Anaphylaxis following intravenous paracetamol: the problem is the solution.

Paracetamol is a ubiquitous analgesic and antipyretic that is widely administered, including by anaesthetists. Immediate hypersensitivity reactions to intravenous paracetamol are particularly rare. We report two cases involving four separate episodes of anaphylaxis to intravenous paracetamol in different perioperative settings without a past history of intolerance to the oral form. The allergological investigations are described, during which it became evident that both patients were allergic to an excipient (mannitol) present in the formulation and that neither was allergic to the principal agent (paracetamol). The importance of referral and investigation of perioperative drug reactions is underscored by these two cases.

Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. A preliminary study.

PURPOSE: To study the efficacy and safety of 0.1% Trypan Blue dye to stain the anterior capsule for capsulorhexis in mature and hypermature cataracts. METHODS: This preliminary study included 25 eyes of 25 patients with a unilateral mature or hypermature cataract, including one case of traumatic mature cataract. In all these cases 0.2 ml of 0.1% trypan blue dye was used to stain the anterior capsule. The efficacy and safety of the dye was evaluated on the basis of intraoperative and postoperative observations. RESULTS: In all 25 eyes the capsulorhexis was completed. There was peripheral extension of the capsulorhexis in the eye with traumatic cataract and the stained edge of the anterior capsule helped identification and redirection of the capsulorhexis. Successful phacoemulsification with intraocular lens implantation was performed in all eyes. Adverse reactions related to the dye such as raised intraocular pressure, anterior chamber inflammation and endothelial damage were not observed in the immediate postoperative period or at the end of mean follow-up of 3 months. CONCLUSION: Trypan blue dye staining of the anterior capsule appears to be a very useful and safe technique that simplifies capsulorhexis in mature and hypermature cataracts.

Malignant melanoma of ciliary body: a case report.

Ocular malignant melanomas are infrequently seen in Indian patents and most them involve the choroid. Ciliary body malignant melanoma is rather rare. This case report illustrates an occurrence in an Indian patient.

Lipaemia retinalis in a case of juvenile diabetic ketoacidosis.

A rare case of diabetic retinal lipaemia is described in a 5-year-old child.

Clinical assessment of autonomic functions in anemics.

Sixty five anemics and 20 healthy control subjects carefully age and sex matched were subjected to seven standardised tests to evaluate autonomic status. Due care was taken to remove factors which could interfare with the results. Tests concerned with the basal parasympalhetec tone viz heart rate response to standing (p < 0.001) and intravenous atropine test (p < 0.05) showed significant difference which persisted with severity and type of anemia. Test requiring stimulation of the parasympathatic system i.e. deep breathing test, valsalva maneuver and carotid sinus massage did show not significant difference. No difference of significance was found with postural fall of blood pressure and sustained hand grip test, chiefly concerned with the sympathatic system. These results suggest that anemics have low basal parasympathatic outflow to increase the heart rate as compensatory mechanism. Stimulation of parasympathatic and sympathetic system arouse normal response.

Clinical dysautonomia in diabetes mellitus--a study with seven autonomic reflex function tests.

Thirty-eight patients of NIDDM, 12 of IDDM and 10 healthy age matched controls were subjected to seven standardised autonomic reflex function tests. A scoring criteria was utilised for diagnosing and grading the severity of dysautonomia. Eight patients of IDDM and 24 of NIDDM had dysautonomia. One-third of the patients in each group had grade IV autonomic dysfunction. Severity of autonomic dysfunction was directly related to the duration of disease in NIDDM whereas in IDDM this relation was not seen. Peripheral neuropathy was almost always associated with dysautonomia in NIDDM. On the contrary, in IDDM dysautonomia was independent of peripheral neuropathy. Charcot's arthopathy, dysphagia, constipation and nocturnal diarrhea were always associated with evidence of dysautonomia. Other symptoms viz. gustatory sweating, postural dizziness and impotence did not necessarily indicate dysautonomia.

Caffeine-stimulated fatty acid oxidation is blunted in CD36 null mice.

AIM: The increase in skeletal muscle fatty acid metabolism during exercise has been associated with the release of calcium. We examined whether this increase in fatty acid oxidation was attributable to a calcium-induced translocation of the fatty acid transporter CD36 to the sarcolemma, thereby providing an enhanced influx of fatty acids to increase their oxidation. METHODS: Calcium release was triggered by caffeine (3 mm) to examine fatty acid oxidation in intact soleus muscles of WT and CD36-KO mice, while fatty acid transport and mitochondrial fatty acid oxidation were examined in giant vesicles and isolated mitochondria, respectively, from caffeine-perfused hindlimb muscles of WT and CD36-KO mice. Western blotting was used to examine calcium-induced signalling. RESULTS: In WT, caffeine stimulated muscle palmitate oxidation (+136%), but this was blunted in CD36-KO mice (-70%). Dantrolene inhibited (WT) or abolished (CD36-KO) caffeine-induced palmitate oxidation. In muscle, caffeine-stimulated palmitate oxidation was not attributable to altered mitochondrial palmitate oxidation. Instead, in WT, caffeine increased palmitate transport (+55%) and the translocation of fatty acid transporters CD36, FABPpm, FATP1 and FATP4 (26-70%) to the sarcolemma. In CD36-KO mice, caffeine-stimulated FABPpm, and FATP1 and 4 translocations were normal, but palmitate transport was blunted (-70%), comparable to the reductions in muscle palmitate oxidation. Caffeine did not alter the calcium-/calmodulin-dependent protein kinase II phosphorylation but did increase the phosphorylation of AMPK and acetyl-CoA carboxylase comparably in WT and CD36-KO. CONCLUSION: These studies indicate that sarcolemmal CD36-mediated fatty acid transport is a primary mediator of the calcium-induced increase in muscle fatty acid oxidation.

Outcome of cataract extraction and posterior chamber intraocular lens implantation following glaucoma filtration surgery.

PURPOSE: To evaluate the outcome of cataract extraction (CE) after glaucoma filtering surgery (GFS). METHODS: A total of 77 eyes (77 patients) who underwent CE with posterior chamber intraocular lens (PCIOL) implantation following GFS by a single surgeon were reviewed. Main outcome measures were preoperative and postoperative intraocular pressures (IOPs), visual acuities, medications, astigmatism, bleb survival, time of surgical failure, complications, and success rate. RESULTS: Mean time interval between GFS and CE was 46.8+/-50.9 months (range, 2-348 months). The mean preoperative IOP was 13.9+/-4.7 mmHg (range 3-27 mmHg) and mean postoperative IOP at 3 weeks was 13.6+/-5.5 mmHg (range, 6-44 mmHg). The mean follow-up was 19.5+/-20.1 months (range, 1.4-73 months; median 10.6 months). Complete success was achieved in 59 eyes (76.7%). The cumulative probability of complete success was 91.3+/-3.7, 82.0+/-5.6 and 78.1+/-6.5% at the end of 6 months, 1, and 2 years, respectively. Visual acuity before CE was < or =20/50 in all eyes (100%). Visual acuity at last visit was > or =20/40 in 33 eyes (42.8 %), 20/50-20/80 in 30 eyes (39.0%), < or =20/100 in 14 eyes (18.2%). Risk factors identified for qualified success included age at CE>60 years, interval of < or =5 months between GFS and CE, use of preoperative glaucoma medications, and postoperative IOP >19 mmHg within 2 weeks. CONCLUSIONS: IOP and bleb function was maintained after CE with PCIOL implantation following successful GFS with good visual recovery.

The wider base of the family planning programme.

PIP: The integration of family planning with medical services is the long-term goal for population control in India. To ensure infant survival and thus reduce the numbers of children, family planning has also been linked with maternity and child health services. This wider base for population control is essential but must be coupled with a missionary zeal toward lowering the birthrate. Mass education and motivation are needed through the media, group approaches, and individual contacts. Methods of channeling social pressures in favor of small families needs to be tried. Long-range measures include raising the marriageable age of girls and increasing their education and opportunities for employment. Family planning programs should be directed by social welfare experts as opposed to medical administrators in order to give the family planning program a broad interdisciplinary base for action.^ieng

Chronic fatigue syndrome: a literature review from a physiatric perspective.

To examine the literature on chronic fatigue syndrome (CFS), especially as it relates to cognitive deficits and exercise, more than 200 articles related to CFS were selected from computer-based research as well as pertinent articles noted in the references of individual articles. All were relevant articles on CFS, although articles in a foreign language were excluded. CFS is a controversial diagnosis of exclusion, but certain subgroups do appear to exist. It may represent multiple diseases or multiple stages of the same disease. Although cognitive deficits are commonly reported, the measured impairments are relatively subtle and are in the area of complex information processing speed, or efficiency. Magnetic resonance imaging, single-photon emission computer tomography, and neuroendocrine studies present preliminary evidence suggestive of the cerebral involvement primarily in the white matter. The weakness and fatigue may be the result of alterations in the central nervous system, not in the peripheral muscles. However, it is hard to separate the documented weakness and endurance deficits from deconditioning. Autonomic symptoms such as orthostatic intolerance and a predisposition to neurally mediated syncope may be explained by cardiovascular deconditioning, a postviral idiopathic autonomic neuropathy, or both. The review points out the need for more carefully designed studies of CFS that focus on the relationship between neuropathology, psychopathology and neuropsychologic functioning. The role of exercise as a stimulus for exacerbation or in treatment needs to be further studied using clear diagnostic criteria as well as control groups that carefully match the activity level.

Methods used in the evaluation of clinical competency of physical medicine and rehabilitation residents.

A 17-item questionnaire was designed to determine how physical medicine and rehabilitation (PM&R) training directors assess their residents' clinical competency. A response rate of 83% (62/75) was obtained. Seventy-nine percent (49/62) have a written resident supervision policy, and 73% (45/62) have a written resident probation policy. Ninety-four percent (58/62) believe that their system of evaluating residents' clinical competency is effective, although many commented that it could be improved. 76% (47/62) of the residency training directors made the final decision regarding residents' clinical competency. Fifty-two percent (32/62) have a departmental written examination, and 23% (14/62) have formal oral examinations. Eighteen percent (11/62) use an objective structured clinical examination (OSCE), 8% (5/62) use standardized patients and 3% (2/62) use videotaped patient encounters. Forty percent (25/62) use medical record audits. Fifty percent of the programs have rated at least one resident unsatisfactory during a clinical rotation in the past 3 yr, and 11% (7/62) have reported to the American Board of Physical Medicine and Rehabilitation that the overall clinical evaluation of one resident was unsatisfactory in the past 3 yr. Forty-seven percent (29/62) of the programs have asked at least one resident to leave their program in the past 3 yr. The OSCE is emerging as the state-of-the-art method for assessing clinical skills, although it is expensive. The measurement of clinical competency is important in the certification and recertification process, and our specialty needs better methods to assess these performance skills.

Successful prosthetic fitting of a patient with epidermolysis bullosa dystrophica. Case report.

A patient with recessive dystrophic epidermolysis bullosa developed a squamous cell carcinoma of the right foot resulting in a below the knee amputation. Despite the multiple real and potential skin problems of the stump, she was successfully fitted with a simply designed prosthesis and rehabilitated.

Chief residents in physiatry. Expectations v training.

A large majority of physical medicine and rehabilitation residencies have chief resident positions, but little has been written about the expectations of the program directors and the training of the chief resident to fulfill those expectations. A 20-item questionnaire was mailed to 73 program directors in physical medicine and rehabilitation in May 1992. The participants were asked about selection methods, their perception of the duties of the chief resident(s), their concerns about the chief resident(s) position, the training and the evaluation of the chief resident(s). An 85% (62/73) response rate was achieved. There was a chief resident position(s) in 98% of the programs responding. Chief resident selection was made mostly by appointment of the chairman and/or program director and/or the vote of the faculty. The program directors perceived the most important duties of the chief resident to be: act as a liaison between faculty and the residents, act as a role model, do scheduling, build teamwork and give constructive feedback. The most important skills were considered to be leadership and stress management. Causes of concern were time pressure, abuse of power, stress and work overload. Opportunities to develop leadership and administrative/management skills were considered the most exciting aspects of the position. It was surprising, however, that only 15 of 61 (25%) provided some formal training. Only 28 of 61 (46%) had a position description.

Current status of chairpersons in physical medicine and rehabilitation.

There are currently 77 academic departments, divisions or units of physical medicine and rehabilitation (PM&R) in the United States. The authors conducted a survey to develop a profile of the current chairpersons of PM&R, as well as to assess the short- and long-term needs of the field. The survey addressed basic demographic information as well as the level of formal training and/or experience in various management, patient care and academic areas. The level of satisfaction with various aspects of the position such as workload, relationship with the university and role as a researcher were also measured. The chairpersons were asked when they plan to vacate their position and if they felt there were any members of their faculty who are qualified and ready to assume a chairperson position. Those that identified a qualified individual were then asked whether the person had formal training and/or experience in the various management, patient care and academic areas. The results indicate that, although the chairpersons have a high level of job satisfaction with respect to the challenge of the position and their administrative and supervisory roles, they are least satisfied with their role as a researcher. The field must be concerned with this finding, because academic PM&R units in the United States will experience a substantial change in leadership by the end of the 20th century. Approximately 39% of the current chairpersons who returned the questionnaire are planning to step down by 1999, with an additional 37% unsure when they will vacate the position.(ABSTRACT TRUNCATED AT 250 WORDS)

Physiatric research fellows' perceptions of the quality of their training.

A survey was conducted to evaluate the physiatric research fellowship training. A 22-item questionnaire was sent to the 42 identified physiatrists who had completed at least a 1-yr research fellowship. Twenty-nine of these individuals (69%) responded. The physiatrists, all of whom have completed their research fellowships, uniformly cited competent faculty research mentors as being critical, even if they were not in the same department. Having protected research time as well as a research didactic program and journal club were highly rated issues. The trainees preferred a 2-yr fellowship that also stressed initiation of their own research, grant writing and management experience, and first authorship on research papers. We conclude that the majority of the research fellows agree on what are important issues with respect to their training.

Residency training in physiatry during a time of change: funding of graduate medical education and other issues.

Decision makers at the federal and state level are considering, and some states have enacted, a reduction in total United States residency positions, a shift in emphasis from specialist to generalist training, a need for programs to join together in training consortia to determine local residency position allocation strategy, a reduction in funding of international medical graduates, and a reduction in funding beyond the first certificate or a total of five years. A 5-page, 24-item questionnaire was sent to all physiatry residency training directors. The objective was to discern a descriptive database of physiatry training programs and how their institutions might respond to cuts in graduate medical education funding. Fifty-eight (73%) of the questionnaires were returned. Most training directors believe that their primary mission is to train general physiatrists and, to a much lesser extent, to train subspecialty or research fellows. Directors were asked how they might handle reductions in house staff such as using physician extenders, shifting clinical workload to faculty, hiring additional faculty, and funding physiatry residents from practice plans and endowments. Physiatry has had little experience (29%; 17/58) with voluntary graduate medical education consortiums, but most (67%; 34/58) seem to feel that if a consortium system is mandated, they would favor a local or regional over a national body because they do not believe the specialty has a strong enough national stature. The major barriers to a consortium for graduate medical education allocation were governance, academic, fiscal, bureaucratic, and competition.