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PubMed2000

Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients.

BACKGROUND AND OBJECTIVES: Internal carotid artery dissection has been extensively studied and well-described. Although there has been a recent increase in the number of reported cases of vertebral artery (VA) dissection, the clinical variety of presentation and the early warning symptoms have not been well-described before. Our objectives in this study include: (1) To determine the early symptoms and warning signs which may help the clinician in the early identification and treatment of patients with VA dissection. (2) To explore the variety of clinical presentation of VA dissection and its relation to prognosis. DESIGN AND SETTING: Retrospective analysis of hospital records in a tertiary academic centre for the period 1989-1999. RESULTS: Twenty-six patients were identified (13 men and 13 women). The mean age was 48. Possible precipitating factors were identified in 14 patients (53%). Sporting activity and chiropractic manipulations were the most common (15% and 11% respectively). Headache and/or neck pain was the prominent feature in 88% of patients and was a warning sign in 53%, preceding onset of stroke by up to 14 days. The most common clinical features included vertigo (57%), unilateral facial paresthesia (46%), cerebellar signs (33%), lateral medullary signs (26%) and visual field defects (15%). Bilateral VA dissection presented in six patients (24%). The most common region of dissection was the C1-C2 level (16 arteries, 51%). Intracranial VA dissection was found in eight arteries (25%). The majority of patients (83%) had favorable outcome. Poor prognosis was associated with (1) bilateral dissection; (2) intracranial VA dissection accompanied by subarachnoid hemorrhage. Only two patients reported stroke recurrence. CONCLUSIONS: Our findings show that VA dissection affects mainly middle age persons and involves both sexes equally. Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Although the majority of patients will have excellent prognosis, this was less likely in patients presenting with subarachnoid hemorrhage or bilateral VA dissection. Recurrence rate was low.

Adult↗
PubMed1997

Sertraline in diabetic neuropathy: preliminary results.

UNLABELLED: Previous research has shown that antidepressants have been useful in the treatment of pain, particularly diabetic neuropathy. This study was an initial open investigation into the use of sertraline in diabetic neuropathy. Eight patients with diabetic neuropathy but not depression were treated with increasing doses of sertraline to a maximum of 150 mg/day for 8 weeks. Sertraline treatment led to significant reductions in mean visual analog scale (VAS) ratings, e.g., pain from 71.2 to 23.1 (t = 3.74, p < .01) and paresthesias from 53.8 to 15.0 (t = 4.15, p < .01). Baseline platelet serotonin (5HT) content also correlated significantly with improvement in pain (r = 0.70,p =. 05). Plasma sertraline (SRT) correlated with improvement in paresthesias (r = 0.70). CONCLUSION: This preliminary result indicates the potential application of sertraline to treatment of diabetic neuropathy. A replication is now underway.

1-Naphthylamine↗
PubMed2000

[Alcohol and the peripheral nervous system].

The most frequent consequence of chronic alcohol intake is a toxic polyneuropathy. It results from inadequate nutrition, mainly deficiency of thiamine and other B vitamins. Additionally there is a direct neurotoxic effect of ethanol. Signs and symptoms are 1. distal sensory disturbances with pain, paresthesia, and numbness in a glove and stockings-pattern, 2. weakness and atrophy of distal muscles, pronounced in the lower limbs, 3. loss of tendon jerks, 4. affection of autonomic fibers. Therapy consists in absolute alcohol abstinence, high-caloric nutrition, parenteral thiamine and other vitamins. Against paresthesia and pain, carbamazepine, salicylates, amitryptiline are effective. Parenteral tioctacid may be tried. The prognosis of alcoholic polyneuropathy is favorable, with alcohol abstinence, within several months up to a few years. In chronic alcoholic patients peripheral nerves frequently are injured by compression during alcohol intoxication. Peroneal nerve lesions result from compression in the region of the neck of the fibula during a prolonged lying position, the radial nerve is injured during sitting with the upper arm placed on the backrest of a bench. Usually pressure palsies resolve spontaneously. Rhabdomyolysis is a rare but life-threatening complication of alcoholic delirium. Symptoms are severe muscle pain, swelling of extremities, pigmenturia. The major complications of rhabdomyolysis are renal and respiratory failure, and cardiac arrhythmias due to electrolyte imbalance. Intensive care is needed with control of hyperkalemia, hydration, alkalinization of urine, hemodialysis if indicated.

Alcoholic Neuropathy↗
PubMed2002

Fatigue in patients with chronic hepatitis C.

In numerous studies of symptoms in patients with chronic hepatitis C there has been no systematic assessment of both fatigue and extrahepatic manifestations. Our objective was to assess the prevalence of fatigue in patients with hepatitis C virus (HCV) infection, and to identify associations between fatigue and clinical and biological hepatic and extrahepatic manifestations. We studied 1614 patients. Data were prospectively recorded during the first visit of patients infected with HCV and the prevalence of fatigue and its association with dermatological, rheumatological, neurological and nephrological manifestations; diabetes; arterial hypertension; auto-antibodies, and cryoglobulinaemia were assessed. Then, using multivariate analysis, we identified demographic, biochemical, immunological, virological, and histological factors associated with the presence of fatigue. Fatigue was present in 53% of patients (95% confidence interval 51-56). In 17% of patients (95% confidence interval 15-19) fatigue was severe, impairing activity. Five other extrahepatic manifestations had a prevalence above 10% including, in decreasing order: arthralgia, paresthesia, myalgia, pruritus, and sicca syndrome. In univariate and multivariate analyses, fatigue, in comparison with the absence of fatigue, was associated with female gender, age over 50 years, cirrhosis, depression and purpura. Independent of these associations, fatigue was associated with arthralgia, myalgia, paresthesia, sicca syndrome and pruritus. The prevalence of fibromyalgia (as defined by the association of fatigue with arthralgia or myalgia) was 19% (95% confidence interval 17-21). There was no significant association between fatigue and the following characteristics: viral load or genotype, alcohol consumption, abnormal thyroid function, and type and level of cryoglobulinaemia. Hence, fatigue is the most frequent extrahepatic manifestation in patients infected with HCV. Fatigue is independently associated with female gender, age over 50 years, cirrhosis, depression and purpura.

Adolescent↗
PubMed2002

Minimally invasive thyroidectomy.

BACKGROUND: Conventional thyroidectomies by a direct approach through the neck require long incisions in the neck that can result in prominent scars, hypesthesia, and paresthesia. Minimally invasive procedures have recently been adopted for the surgical treatment of thyroid disease as a means of preventing such problems. METHODS: In the present paper, the anterior chest approach and axillary approach to endoscopic thyroidectomy are described. RESULTS: Twenty-two patients were treated by the anterior chest approach to endoscopic thyroidectomy and 28 patients by the axillary approach. The only complication was one case of postoperative emphysema. The patients were satisfied with the cosmetic results of the procedures and with the minimal degree of postoperative hypesthesia, paresthesia and discomfort. CONCLUSION: Endoscopic thyroidectomy may become the procedure of choice for the surgical treatment of carefully selected patients with thyroid disease.

Adult↗
PubMed2004

Management of steal syndrome resulting from dialysis access.

Ischemic steal secondary to a hemodialysis arteriovenous (AV) access occurs in approximately 10% of cases. The pathophysiological basis of this condition is a marked decrease or reversal of flow in the arterial segment distal to the AV fistula or AV graft, induced by the low resistance of the fistula outflow. Clinically it can manifest with either mild symptoms (coolness, paresthesia, and absence of distal pulses), or severe symptoms (rest pain, severe paresthesia, paralysis, cyanosis, and gangrene) immediately after construction of the AV access or later after its inception. Diagnosis is based on clinical manifestations, aided by the vascular laboratory and angiography. Mild cases can be observed closely, most of them will reverse in a few weeks. In order to prevent permanent sequela, severe cases require immediate intervention. Several surgical treatments have been used: access ligation, banding, elongation, distal arterial ligation, and distal revascularization-interval ligation. Best results, with maintenance of access function and reversal of symptoms, have been obtained with the distal revascularization-interval ligation procedure.

Arm↗
PubMedDate not supplied

Use of computed tomography for maxillary nerve block in the treatment of trigeminal neuralgia.

BACKGROUND AND OBJECTIVES: Maxillary nerve block has traditionally been performed by using external anatomic landmarks. However, the classic approach to the nerve may be confounded because of anatomic variability. We describe a technique for the block using the suprazygomatic route guided by computed tomography (CT). CASE REPORT: A 90-year-old woman had a 30-year history of episodic pain in her right maxillary region. We attempted to block the maxillary nerve with classic technique, but we could not identify the nerve by eliciting paresthesia. In addition, bleeding was noted after repeated attempts. To minimize complications and confirm the correct position of the needle tip, we planned the block with a suprazygomatic approach using CT guidance. The needle was inserted without paresthesia. The CT scan showed the needle tip was placed at the entrance of the pterygopalatine fossa and the distribution of contrast medium spread appropriately around the pterygopalatine fossa. After confirming the clinical effect and lack of complications of the block using the local anesthetic, 0.5 mL of 7% phenol was injected. This technique resulted in complete sensory loss in the area innervated by the maxillary nerve, and did so without complications. CONCLUSIONS: A maxillary nerve block guided by a CT imaging is an alternative to classic techniques.

Aged↗
PubMedDate not supplied

Technical aspects and postoperative sequelae of spinal and epidural anesthesia: a prospective study of 3,230 orthopedic patients.

BACKGROUND AND OBJECTIVES: Major complications after spinal or epidural anesthesia are extremely rare. The occurrence of less serious and transient sequelae and complaints may be underestimated if there is no established organization for the systematic and continuous surveillance of patients after anesthesia. This study was designed to evaluate the possible relationship between various block-related occurrences and the intra- and postoperative side effects and complaints. METHODS: This prospective study included 3,230 orthopedic patients operated on under neuraxial block. The block was performed by single-dose (single-shot spinal anesthesia [SPIN], 80.6%), continuous spinal anesthesia (CSA, 10.3%), or combined spinal and epidural anesthesia (CSE, 9.1%) technique. The patient position during surgery and a detailed description of block performance and equipment, as well as all intraoperative problems, were immediately recorded. Every patient was given a standardized questionnaire to be completed and returned after 1 week. RESULTS: The overall incidence of paresthesia was 12.8%, being most frequent during spinal catheter insertion with multiple attempts. Postoperative sensory disturbances (numbness, dysesthesia) occurred unrelated to paresthesia elicited by the puncture or catheterization. The failure rates (SPIN, 1.0%; CSA, 1.5%; and CSE, 1.0%) were quite low. Asystole with successful resuscitation, occurred in 1 patient with CSE but, overall, hemodynamic perturbations were more common with the continuous techniques. On the first postoperative day, decreased sensation of the skin was significantly more frequent after the continuous techniques, still present in 6.5% of SPIN patients, 6.1% of CSA patients, and 17.2% of CSE patients 1 week after surgery. These disturbances were also related to the use of a tourniquet and lateral position of the patient during surgery. The frequency of postdural puncture headache (PDPH) was similar for the different techniques (SPIN, 0.9%; CSA, 1.5%; and CSE, 1.7%). About one third of the patients reported strong postoperative pain on the day after the operation, and 5.6% continued to report this at 1 week. CONCLUSIONS: Although sensory changes were quite frequent, they were mild and transient. Rather than having been caused by the anesthetic technique, per se, a "nonanesthetic" reason (position, tourniquet, immobilization) should also be considered as their origin. Sensory disturbances, as well as strong pain for at least a week, were reported by several patients, and to become aware of these problems and improve the quality of treatment, a universal regional anesthesia follow-up system is recommended.

Adolescent↗
PubMedDate not supplied

Quality of analgesia when air versus saline is used for identification of the epidural space in the parturient.

BACKGROUND AND OBJECTIVES: Identification of the epidural space is often performed using the loss-of-resistance technique (LOR), commonly with air or saline. The effect of air or saline on the quality of labor epidural analgesia has not been adequately studied. METHODS: Women who requested labor epidural analgesia were randomly assigned to 1 of 2 groups depending on the syringe contents used for the LOR technique and injected into the epidural space. In the air group (n = 80) the anesthesiologist used 2 mL of air, and in the saline group (n = 80) the anesthesiologist used 2 mL of 0.9% saline. After LOR was obtained, a multiorifice epidural catheter was threaded 5 cm into the epidural space and 13 mL of bupivacaine 0.25% was administered in divided doses. The success of the epidural block was determined by asking the patient if she required additional medication 15 minutes later. The occurrence of paresthesias and intravascular or subarachnoid catheters was noted. RESULTS: In the air group, 36% of patients requested additional pain medication, and in the saline group 19% requested additional medication (P =.022). We were not able to find a statistically significant difference between groups in the incidence of paresthesias (42% air v 51% saline), intravascular catheters (5% air v 8% saline), or subarachnoid catheters (0 in both groups). CONCLUSIONS: Using 0.9% saline for the LOR technique is associated with better analgesia as compared with air for labor analgesia, and this advantage should be considered when selecting the syringe contents for the LOR technique.

Adolescent↗
PubMed1998

Cryptogenic sensory and sensorimotor polyneuropathies.

Chronic sensory or sensorimotor polyneuropathy is a common clinical problem referred to neurologists. Even with modern diagnostic approaches, up to one-third of them will remain unclassified. Recent studies have provided insight into their clinical spectrum and course. The age of onset tends to be in the sixth to seventh decade of life. Symptoms progress slowly, and most patients present with paresthesias or pain. Cryptogenic polyneuropathies are almost exclusively axonal on clinical, electrophysiologic, and histologic grounds. Overall, the prognosis is favorable, and only a small minority of patients develop significant motor disability or physical incapacitation. Progression to a nonambulatory state essentially never occurs. Successful management should focus on rational pharmacotherapy for painful paresthesias combined with patient education and reassurance.

Education, Medical, Continuing↗
PubMed1994

Inflammatory pseudotumors of the skull base.

Inflammatory pseudotumor is a rare affliction of the skull base with a propensity for locally aggressive growth. Frequently, the location of involvement does not lend itself to conventional biopsy techniques, resulting in diagnostic and treatment dilemma. A retrospective review of three unusual cases of skull base inflammatory pseudotumors is reported. These lesions illustrate the difficulty of management by virtue of their histopathology and behavior. They are clinically and radiographically indistinguishable from invasive neoplasms. One involved the petrous apex with bony erosion; a second case presented with pain and trigeminal paresthesia secondary to an infiltrative lesion in the clivus and the sphenoid sinus; and the third case involved peritubal soft tissues of the infratemporal fossa, with mandibular paresthesia and middle ear effusion. All three lesions were resected via lateral skull base approaches with no evidence of recurrence. Because of the inherent nature of this lesion and its rarity, inflammatory pseudotumor should remain a diagnosis of exclusion. When suspected, surgical approaches should be designed to allow complete extirpation with limited morbidity.

Journal Article↗
PubMed1983

Herpes simplex virus proctitis in homosexual men. Clinical, sigmoidoscopic, and histopathological features.

Acute herpes simplex virus (HSV) infection was detected in 23 of 102 consecutively examined, sexually active male homosexuals who presented with anorectal pain, discharge, tenesmus, or hematochezia, as compared with 3 of 75 homosexual men without gastrointestinal symptoms (P less than 0.01). Findings that were significantly more frequent in men with HSV proctitis than in men with proctitis due to other infectious causes included fever (48 per cent), difficulty in urinating (48 per cent), sacral paresthesias (26 per cent), inguinal lymphadenopathy (57 per cent), severe anorectal pain (100 per cent), tenesmus (100 per cent), constipation (78 per cent), perianal ulcerations (70 per cent), and the presence of diffuse ulcerative or discrete vesicular or pustular lesions in the distal 5 cm of the rectum (50 per cent). Serologic evidence indicated that 85 per cent of the men with symptomatic HSV proctitis were having their first episode of HSV-2 infection. The diagnosis of HSV proctitis is suggested by the presence of severe anorectal pain, difficulty in urinating, sacral paresthesias or pain, and diffuse ulceration of the distal rectal mucosa.

Acute Disease↗
PubMed2002

Diagnosis and management of chronic compartment syndrome.

BACKGROUND: This article describes the diagnosis and management of chronic compartment syndrome and functional popliteal entrapment syndrome, unusual causes for claudication in young adults. METHODS: A total of 276 patients (<50 years old) with isolated muscle cramping, swelling, and plantar paresthesia were routinely evaluated with compartment pressures (normal < 15 mm Hg), stress plethysmography, and selectively evaluated with pulse volume recordings and arteriography. RESULTS: Patients were young (mean 28.4 years) with long-standing symptoms (mean 24 months), affecting 1 or both lower extremities (32% vs 68%, respectively). Of the patients, 84 were male (30%) and 192 were female (70%). Common symptoms were isolated muscle cramping (100%) or swelling (40%), and plantar paresthesia (20%). Of 436 treated compartments, 316 were anterolateral, 70 deep-posterior, and 50 superficial-posterior. Mean compartment pressure was 28 mm Hg. Resting pulse volume recordings were abnormal in 6 patients (2.5%); 82 had positive popliteal entrapment tests (30%), but symptoms were present in only 21 (9.7%). Open fasciectomy was performed in all patients with chronic compartment syndrome or functional entrapment. Local anesthesia was used in 243 (88%) and general in 33 patients (12%). Mean follow-up was 60 months. Of the 276 patients, 92% had full relief of symptoms and returned to normal daily or athletic activity. Eight percent obtained symptomatic relief, but activity was limited because of new compartment symptoms or other orthopedic injury. CONCLUSIONS: Open fasciectomy for chronic compartment and functional entrapment syndromes is effective therapy.

Adolescent↗
PubMedDate not supplied

Methylmercury in populations eating large quantities of marine fish.

A Peruvian population was identified that was chronically exposed to methylmercury from the long-term consumption of ocean fish. The weekly fish intake averaged 10.1 kg per average family of 6.2 persons. Blood methylmercury concentrations ranged from 11 to 275 ng/ml, with a mean of 82 ng/ml. Paresthesias were reported by 29.5% of the population. In contrast, a nearby control population had a mean weekly fish consumption of 1.9 kg per average family of 6.4 persons. Their blood methylmercury levels were 3.3-25.1 ng/ml, with a mean of 9.9 ng/ml. Paresthesias were reported by 49.5% of this control group. No individual was identified with symptoms or signs that could be attributed to methylmercury intoxication.

Adolescent↗
PubMed2026

A status update on the unkept promise of high-frequency spinal cord stimulation for treatment-refractory chronic migraine.

INTRODUCTION: Chronic migraine (CM) refractory to conventional pharmacotherapy (r-CM) remains a debilitating neurological condition with limited therapeutic options. High-frequency spinal cord stimulation at 10 kilohertz (HF-SCS) has recently emerged as a distinct neuromodulatory paradigm for this patient population. Unlike traditional spinal cord stimulation, HF-SCS operates above the frequency range that generates paresthesia, thereby eliminating stimulation-induced sensation while potentially engaging unique analgesic mechanisms. AREAS COVERED: This focused narrative review synthesizes the available clinical evidence, technical considerations, and mechanistic hypotheses specifically pertaining to cervical HF-SCS for refractory chronic migraine (r-CM). The authors further provide their expert perspectives on the future of this technology as a treatment option for refractory chronic migraine. EXPERT OPINION: Current data from prospective open-label studies and retrospective case series suggest that cervical HF-SCS may reduce monthly migraine days, facilitate conversion from chronic to episodic migraine patterns in some implanted patients, and may improve headache-related disability and quality of life over at least 52&#x2009;weeks of follow-up. The paresthesia-free nature of HF-SCS confers a distinct advantage for both patient tolerability and future trial design, as it permits sham-controlled methodologies that have historically been impossible with conventional neurostimulation. However, these findings remain preliminary and should be considered hypothesis-generating pending confirmation in adequately powered randomized sham-controlled trials.

Humans↗
PubMed2000

Pyrethroid insecticides: poisoning syndromes, synergies, and therapy.

BACKGROUND: Pyrethroid insecticides are widely used, but there have been relatively few reports of systemic poisoning. These reports have, however, shown that pharmacotherapy is difficult and that the duration of poisoning can be unexpectedly long. Pyrethroids are ion channel toxins prolonging neuronal excitation, but are not directly cytotoxic. Two basic poisoning syndromes are seen. Type I pyrethroids produce reflex hyperexcitability and fine tremor. Type II pyrethroids produce salivation, hyperexcitability, choreoathetosis, and seizures. Both produce potent sympathetic activation. Local effects are also seen: skin contamination producing paresthesia and ingestion producing gastrointestinal irritation. The slow absorption of pyrethroids across the skin usually prevents systemic poisoning, although a significant reservoir of pyrethroid may remain bound to the epidermis. Carboxyesterase inhibitors can enhance pyrethroid toxicity in high-dose experimental studies. Hence, the unauthorized pyrethroid/organophosphate mixtures marketed in some developing countries may precipitate human poisoning. Pyrethroid paresthesia can be treated by decontamination of the skin, but systemic poisoning is difficult to control with anticonvulsants. Pentobarbitone, however, is surprisingly effective as therapy against systemic type II pyrethroid poisoning in rats, probably due to its dual action as a chloride channel agonist and a membrane stabilizer.

Animals↗
PubMed2004

Prevalence of clinical symptoms associated with highly active antiretroviral therapy in the Women's Interagency HIV Study.

BACKGROUND: The extended use of antiretroviral drugs among human immunodeficiency virus (HIV)-seropositive individuals underscores the need for a comprehensive evaluation of therapy-associated clinical symptoms. METHODS: Beginning in April 2000, 364 HIV-seronegative and 1256 HIV-seropositive women enrolled in a multicenter cohort study reported clinical symptoms that included abdominal pain, diarrhea, anorexia, nausea and/or vomiting, myalgias, fatigue, fever, body fat redistribution, dizziness, headaches, paresthesias, xerostomia, nephrolithiasis, and rash. We examined the prevalence of symptoms with respect to HIV infection and the use of highly active antiretroviral therapy (HAART), using data-correlation models. RESULTS: In the 6 months before a study visit, 49% of HIV-seronegative women, 67% of HIV-seropositive women not receiving therapy, and 69% of HIV-seropositive women receiving HAART reported any clinical symptom. The odds ratios (ORs) for reporting any symptom were 1.4 (95% confidence interval [CI], 1.1-1.8) for women who changed HAART regimens and 0.9 (95% CI, 0.7-1.1) for women reporting stable HAART use, compared with those reporting no therapy use. Significant findings (P<.05) for particular symptoms were an increased odds of diarrhea, nausea and/or vomiting, body fat redistribution, myalgias, and paresthesias, when data for women who changed HAART regimens were compared with those for women not receiving therapy. The OR for reporting any symptom was 1.5 (95% CI, 1.2-1.9) for women who switched HAART regimens and 1.6 (95% CI, 1.3-1.9) for women who discontinued HAART, compared with those reporting stable HAART use. CONCLUSIONS: Our findings confirm the high prevalence of clinical symptoms among HIV-seropositive women who changed HAART regimens. The high prevalence of symptoms among HIV-seronegative women and HIV-seropositive women not receiving therapy demonstrates that caution should be used when attributing the occurrence of symptoms entirely to HAART.

Adult↗
PubMed2004

Forearm compression by laparoscopic hand-assist devices.

BACKGROUND AND PURPOSE: Laparoscopic hand-assist devices have facilitated the broad application and acceptance of laparoscopy in urology and other surgical fields. This study evaluated forearm compression by these devices. MATERIALS AND METHODS: Five commercially available hand-assist devices were tested (Gelport, Intromit, PneumoSleeve, Handport, LapDisc). In three surgeons using a porcine model, compressive forces were measured along the paths of the median and ulnar nerves at the point of maximum proximal forearm circumference using FlexiForce A101 sensors. Glove size for all three surgeons was 7 1/2; however, the maximum forearm circumference ranged from 26 to 33 cm. The hand-assist devices were placed in pigs after skin and fascial incision (9 cm), and the insufflation pressure was set at 18 mm Hg. Surgeons subjectively rated the ease of device insertion and hand insertion, degree of forearm compression, and the development of paresthesias. RESULTS: The LapDisc was rated superior with regard to insertion. The Gelport was rated superior for hand insertion and removal; however, moderate to severe forearm compression and paresthesias were reported. The maximum forearm compression forces were highest with the LapDisc (97 mm Hg) and the Gelport (78 mm Hg) and lowest with the Handport (33 mm Hg). CONCLUSION: The choice of hand-assist device is dependent on its ease of use, efficacy at maintaining insufflation, and effect on the surgeon's performance and fatigue. The impact of forearm compression should be considered in the selection of the hand-assist device and in the development of new devices.

Animals↗