Comparing Echocardiograms of Haitian and non-Haitian Stroke Patients.

INTRODUCTION: Haitian stroke patients had higher diastolic and mean arterial blood pressures, compared with non-Haitian controls. Therefore, we hypothesized that Haitians would have a higher prevalence of left ventricular hypertrophy and decreased ejection fraction. METHODS: Using the Haitian Stroke Database, a cohort study was conducted. The following transthoracic echocardiographic parameters of 52 Haitians and 111 non-Haitians were compared: left ventricular hypertrophy; ejection fraction; right and left ventricular internal dimension at diastole; and left atrial size. RESULTS: Left ventricular hypertrophy and decreased ejection fraction were more prevalent among Haitians (78% vs. 63%; p=.062 and 21% vs. 13%; p=.173, respectively). Neither reached statistical significance. Left atrial enlargement was significantly more prevalent among non-Haitians (36% vs 15%; p=.007). CONCLUSIONS: Left ventricular hypertrophy and decreased ejection fraction were more prevalent in Haitians, but neither finding reached statistical significance. Larger samples are needed for further understanding of stroke comorbidities in Haitians.

How Educators Can Help Prevent False Brain Death Diagnoses.

It is critical for brain death diagnosis to be accurate. Although standardized guidelines and institutional protocols for brain death determination exist, for many physicians, lack of understanding about brain death leads to confusion and muddles interactions with patients' loved ones at the end of life. Using a case-based approach, this article demonstrates what tends to go wrong in erroneous brain death diagnoses and clarifies what physicians and educators should do to help avoid these errors.

Peripheral neuropathy of the extremity after hyperbaric exposure.

BACKGROUND: Neurological deficits occurring after diving or hyperbaric exposure are typically due to central nervous system decompression illness (DCI). However, consideration of alternate diagnoses is sometimes warranted. CASE REPORT: A 47-yr-old female hyperbaric technician developed foot drop 2 d following her last hyperbaric exposure. She had worked in chamber once daily at 45 fsw for 90 min. The breathing gas was air until the last 15 min, during which she breathed oxygen. Her history was complicated by a gastric bypass and weight loss totaling 160 pounds within the preceding 9 mo. She was treated for presumed neurological DCI without improvement. The adherence to safe hyperbaric protocols, delayed presentation, ongoing medical issues, and lack of response to therapy brought the diagnosis into question. Extensive neurological evaluation, including nerve conduction studies, revealed a common peroneal mononeuropathy. We concluded that her neuropathy was more likely due to extreme weight loss and malnutrition than peripheral nervous system DCI. DISCUSSION: There are rare reports of DCI affecting the peripheral nerves of the extremities. A literature search revealed only three such cases. Two further reports describe peripheral neuropathy in the extremities of divers that were attributed to other causes: compression by a weight belt and vasculitis. However, peroneal neuropathy is one of the most common focal mononeuropathies of the lower extremity and has been reported in association with extreme weight loss and malnutrition. We attributed our diver's neuropathy to extreme weight loss and malnutrition rather than DCI.

[Treatment of mucormycosis with adjunctive hyperbaric oxygen: five cases treated at the same institution and review of the literature]. / Tratamiento adjunto con oxigenación hiperbárica en mucormicosis. Presentación de cinco casos tratados en la misma institución y revisión de la literatura.

INTRODUCTION: Mucormycosis is an invasive fungal infection that affects decompensated diabetics, immunosupressed patients and occasionally healthy individuals. Despite advances in anti-fungal therapy and surgical techniques, the morbidity and mortality remain high. Adjuvant hyperbaric oxygen therapy (HBO) has been proposed based on pathophysiology and several favorable clinical reports. MATERIAL AND METHODS: A chart review of mucormycosis patients referred to the HBO service was performed. Also an electronic search in Medline of relevant literature was undertaken. RESULTS: Five mucormycosis patients referred for HBO had complete charts available. Four had craniofacial involvement and one had left upper extremity involvement. The predisposing diseases were leukemia (n = 3), diabetes mellitus plus sarcoidosis (n = 1), and trauma (n = 1). All patients were managed with amphotericin B, surgical debridement and HBO. Survival was 60% (3/5) three months after the diagnosis was established. The literature was scarce but favors HBO. CONCLUSION: Considering the pathophysiology of mucormycosis adjuvant HBO therapy seems reasonable. However, the clinical experience is still too limited to make HBO part of the standard of care. Prospective, randomized, controlled trials will help to define the role of HBO in this devastating infection.

Decompression sickness in Miskito Indian lobster divers: review of 229 cases.

BACKGROUND: The Miskito Indian lobster divers of Central America employ very provocative diving profiles and experience severe neurological decompression sickness (DCS) and/or arterial gas embolism (AGE). Scientific data are scarce regarding the clinical patterns of injury, response to treatment, and functional outcomes for such cases. METHODS: A retrospective review of 229 cases of DCS and/or AGE was conducted at 2 hyperbaric units in Central America. RESULTS: The following deficits were recorded on presentation: any neurological deficit: 94%; motor: 79%; sensory: 60%; urinary: 48%; reflex: 45%; and loss of consciousness: 20%. The patterns of weakness (n = 182) were as follows: paraparesis: 27%; paraplegia: 26%; lower extremity monoparesis: 14%; lower extremity monoplegia: 6%; quadriparesis: 4%; hemiparesis: 4%; hemiplegia: 3%; and quadriplegia: 2%. Treatment was delayed by a mean and median of 5 and 2 d, respectively. The majority received hyperbaric oxygen and systemic steroids. Motor function on discharge (n = 182) was as follows: normal: 30%; paraparesis: 15%; lower extremity monoparesis: 15%; paraplegia: 3%; quadriparesis: 2%; hemiparesis: 2%; and missing data/other: 33%. Gait on discharge (n = 182) was as follows: normal: 19%; abnormal: 19%; required one crutch: 10%; required two crutches: 16%; not ambulatory: 5%; and missing data: 31%. DISCUSSION: The majority of severe injuries could be localized to the thoracolumbar spinal cord. One-fifth had bilateral cerebral dysfunction manifested by loss of consciousness. Despite long delays to treatment, divers responded to hyperbaric oxygen. At the time of discharge, almost a third had complete recovery of strength and the majority were ambulatory.

Tratamiento adjunto con oxigenación hiperbárica en mucormicosis. Presentación de cinco casos tratados en la misma Institución y revisión de la literatura / Treatment of mucormycosis with adjunctive hyperbaric oxygen: five cases treated in the some institution and review of the literature

Introduction. Mucormycosis is an invasive fungal infection that affects decompensated diabetics, immunosupressed patients and occasionally healthy individuals. Despite advances in anti-fungal therapy and surgical techniques, the morbidity and mortality remain high. Adjuvant hyperbaric oxygen therapy (HBO) has been proposed based on pathophysiology and several favorable clinical reports. Material and methods. A chart review of mucormycosis patients referred to the HBO service was performed. Also an electronic search in Medline of relevant literature was undertaken. Results. Five mucormycosis patients referred for HBO had complete charts available. Four had craniofacial involvement and one had left upper extremity involvement. The predisposing diseases were leukemia (n = 3), diabetes mellitus plus sarcoidosis (n = 1), and trauma (n = 1). All patients were managed with amphotericin B, surgical debridement and HBO. Survival was 60% (3/5) three months after the diagnosis was established. The literature was scarce but favors HBO. Conclusion. Considering the pathophysiology of mucormycosis adjuvant HBO therapy seems reasonable. However, the clinical experience is still too limited to make HBO part of the standard of care. Prospective, randomized, controlled trials will help to define the role of HBO in this devastating infection.

Introducción. La mucormicosis es una infección micótica invasiva que se presenta principalmente en pacientes diabéticos descompensados, pacientes con afección del sistema inmune, e incluso en individuos previamente sanos. A pesar de los avances en medicamentos y técnicas quirúrgicas la morbimortalidad es todavía muy elevada. La terapia adjunta con oxígeno hiperbárico (OHB) ha sido sugerida con base en fundamentos fisiopatológicos y algunos reportes clínicos favorables. Material y métodos. Revisión de expedientes de pacientes referidos al Servicio de OHB con diagnóstico de infecciones micóticas invasivas. Búsqueda electrónica en Medline de literatura pertinente. Resultados. Cinco pacientes con diagnóstico clínico e histopatológico de mucormicosis con expediente completo fueron referidos a OHB para terapia adjunta. Cuatro presentaron afección craneofacial y uno afección de la extremidad superior izquierda. La enfermedad predisponente fue leucemia (n = 3), sarcoidosis y diabetes mellitus (n = 1) y trauma (n = 1). Todos fueron manejados con anfotericina B, debridación quirúrgica y OHB. La sobrevida fue 60% (3/5) tres meses después del diagnóstico. La literatura al respecto es escasa, pero favorece al OHB. Conclusión. Con base en la fisiopatología de la mucormicosis la terapia adjunta con OHB parece lógica. No obstante, la información clínica es todavía muy limitada para recomendar OHB rutinariamente en estos pacientes. Estudios prospectivos, aleatorios, controlados ayudarán a definir el papel del OHB en el manejo de esta devastadora infección.

Invasive aspergillosis treated with adjunctive hyperbaric oxygenation: a retrospective clinical series at a single institution.

BACKGROUND: Invasive aspergillosis is the leading cause of early death in many transplant centers and has a major impact on the management of hematologic malignancies. The mortality rate with current therapy (amphotericin B and surgery) has remained unacceptably high. In vitro data along with a few case reports have suggested a potential benefit of hyperbaric oxygen (HBO). METHODS: We retrospectively studied all patients referred to our service when histologic specimens suggested invasive aspergillosis. Our main assessment of outcome was survival 3 months after initiation of HBO. RESULTS: Ten patients were included. All received adjunctive HBO along with the standard of care. Rhinosinusinal infection was the primary presentation. The most common underlying conditions were hematologic malignancies. Six patients were free of signs of infection 3 months after the first HBO treatment. CONCLUSIONS: Adjunctive HBO appears to be a valuable tool in this devastating condition. Further studies are warranted to clarify its role.