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The intravenous, intramuscular and oral administration of 4 mg lorazepam given to adults will effectively reduce the psychic sequelae of ketamine to acceptable limits.
Two cases of adverse sequelae associated with the use of 2.5% thiopentone are reported: one involved extensive local venous thrombosis at the site of the injection causing great distress to the patient; the other involved a histaminoid reaction in a patient who, like others who have been reported with this type of reaction, had a history of allergy.
Four patients who developed unusual neurological sequelae after outpatient anaesthesia are described. Propofol is strongly implicated as the cause. All four patients were female with no previous history of psychiatric disorder or neurological disease, unpremedicated, and had procedures of duration less than 20 minutes. Hyperreflexia and hypertonicity were present postoperatively and the reactions appeared to be triggered by an external stimulus. Three patients were examined by a neurologist and had a normal electroencephalograph. Two patients were on the same operating list; quality control was carried out on the anaesthetic agents used, and blood samples sent for toxicology showed no abnormalities. Mechanisms underlying these reactions are discussed.
The healing of tracheostomy and cuff-induced tracheal injury was followed up in 48 tracheostomized patients (44 men and 4 women). The patients were studied by means of tracheoscopy, fluoroscopy and tracheography, with a positive contrast medium. At extubation, tracheoscopy revealed 12 mild, 23 moderate and 13 severe injuries at the cuff level. Three months after extubation, the stoma had closed in 89% of the patients studied. In 85% of the patients, the side wall of the stoma was found to have collapsed inwards and in 71% scars were observed at the cuff level. No significant changes took place after the follow-up study at 3 months. At tracheography it was found that narrowing of the tracheal diameter at the stomal level was of only mild or moderate degree (i.e. 0-33%). There was not a single instance of severe stenosis. At the cuff level, a slight inward collapse of the side wall was observed in one patient, and in all the other patients the lumen was normal. Fluoroscopy did not reveal severe tracheomalacia in any patient. Increased mobility of the stomal scar, especially in connection with coughing was seen in some patients. One tracheo-innominate artery erosion and one bleeding granulation tissue at the stoma were confirmed during follow-up. Surgical trauma to the trachea at the stoma seems to be a more potent cause of subsequent narrowing of the trachea than the cuff. Even though severe injuries may also heal with few sequelae, the use of tracheostomy tubes with large, low-pressure cuffs, which have been shown to cause less damage to the trachea, is indicated.
The isometric contraction pattern was followed in three female and two male patients with lower motoneuron paralysis due to sequelae from poliomyelitis in 1942-48. In uninstructed contractions, force increased slowly to an almost horizontal level which could be kept up for as long as desired. During rapid maximal voluntary contractions, a "biphasic" mechanogram was seen in 49% of 204 contractions, with a first maximum after 0.3 s (0.1-0.9), separated by a notch from a second maximum after 1.1 s (0.3-2.3). In the rest of the contractions, force could not be generated rapidly, despite the intention of the subjects, and a single maximum in the mechanogram was seen after 0.9 s (0.2-2.4). In contractions where a biphasic contraction pattern was seen, the electromyographic activity was greatest during approximately the first one half second of the contraction. In the other contractions the electromyographic activity was about the same during the whole contraction. The results suggest that the mechanograms are composed of a high innervation threshold, fast phasically active component, and a low innervation threshold, slow tonically active component. Fade represents the waning of tension in the phasically active component present in some contractions, while this component appears to be eliminated by poliomyelitis in other muscle contractions.
One hundred general or orthopaedic surgery patients (ASA I-II) were randomly given either indomethacin (25-50 mg bolus plus infusion, 5-7.5 mg h-1) in lactated Ringer solution intravenously in one hand and only lactated Ringer solution into a corresponding vein of the other hand (50 patients) or only lactated Ringer solution intravenously in both hands (50 patients), starting before anaesthesia induction and ending at 7 a.m. the following morning. All anaesthetic drugs were given equally divided into both drips. The need for additional analgesia as well as venipuncture and infusion sequelae were registered on the postoperative morning in a double-blind fashion. The mean +/- s.d. oxycodone dose in the postoperative observation period was lower in the indomethacin group (18 +/- 16 mg) than in the control group (27 +/- 20 mg) (n.s.). There was a lower number of patients requiring oxycodone more than once in the indomethacin group than in the control group (P less than 0.05). Fewer patients in the indomethacin group (22%) had inflammatory changes at the venipuncture site than in the control group (46%) (P less than 0.05). There was no difference between hands; i.e. in patients given indomethacin inflammatory changes were equally common in both hands. No thrombophlebitic complications developed, which was confirmed by a mailed questionnaire (response 96/100) 2 weeks after surgery.
The development of the anconeal process its lesions and their sequelae were scrutinized during the follow-up radiographic study (every 5 months) of porcine osteochondrosis of elbow joint bones done in 80 Danish Landrace pigs from day 42 of age to 38 months of age. The anconeal process was observed radiologically to be ossified at the age of between 6 to 7 months. Normally it ossifies by pyramidal extension from the proximal ulna. However, fragmented/ separated anconeal process lesion was demonstrated in 15 pigs (the process was "ununited' with the rest of the proximal ulna). The diagnosis was confirmed in nine pigs at gross post-mortem and microscopically when the pigs were slaughtered due to other reasons than lameness of the front leg. These cases were interpreted as "fragmented/separated anconeal process' (FAP/SAP). This lesion showed a tendency to heal with increasing age. The lesions were healed in all surviving pigs at the age of 25-26 months.
Between January 1982 and June 1989 in South Australia 19 infants under 2 years of age have had serious sequelae following an apparent life threatening event (ALTE) for which no cause could be identified. Thirteen of these children have died, four survive with severe hypoxic damage, one has normal psycho-motor development and epilepsy, and another has mental retardation and strabismus. Study of these infants suggests heterogeneity in the cause of both sudden infant death syndrome (SIDS) and ALTE, and occasional links between the two.
OBJECTIVE: To report long-term ophthalmological sequelae in extremely premature infants at 5 years and to determine the relationship between neonatal variables (including retinopathy of prematurity; ROP) and the 5 year ophthalmological outcome of these infants. METHODOLOGY: The study cohort comprised 84 surviving infants born with a birthweight < 1000 g or gestational age < 28 weeks from June 1985 to December 1989. All infants had an ophthalmological assessment between 34 and 40 weeks post conceptional age to document grade of ROP and were assessed at 5 years of age for fundoscopy, visual acuity, refractive error and ocular mobility. RESULTS: Of the 84 long-term survivors 69 (82%) were formally assessed at 5 years. Overall, 30 (43%) had some form of ocular disorder. Nineteen (27%) had reduced visual acuity of < 6/6 and three of these were blind. Myopia > -0.5 dioptre was noted in eight (12%), hypermetropia > or = 2.0 dioptre in five (8%), astigmatism in seven (11%) and strabismus was present in nine (14%) of the cohort. There was a significant relationship (P < 0.0001) between the incidence of ocular disorders and ROP. However, even those premature children without ROP had a 31% incidence of ocular disorder at 5 years. CONCLUSION: Long-term ophthalmological follow-up is recommended in all extremely premature infants regardless of the presence of ROP in the neonatal period.
Twenty-three cases are reported in which serious late sequelae of previously repaired hypospadias led to difficult technical problems in repair. Chordee, rotation and fistulae often complicated persistent strictures. To avoid the risk of fistula when operating upon previously scarred penile skin, a method of repairing or replacing the diseased anterior urethra is described, based upon the principles of the dartos pedicle island patch.
AIMS: To examine whether motivating patients to gain expertise and closely follow their risk parameters will attenuate the course of microvascular and cardiovascular sequelae of diabetes. METHODS: A randomized prospective study on 165 patients with diabetes mellitus Type 2, hypertension (> 140/90 mmHg) and hyperlipidaemia (LDL-C > 3 mmol/l), referred for consultation to a diabetes clinic in an academic hospital. Patients were randomly allocated to standard consultation (SC) or to a patient participation (PP) and teaching programme. Follow-up continued by primary care physicians. RESULTS: The mean follow-up was 7.7 years. SC group patients each attended eight annual consultations. The PP patients initiated on average 1.2 +/- 0.8 additional consultations per annum. The relative risk (RR) over 8 years, for the combined cardiovascular event index in the intervention (PP) vs. the control (SC) group was 0.65 (95% CI 0.41-0.89, P = 0.001). Nephropathy developed in 14 vs. 7 patients in the SC and PP groups, respectively, RR 0.50 (95% CI 0.28-0.85, P = 0.02), retinopathy developed in 35 vs. 21 patients, RR 0.60 (95% CI 0.21-0.82, P = 0.03). Throughout the study, period blood pressure, LDL-C and HbA1c were significantly lower in the PP than in the SC patients. CONCLUSION: Well-informed and motivated patients, were more successful in maintaining good control of their risk factors, resulting in reduced cardiovascular risk and slower progression of microvascular disease.
OBJECTIVE: To assess maternal morbidity, and neonatal outcome and especially long term sequelae in infants born preterm due to maternal or fetal indications. DESIGN: Analysis of retrospective cohort. SETTING: Oulu University Central Hospital, Finland. POPULATION: One hundred and three women, who were between the 24th and the 33rd week of pregnancy, delivered by caesarean delivery because of maternal or fetal indications. They were matched with 103 women who had spontaneous preterm delivery at corresponding gestational weeks between 1990-1997. MAIN OUTCOME MEASURES: Maternal morbidity, reasons for caesarean delivery, neonatal mortality and morbidity rates, and later development of the infants. RESULTS: Pre-eclampsia was diagnosed in 57% of the women in the indicated group and only in one woman in the control group. All infants in the indicated group and almost a third in the control group were born by caesarean birth; the main indication was threatening fetal asphyxia. There was a significant difference in neonatal mortality rates between the groups (175 vs 78 per thousand live births in the indicated vs control infants; RR 2.3, 95% CI 1.02, 4.9) and the main cause of death was respiratory insufficiency: 64% in the indicated group and 22% in the controls; RR 2.9, 95% CI 0.8, 10. Respiratory distress syndrome occurred more often (73% vs 53%, RR 1.4, 95% CI 1.1, 1.7) and it was more severe and more complicated in infants in the indicated group, compared with those in the control group. Symptomatic chronic lung disease at one year of age was more common in infants in the indicated group than in the control group (15% vs 3%; RR 4.6, 95% CI 1.4, 15.9). CONCLUSIONS: Not only the risks of neonatal mortality and morbidity but also long term pulmonary consequences, appear to be greater in infants born preterm by indicated delivery than in preterm infants born spontaneously at corresponding weeks.
The occurrence of headache as a sequela of low back pain was examined in a sample of chronic pain patients. All patients had low back pain without history of head, neck, or upper back injury or headache onset simultaneous with the low back pain. Consistent with prior research, headache was found to be a common concomitant of back pain. In many patients, headache was found to have begun or exacerbated markedly after onset of low back pain. Prevalence of migraine in female patients was significantly higher than the population prevalence for females in the United States; this was not true for male patients. Potential mechanisms for explaining the high prevalence of migraine following low back pain are discussed, including increased muscle tension, psychosocial factors, and analgesic overuse.
BACKGROUND AND AIMS: Ileal pouch-anal anastomosis (IPAA) improves quality of life (QOL) for ulcerative colitis patients who require surgery. Crohn's disease (CD) of the pouch, pouchitis, cuffitis, and irritable pouch syndrome (IPS) have an adverse impact on physical and psychological well-being, which can compromise the gain in QOL after the surgery. Their clinical, endoscopic, and histologic features have not been fully characterized. The aim of this study was to compare demographic, clinical, endoscopic, and histologic features between CD of the pouch, pouchitis, cuffitis, IPS, and normal pouches. METHODS We enrolled 124 patients: normal pouches (N = 26), CD of the pouch (N = 23), pouchitis (N = 22), cuffitis (N = 21), and IPS (N = 32). Symptomatology, endoscopy, histology, and the Cleveland Global QOL and the Irritable Bowel Syndrome-QOL scores were compared among the groups. RESULTS: Univariate analysis of demographic and clinical data showed a possible association between NSAID use and pouchitis, extraintestinal manifestation and cuffitis, and antidepressant use and IPS. There were no differences in the Pouchitis Disease Activity Index symptom scores between the disease groups, with an exception of bleeding, which occurred almost exclusively in cuffitis. Endoscopy was useful in discriminating between CD of the pouch, pouchitis, cuffitis, and normal pouches or IPS. Patients with diseased IPAA had worse QOL scores. CONCLUSIONS: Symptoms largely overlapped among the disease groups of IPAA. Endoscopy is valuable for diagnosis. Inflammatory or noninflammatory sequelae of IPAA adversely affected patients' QOL.
An in vitro model was employed to study the potential role of streptococcal extra-cellular products, rich in streptolysin O, in cellular injury as related to streptococcal infections and post-streptococcal sequelae. Extra-cellular products (EXPA) rich in streptolysin O were isolated from type 4, group A hemolytic streptococci grown in a chemostat, in a synthetic medium. EXPA induced moderate cytopathogenic changes in monkey kidney epithelial cells and in rat heart cells pre-labeled with 3H-arachidonate. However very strong toxic effects were induced when EXP was combined with oxidants (glucose oxides generated H2O2, AAPH-induced peroxyl radical (ROO.), NO generated by sodium nitroprusside) and proteinases (plasmin, trypsin). Cell killing was distinctly synergistic in nature. Cell damage induced by the multi-component cocktails was strongly inhibited either by micromolar amounts of gamma globulin, and Evan's blue which neutralized SLO activity, by tetracycline, trasylol (aprotinin), epsilon amino caproic acid and by soybean trypsin inhibitor, all proteinase inhibitors as well as by a non-penetrating PLA2 inhibitor A. The results suggest that fasciitis, myositis and sepsis resulting from infections with hemolytic streptococci might be caused by a coordinated 'cross-talk' among microbial, leukocyte and additional host-derived pro-inflammatory agents. Since attempts to prolong lives of septic patients by the exclusive administration of single antagonists invariably failed, it is proposed that the administration of 'cocktails' of putative inhibitors against major pro-inflammatory agonizes generated in inflammation and infection might protect against the deleterious effects caused by the biochemical and pharmacological cascades which are known to be activated in sepsis.
A case of valproic acid poisoning with coma and neurological sequelae is presented. The course of the intoxication was severe with affection of the brain, heart and liver. The patient remained in coma for thirteen days. After this he recovered slowly although reduction in vision still persisted after two months. The toxicity of valproate is discussed.
A summary of clinical data is presented on 34 men and 52 women patients with brain syndrome associated with delayed neuropsychiatric sequelae following acute carbon monoxide intoxication. Their ages ranged from 34 to 82 years, with peak incidence in the sixth and seventh decade. Possible etiological factors were age, duration of unconsciousness on acute intoxication, and previous physical illness. The onset was relatively sudden after the apparent clear period which ranged from 2 to 40 days (mean 22.5 days). The most frequent symptoms were apathy, dull facial expressions, dementia, such as amnesia and disorientation, hypokinesia, mutism, irritable distractibility, urinary and/or fecal incontinence, gait disturbance and abnormal neurological signs and reflexes. EEG was abnormal in 33 of the 57 cases (58%). Of 27 patients who were given a computed tomographic brain scan, 15 patients were abnormal. The prognosis was relatively good in the follow-up study of 56 patients. Only age was related to a better prognosis.
INTRODUCTION: The rat model of cavernous nerve (CN) injury has been developed in an effort to define the functional and structural consequences of neural trauma in the corpus cavernosum. However, there is no universally accepted method of inducing nerve injury in this model, with neurotomy and crush models being used currently. To address this issue, we induced CN injury using various techniques in an effort to compare the hemodynamic sequelae of these injuries. METHODS: Twenty-five adult male Sprague-Dawley rats were divided into five groups: (1) control: laparotomy only; (2) exposure: laparotomy and exposure of cavernous nerves bilaterally without nerve manipulation; (3) neurotomy; bilateral neurotomy; (4) bulldog crush: bilateral nerve crush with bulldog vascular clamp; and (5) hemostat nerve crush: bilateral nerve crush with a hemostat. Ten days later, a second operation was performed during which systemic mean arterial pressure (MAP) and intracavernosal pressure (ICP) were measured in response to CN stimulation proximal to the site of injury. Hemodynamic endpoints assessed included ICP/MAP ratio, rate of tumescence, and rate of detumescence. RESULTS: The ICP/MAP ratio (mean +/- 95% confidence interval) in the control group was 70 +/- 4%. ICP/MAP ratios were significantly reduced in all CN injury groups compared with control group: exposure: 41 +/- 10% (P < 0.001); neurotomy: 35 +/- 15% (P < 0.001); bulldog crush: 39 +/- 13% (P < 0.001); hemostat crush: 31 +/- 9% (P < 0.0001). No significant difference existed in ICP/MAP ratios between the injury groups. Of note, the exposure group also demonstrated significant functional alterations. The rates of tumescence and detumescence were significantly reduced in all groups compared with the control group. CONCLUSION: No significant difference in the magnitude and consistency of hemodynamic alterations has been demonstrated in all CN injury models assessed in this study.