Long-term results of 405 refractory trigeminal neuralgia surgeries in 256 patients.

BACKGROUND AND OBJECTIVES: The initial response of trigeminal neuralgia to medication is about 69%. However drug therapy is ineffective in 25% of patients and about 8% become drug-intolerant. These patients proceed to surgical interventions, which require constant appraisal to determine their efficacy and acceptability. The purpose of this study was to evaluate the long-term outcome of surgical interventions for trigeminal neuralgia to offer a guide to patients and surgeons when choosing the right procedure for the appropriate patient and to investigate the effects of patients' and surgeons' preferences on the outcome. PATIENTS AND METHODS: The study design was consecutive case review. Participants were 256 consecutive patients with refractory trigeminal neuralgia, who underwent 405 surgical procedures to control trigeminal neuralgia. The main outcome measures were: the response rate, time to pain recurrence and surgical complications. 172 were fit for microvascular decompression (MVD), glycerol injection (GI) or radiofrequency thermocoagulation (RF) and were offered the choice between the three procedures; 95 went for MVD and 77 underwent either GI or RF. The choice between GI and RF was a surgical decision. RESULTS: The 3-year success rate was 54.8% in patients who underwent GI and 70.7% in patients who underwent percutaneous RF. In contrast 85.6% of patients who underwent MVD remained pain-free at 3 years. The complication rate following these surgical interventions was relatively low with no deaths. CONCLUSIONS: Surgical intervention for the treatment of refractory trigeminal neuralgia is effective and safe and should be considered in patients after failed medical therapy. Whilst MVD offered the best long-term outcome in this series, percutaneous GI or RF offered a safe and reliable alternative for those who chose to undergo these procedures.

Initial experiences with telerehabilitation and contingency management programs for the prevention and management of pressure ulceration in patients with spinal cord injuries.

Two alternative treatment methods for preventive interventions for pressure ulcers, tele-rehabilitation and contingency management, are discussed. Telerehabilitation uses a videophone that transmits both audio and still images over a telephone line. Using this technology, the WOC nurse can interview a patient who cannot be present at a clinic because of physical condition or distance. Telerehabilitation allows the nurse to assess a patient's pressure ulcer, consult with appropriate caregivers, and make recommendations for treatment. Contingency management procedures are designed for patients with high rates of noncompliance in skin care. The patients are seen as outpatients and are compensated systematically for appropriate skin care (ie, the lack of pressure ulcers). Examples of each of these patient interventions is described, discussed, and contrasted.

The ethics of using contingency management to reduce pressure ulcers: data from an exploratory study.

Although there is a widely held argument that pressure ulcers are preventable, they continue to cause major healthcare and financial problems. The blame for pressure ulcers has typically focused on the patient's self-neglect or self-destructiveness. However, more recently, there has been a call for a paradigm shift from the current "paternalistic" medical model to one that includes the patient as a participant in his or her own care. Contingency management, a procedure well known in behaviorism, is presented as one such possibility. Controversy about the use of monetary reward, as well as discussion of initial efficacy in a current study, are discussed.

Using telemedicine in the treatment of pressure ulcers.

Pressure ulcers are dynamic and therefore require frequent assessment and immediate treatment. For many patients who live long distances from rehabilitation hospitals, frequent assessment and immediate treatment are often unavailable. Recent advances during the last two decades have resulted in the development of telemedicine--long-distance delivery of medical education and services to patients. This pilot study reports on a patient enrolled in a telemedicine program during his fifth hospitalization for pressure ulcers in 16 months. Although this is only a single case study, the results suggest the potential efficacy of this new intervention.

Organization of Chemically Activated Food Search Behavior in Procambarus clarkii Girard and Orconectes rusticus Girard Crayfishes.

The feeding responses of decapod crustaceans to chemical stimuli have most often been evaluated in terms of one defining act, ignoring the organization of the behavior. To gain greater insight into foraging behavior, we considered the organization of food-search behavior in evaluating the responses of two species of crayfishes to a feeding stimulant. We also examined the effects of food deprivation on the behavioral organization and whether a behavioral dichotomy exists between food search and feeding behavior in these species. Individual crayfish of the species Procambarus clarkii and Orconectes rusticus were presented with infusions of a feeding stimulant consisting of a supernatant leachate of 100 ml water and 1 g of fish flakes. The stimulant was injected with a syringe and small-bore plastic infusion tubing into the center of a behavioral arena 25 cm square and 15 cm deep. Total injection time was 20 s. Experimental groups were presented with either the full-strength leachate (100%) or one of five dilutions: 75%, 50%, 25%, 10%, or 0% (controls) of full-strength. The feeding stimulant was presented either the day after the crayfish were fed or after one week of food deprivation. We analyzed three components of food-search behavior--detection, probing (near-field search), and locomotion (far-field, or distant, search)--recording the order of occurrence and the latency time to initiation for each behavior. When presented with the stimulus following regular feeding, both species responded to concentrations {ge}50% full-strength with probing behavior (near-field search) prior to locomotion, and to concentrations <50% full-strength with locomotion prior to, or even in the absence of, probing. Detection always occurred first. These results indicate that chemical stimuli preferentially activate distant food search in both species and that a behavioral dichotomy exists between food search and feeding behavior. One week of food deprivation had no effect on the organization of food-search behavior in P. clarkii; however, groups of unfed O. rusticus presented with 25% and 10% full-strength concentrations probed prior to locomotion, indicating a change in behavioral organization.

Discriminative stimulus effects of butorphanol: influence of training dose on the substitution patterns produced by Mu, Kappa and Delta opioid agonists.

The discriminative stimulus effects of butorphanol were examined in separate groups of pigeons trained to discriminate either a low (0.1 mg/kg), medium (1.0 mg/kg) or high (5.6 mg/kg) dose of butorphanol from saline. The mu-selective opioid antagonist naloxone was considerably more potent than the delta-selective opioid antagonist naltrindole in antagonizing the effects of butorphanol. In each of the training dose groups, the mu opioid agonists morphine, l-methadone and fentanyl, as well as buprenorphine, (-)-pentazocine, nalbuphine, (-)-metazocine and nalorphine, substituted completely for the butorphanol stimulus. The rank order of potency for these compounds in substituting for the butorphanol stimulus was similar across training dose groups and similar to those reported in studies in which fentanyl or morphine were used as training stimuli. (-)-N-allylnormetazocine (NANM) and levallorphan substituted completely for the butorphanol stimulus in the low-dose group, and substituted partially for and antagonized partially the butorphanol stimulus in the medium- and high-dose groups. The kappa opioid agonists spiradoline, bremazocine, U50,488 and U69,593 substituted partially for butorphanol in the low-dose group, an effect that was not reversed by naloxone. In the medium- and high-dose groups, these kappa opioid agonists produced predominantly saline-appropriate responding. The delta opioid agonist BW373U86 substituted completely for butorphanol in the low-dose group, and naltrindole was more potent than naloxone in antagonizing these effects. In the medium- and high-dose groups, BW373U86 substituted partially for the butorphanol stimulus. Unlike the substitution patterns produced by the mu, kappa and delta opioid agonists, the sigma/phencyclidine compounds (+)-cyclazocine and (+)-NANM and the barbiturate pentobarbital produced predominantly saline-appropriate responding in all training dose groups. The present findings suggest that opioids with agonist activity at mu, kappa and delta opioid receptors share similar stimulus effects with a low training dose of butorphanol, whereas only opioids with agonist activity at the mu opioid receptor share stimulus effects with a medium and high training dose of butorphanol.

Opioids and rate of positively reinforced behavior: III. Antagonism by the long-lasting kappa antagonist norbinaltorphimine.

Various opioid compounds were examined before and after administration of a 40µg (i.c.v.) dose of norbinaltorphimine (nor-BNI) in rats responding under a fixed ratio 20 schedule of food presentation. At time points ranging from 1 to 133 days after administration of nor-BNI, the dose-effect curve for the kappa opioid bremazocine was shifted to the right of that obtained prior to the administration of nor-BNI. The magnitude of these rightward shifts were somewhat larger at day 14 than day 1, remained unchanged between days 14 and 49, and then declined between days 70 and 133. Nor-BNI also produced large rightward shifts in the dose-effect curves for the kappa opioids U50,488, spiradoline and U69,593, and a small rightward shift in the curve for ethylketocyclazocine. In contrast, nor-BNI did not alter the dose-effect curves for (-)-n-allylnormetazocine, (-)-cyclazocine, nalorphine and the mu opioid morphine. The present findings indicate that the rate-decreasing effects of bremazocine, U50,488, U69,593, spiradoline and ethylketocyclazocine are mediated by agonist activity at the kappa opioid receptor(s). These findings also indicate that nor-BNI is a long-lasting and kappa opioid-selective antagonist that offers a number of advantages over naloxone and naltrexone as a pharmacological tool for examining the kappa opioid-mediated activity of opioid compounds.

Injuries sustained from high velocity impact with water: an experience from the Golden Gate Bridge.

Over 720 persons are reported to have died jumping from the Golden Gate Bridge. A review of 100 consecutive autopsies showed that, in the majority of cases, massive pulmonary contusion, pneumothorax, laceration or perforation of the heart, great vessels, or lungs by displaced ribs were the causes of immediate death. Irreparable fractures of the liver or spleen were the most common abdominal injuries. The persons fatally injured appeared to have entered the water in a horizontal position, experiencing maximal deceleration. In contrast, six survivors entered the water feet first with more gradual deceleration. These survivors remained conscious but sustained similar injuries of lesser degree; only one sustained rib fractures. Fifty per cent had fractures of the liver or spleen requiring operative therapy. Fifty per cent sustained lung contusions and subsequent pneumothoraces. Suspicion of underlying injuries to the liver, spleen, and lungs is essential during resuscitation of those who survive impact with water.

Further experience with anterior gastric fixation in the management of hiatal hernia.

Anterior gastropexy in properly selected patients is a simple, safe, and effective procedure for the surgical correction of symptomatic esophageal reflux in the presence of a sliding type of hiatal hernia not accompanied by fibrosis and secondary shortening of the esophagus. This technic is particularly useful in poor risk, elderly, and excessively obese patients and as an adjunct to other intraabdominal procedures.

Unusual manifestations of pancreatic pseudocysts and their surgical management.

Six cases representing selected complications of pancreatic pseudocyst are reported and their surgical management is discussed. Patients with mediastinal extension of a pseudocyst frequently present with symptoms in the chest rather than in the abdomen. Chronic recurrent pleural effusion, rich in protein and amylase, often accompanies mediastinal extension of a pancreatic pseudocyst. It is important to recognize that such an effusion almost certainly represents disruption of the pancreatic duct with formation of a pancreatic pseudocyst or a pancreaticopleural fistula. Internal drainage from below the diaphragm is the treatment of choice for pancreatic pseudocysts extending into the mediastinum. To be certain that obstructive jaundice is due to a pancreatic pseudocyst, there must be operative demonstration of compression of the common bile duct by the pseudocyst, relief of the obstruction by surgical drainage of the cyst, and subsequent disappearance of jaundice. Cysts that cause jaundice are located in the head of the pancreas, and cystoduodenostomy is the treatment of choice. Intraperitoneal rupture has been associated with a high mortality, but with adequate fluid replacement, prompt evacuation of the cyst contents from the peritoneal cavity, and adequate drainage, mortality can be lowered. Pancreatic ascites is much more common than is generally supposed and may result from a leaking pancreatic pseudocyst. In contrast to cirrhotic ascites, pancreatic ascites produces elevation of both the serum amylase level and protein concentration. Massive hemorrhage from pancreatic pseudocysts is usually due to the development of a false aneurysm in a branch of the celiac axis in the wall of the pseudocyst, with subsequent rupture of the aneurysm into the gut or peritoneal cavity. Any patient with a pancreatic pseudocyst who shows signs of bleeding should have prompt arteriography for determination of the bleeding site and appropriate surgical control. Pancreaticobronchial fistula is a rare complication. Treatment should be directed toward adequate drainage of the pseudocyst in the abdomen.