[Traumatic nerve damage: causes, approaches and prognosis]. / Traumatische Nervenschäden : Ursachen, Vorgehen, Prognose.

Whereas minor injuries to peripheral nerves merely lead to a circumscribed damage of the myelin sheath which is completely healed within 3 months, penetrating injuries lead to degeneration of the distal axonal fragment (Waller degeneration) and simultaneously to time-dependent alterations in the effector organs, in the perikarya in the medulla and spinal ganglia as well as in the brain. Animal experimental studies and also findings in humans confirm that the conditions for regeneration of nerve fibers are most favorable in the first days and weeks following injury. Therefore, for optimal therapy it should be clarified as early as possible whether there is a chance for reinnervation using exclusively conservative therapy or whether an operative reconstruction is necessary due to the severity of structural damage. Imaging investigation procedures, such as neurosonography and magnetic resonance (MR) neurography can provide decisive information on this aspect. As a rule, the decision on the indications for a nerve operation should be made within the first 3 months. Even with optimal therapy the healing process of severe neural injuries is often unsatisfactory. For some years novel procedures for improvement of nerve regeneration have been tested in animal experiments which involve totally different points in the healing process. It is hoped that with these approaches procedures for improvement in the treatment of nerve injuries in humans can be developed in the near future.

The EMIT FreeLevel ultrafiltration technique compared with equilibrium dialysis and ultracentrifugation to determine protein binding of phenytoin.

A rapid new ultrafiltration technique (EMIT FreeLevel System I) for the routine measurement of unbound phenytoin concentrations was evaluated. The precision of this procedure was sufficient (between-days coefficient of variation, 11.7%). The results obtained by the ultrafiltration technique for the percentage of free phenytoin in samples from about 40 non-uraemic patients treated with this drug were in good agreement with those determined by ultracentrifugation and equilibrium dialysis (ultrafiltration vs ultracentrifugation, y = 0.94x + 0.60%; ultrafiltration vs equilibrium dialysis, y = 1.02x - 0.60%). The mean value of the results obtained by ultracentrifugation was significantly about 8% lower than that observed with equilibrium dialysis, apparently due to a sedimentation of free phenytoin during ultracentrifugation. With the methods used in our study, the mean values of percentage phenytoin bound to serum proteins obtained in samples from non-uraemic patients ranged from 91.8 to 92.8%. All 3 methods yielded similar binding curves for phenytoin, with spiked human pool sera containing albumin concentrations between 19 and 45 g/L. A rise of the unbound phenytoin fraction was observed with increasing total concentrations of the drug and a decrease of the albumin concentration. With samples from non-uraemic patients (n = 203), a rather good correlation was found between free and total phenytoin concentrations (r = 0.91). In a number of patients (n = 11), free phenytoin concentrations correlated better than total phenytoin concentrations with the clinical status. Patients with free phenytoin concentrations of less than or equal to 2.1 micrograms/ml and total phenytoin concentrations above the therapeutic range did not show signs of toxicity. From the results of our study it is concluded that the EMIT FreeLevel ultrafiltration technique is very well-suited for a rapid and reliable separation of unbound phenytoin. In patients with altered protein binding or an unusual clinical response, free phenytoin determinations appear to be necessary for proper interpretation of total phenytoin levels and rational dosage adjustment.

Brachial plexus injury after cardiac surgery. The role of internal mammary artery preparation: a prospective study on 1000 consecutive patients.

Brachial plexus injury is a typical complication after median sternotomy. A prospective study was performed on 1000 consecutive patients to determine whether preventive actions, including lower position and least possible opening of the sternal retractor, help to reduce the complication rate. Twenty-seven patients were observed with postoperative brachial plexus injury. Nerve conduction measurements and electromyography were performed. Patients without preparation of the internal mammary artery had a complication rate of less than 1%, whereas the complication rate of those patients with preparation of the internal mammary artery was as high as 10.6%. The main symptoms were continuous pain and motor and sensory disturbances. Most frequent were lesions corresponding to the roots C8-T1. Six patients had Horner's syndrome; three had ptosis only with no other signs of Horner's syndrome. Symptoms persisted in eight patients more than 3 months after the operation, and one patient still had intractable pain. Increasing use of internal mammary artery grafts in coronary artery bypass demands measures to protect the brachial plexus.

Familial migraine coma: a case study.

A family suffering from a rare malignant type of migraine is described. The syndrome is characterized by episodes of coma with meningitic signs and fever and pareses as well as persistent cerebellar signs. Coma attacks last up to several days and can be precipitated by minor head trauma, vigorous work and angiography. From a study of this family and the literature, it is concluded that this syndrome has to be included in the differential diagnosis of coma and that angiography should be avoided in the patients.

Spinal cord injury caused by a lateral C1-2 puncture for cervical myelography.

A case is reported of a metrizamide injection into the cervical spinal cord during myelography via a lateral C1-2 puncture. This resulted in a mild persistent neurological deficit. The literature is reviewed.

A three-year prospective study of systemic manifestation in rheumatoid arthritis.

Rheumatoid arthritis (RA) as a systemic disease can attack many other organs in addition to the joints. A variety of pathological lesions of the blood vessels are responsible for the extra-articular features (EAF). In the present study, we investigated firstly whether the presence of blood vessel changes in one organ--namely the skin--may indicate blood vessel pathology and, consequently, EAF in other organs. Secondly, we investigated the number of EAF in individual patients with RA, and observed whether this changed during the course of the disease. Fifty-one RA-patients (40 female, 11 male; ages had a mean of 49.5, minimum 19, maximum 73 years; mean duration of RA was 7.3, minimum 0.25, maximum 41 years) were included in the study. Punch biopsies from the posterior calf were examined immunohistologically for vessel wall immune deposits. Further, EAF were determined by means of instrumental clinical methods such as pulmonary function test, echocardiography, electromyography, and nerve conduction velocity measurement. At the first investigation 21/51 patients had skin vessel wall immune deposits (SVWID). Five patients--all showed SVWID at first investigation--died during the three-year investigation period, 10 patients could not be followed-up for unknown reasons; the skin biopsy of one patient could not be assessed. At the final investigation, we found SVWID in 11/35 patients. SVWID-positive patients had more EAF compared to SVWID-negative patients; this was true both, at the first investigation (1.85 EAF/patient vs 1.05 EAF/patient) and at the final investigation (1.91 EAF/patient vs 0.67 EAF/patient).(ABSTRACT TRUNCATED AT 250 WORDS)

An animal model for aseptic necrosis after intramuscular injections.

Ten drugs or vaccines commonly given to patients by intramuscular injection were injected into the femoral artery of normal young anaesthetized pigs, in order to establish an animal model for macroscopically identifiable aseptic tissue necrosis (Nicolau syndrome). Despite the wide range of constituents and chemical groupings in the drugs which had caused Nicolau syndrome in patients, when injected into the pigs a typical pattern of reactions could be observed for many of them, as follows: the leg contracted rapidly, the skin area supplied by this artery initially became pale and then bluish-red with an irregular reticular appearance before finally tissue necrosis developed. These reactions are comparable to the symptoms of Nicolau syndrome in man. However, no reactions were seen when drugs or vaccines which have not been known to cause aseptic necrosis in man, e.g. tetanus toxoid, influenza vaccine or triamcinolon, were injected i.a.

Isolated complete paralysis of the tensor fasciae latae muscle.

We report on an isolated complete paralysis of the tensor fasciae latae muscle, which led to a minimal functional disability.

[Iatrogenic lesions of peripheral nerves in surgery]. / Iatrogene Läsionen peripherer Nerven in der Chirurgie.

The frequency of various iatrogenic nerve injuries is reported based on an evaluation of representative material from medical liability proceedings. During operations, nerve injuries occurred most frequently in the neck (lymph node biopsy, thyroidectomy) and the extremities (operations on the hand, total hip arthroplasty). Paralysis of the sciatic nerve following intragluteal injection is still the main injury caused by injection.

[Aseptic tissue necrosis: a severe complication after intramuscular injections]. / Aseptische Gewebsnekrose: eine schwerwiegende Komplikation nach intramuskulärer Injektion.

Aseptic necrosis after intramuscular injection (Nicolau syndrome) occurred in 38 patients. Symptoms were severe immediate pain, swelling and livid discoloration of the skin with development of gangrene of skin and muscle tissue. It was the result of an unintentional intra-arterial injection of toxic substances: to assume an allergic reaction is unwarranted. Since irreversible tissue damage occurs within a short time, treatment results are unsatisfactory. For this reason prevention is essential. Using proper precautions, intra-arterial injections can be largely avoided. Since the greater proportion of these severe complications occurs after the administration of antirheumatic drugs, there should be a fundamental reconsideration of the need for intramuscular application of such drugs, as pharmacologically it is not essential.

[Malpractice in otorhinolaryngology. Report of experiences of the Board of Arbitration in Hannover]. / Uber Behandlungsfehler in der Hals-Nasen-Ohren-Heilkunde. Ein Bericht über Erfahrungen der Schlichtungsstelle in Hannover.

In this article we report on the observations of an arbitration board for medical indemnity problems. The task of this board is to settle disputes concerning the reproach of medical malpractice privately. The producers of the arbitration board are explained. In a survey the proceedings with claims against otorhinolaryngologists are presented. Iatrogenic damages were most often seen after nasal sinus surgery. Recurrent laryngeal nerve palsy after thyroidectomy, spinal accessory palsy after posterior triangle operations and complications after intramuscular injections are frequent iatrogenic injuries of general interest.

[Idiopathic autonomic neuropathy. An important disease in differential diagnosis]. / Idiopathische autonome Neuropathie. Eine differentialdiagnostisch wichtige Erkrankung.

HISTORY AND CLINICAL FINDINGS: Two weeks after a mild viral infection a previously healthy 22-year-old woman developed ileus, a severe abnormality of orthostasis, sicca (Sjögren's) syndrome, bilateral miosis and generalized hyphidrosis. Pelvic endoscopy and laparotomy failed to clarify the cause of the mechanical ileus. INVESTIGATIONS: Neurological examination revealed an isolated abnormality of the autonomic system, involving both sympathetic and parasympathetic components. Schellong's, Schirmer's and the ninhydrin tests were markedly abnormal. There was no heart rate variation on breathing and a post-Valsalva hypotensive blood pressure overshoot. Further tests failed to find a cause of the neuropathy. DIAGNOSIS, TREATMENT AND COURSE: The diagnosis of idiopathic panautonomic neuropathy (pandysautonomia) was made. The ileus and hypotension were treated symptomatically with neostigmine, cisapride, midodrine and, initially, with enemas, nasogastric tube feeding and parenteral fluids. The patient was free of symptoms at follow-up examination a year later. CONCLUSIONS: Idiopathic autonomic neuropathy should be considered in the differential diagnosis of functional abnormalities of the sympathetic and/or parasympathetic nervous system, especially in previously healthy young people, in the presence of orthostatic, unexplained gastrointestinal and hidrotic symptoms.

The importance of skin vessel wall immune deposits in the course of the systemic and articular features of rheumatoid arthritis. A prospective study.

Fifty-one rheumatoid arthritis patients were examined prospectively during a 3-year investigation period by means of immunohistological, histological, and instrumental clinical methods. Skin vessel wall immune deposits (SVWID) were found in 21/51 patients at the first and in 11/35 patients at the concluding investigation. Patients with SVWID showed more extra-articular features, more rapid progress of joint damage, higher mortality frequency, higher inflammatory activity, and higher levels of circulating immune complexes, compared with patients without SVWID.