% (ten patients). In group 3 (severe entrapment symptoms), seven patients (23.3%) showed moderate results and in four patients (13.3%) the outcome was poor. Considering that most of our patients had severe entrapment with advanced muscle atrophy, the overall outcome of decompression was satisfactory.

[Significance of double crush in carpal tunnel syndrome]. / Die Bedeutung des Double Crush beim Karpaltunnelsyndrom.

From June 1992 to October 1995, 224 patients were operated on carpal tunnel syndrome. We treated 71 male and 153 female patients. During our investigations, we found that one third of the patients suffered from a double crush syndrome. 84% of the patients suffered from one or more predisposing accompanying diseases. In most of them (42%) we found rheumatic diseases, 19% diabetes mellitus, 8% hyperuricaemia, and 6% hypothyreosis. In 33%, we observed a very short history and a bilateral carpal tunnel syndrome. According to the preoperative tests, four different groups of patients regarding electrophysiological parameters and the graduation of thenar atrophy were differentiated. The fourth group was composed of patients with double crush syndrome, who continued to complain of considerable pain despite surgery, the operated hand remaining both weak and awkward in its movements. Inspired by the prospective study by Dellon (1992) and our results, we will perform a retrospective analysis of the longterm effect of carpal tunnel release in diabetic neuropathy.

Predicaments of the closed ward staff.

Coordinated team work is a sine qua non for efficient functioning of a therapeutic ward. Extreme violence on the part of a patient may disrupt the working relationship within the team to the extent of causing its members to question their choice of profession. Physical assaults and allegations of professional or personal misconduct brought forward by a patient and his/her family may undermine the competence of the attending staff. Recognition by the health, legal and psychiatric authorities of the difficulties to which the personnel on an acute closed ward is continually exposed may alleviate staff burnout. This in turn will contribute to better management of the patients.

[Ephedrine psychosis].

Ephedrine has both alpha- and beta-adrenergic activity, and both direct and indirect effects on receptors. Its stimulatory effects on the central nervous system are more prolonged, though less potent, than those of adrenalin. It raises blood pressure both by increasing cardiac output and inducing peripheral vasoconstriction. It is still commonly used as a bronchodilator. However, since prolonged use leads to decreased effectiveness, patients tend to increase the dose themselves. The clinical picture of ephedrine psychosis resembles that induced by amphetamines: primarily a paranoid psychosis with delusions of persecution and auditory and visual hallucinations in a setting of unclouded consciousness. We present a 57-year-old woman who had been taking a usual dose of ephedrine for bronchial asthma (50 mg 3 times a day) for more than 30 years. When her husband died she developed depression, for which she tried to use ephedrine as an antidepressive, increasing the dose to 500 to 1000 mg a day over the course of half a year. She developed paranoid psychosis with delusions of persecution and auditory hallucinations, despite a clear sensorium. Recovery was rapid after ephedrine was gradually reduced to 200 mg a day and a small dose (200 mg) of the neuroleptic thioridazine was added.

[Intravascular hemolysis caused by intravenous glycerin infusion in a patient with artificial mitral valve]. / Intravénás glycerininfúzió okozta intravascularis haemolysis mitrális mübillentyüvel élö betegben.

The case history of a sixty two years old patient is presented by the authors. The patient with an artificial mitral valve was admitted to the hospital because of sudden onset of left sided hemiparesis. The cerebrovascular accident which occurred because of a cerebral embolus as well as the heart murmurs and intravascular haemolysis were thought to be present because dysfunction of the artificial valve. Transthoracal and transesophageal echocardiography revealed a thrombus in the right atrium and a patent foramen ovale, however did not prove artificial valve dysfunction. A paradox embolus from the right atrium caused the hemiparesis. The intravascular haemolysis was caused by the 10% glycerol infusion used for the treatment of the cerebrovascular accident. The authors discuss the observations on the glycerol induced intravascular haemolysis and it has been pointed out, that all kinds of parenteral glycerol use can cause intravascular haemolysis. No Hungarian publication was found on glycerol induced haemolysis.

[The clinical value of coronary flow reserve in ischemic heart disease as measured by dipyridamole stress transesophageal echocardiography]. / A dipyridamol-terheléses transoesophagealis echokardiográfia segítségével számított coronaria-áramlási rezerv klinikai értéke ischaemiás szívbetegségben.

The relationship between coronary flow reserve and the result of coronarography was examined. 152 patients were investigated by stress transoesophageal echocardiography and coronary angiography. The value of coronary flow reserve was significantly lower in cases of significant coronary stenosis than in those patients who had a normal coronarography (in patients with left anterior descending coronary artery stenosis: 1.77 +/- 0.47 vs in cases with normal coronary angiogram: 3.19 +/- 1.15). There was no difference in the value of CFR in those cases where not only LAD stenosis but CX or RC stenosis was also found. The value of coronary flow reserve was significantly higher in RC or CX patients than that of LAD patients. In patients with positive stress and negative coronarography (X syndrome) the coronary flow reserve was 1.23 +/- 0.2, which value was significantly lower as compared to patients with significant coronary stenosis.

Circulatory consequences of reduced endogenous nitric oxide production during small-volume resuscitation.

Hypertonic small-volume resuscitation transiently restores the cardiovascular function during various circulatory disturbances. Nitric oxide (NO) is an important mediator of flow-induced peripheral and central hemodynamic changes, and therefore, we hypothesized that a decreased endogenous NO production could influence the consequences and the effectiveness of hypertonic fluid therapy. The main goal of this study was to outline and compare the circulatory effects small volume hypertonic saline-dextran (HSD, 7.5% NaCl-10% dextran; 4 ml/kg iv) infusion with (n=7) or without (n=7) artificially diminished NO production in normovolemic anesthetized dogs. HSD administration significantly increased cardiac index (CI), coronary flow (CF) and myocardial contractility, and elevated plasma nitrite/nitrate (NOx) and endothelin-1 (ET-1) levels. However, the late (2 h) postinfusion period was characterized by significantly decreased myocardial NO synthase (NOS) and enhanced myeloperoxidase activities. Pre-treatment with the non-selective NOS inhibitor N-nitro-L-arginine (NNA, 4 mg/kg) immediately increased cardiac contractility, and the HSD-induced CI and CF elevations and the positive inotropy were absent. Additionally, plasma ET-1 levels increased and NOx levels were significantly decreased. In conclusion, our results demonstrate that HSD infusion leads to preponderant vasoconstriction when endogenous NO synthesis is diminished, and this could explain the loss of effectiveness of HSD resuscitation in NO-deficient states.