Successful perioperative management of a patient with C1 esterase inhibitor deficiency with a novel bradykinin receptor B2 antagonist.

We present the case of a 28-year-old female with a previous diagnosis of C1 esterase inhibitor deficiency presenting for dental extractions under general anaesthesia. Following prophylaxis with a new bradykinin receptor 2 antagonist (icatibant), surgery was carried out uneventfully with an unremarkable postoperative course.

Ketamine-associated lower urinary tract destruction: a new radiological challenge.

AIM: Ketamine is a short-acting dissociative anaesthetic whose hallucinogenic side effects have led to an increase in its illicit use amongst club and party goers. There is a general misconception amongst users that it is a safe drug with few long term side effects, however ketamine abuse is associated with severe urinary tract dysfunction. Presenting symptoms include urinary frequency, nocturia, dysuria, haematuria and incontinence. MATERIALS AND METHODS: We describe the radiological findings found in a series of 23 patients, all with a history of ketamine abuse, who presented with severe lower urinary tract symptoms (LUTS). Imaging techniques used included ultrasonography (US), intravenous urography (IVU), and computed tomography (CT). These examinations were reviewed to identify common imaging findings. All patients with positive imaging findings had also undergone cystoscopy and bladder wall biopsies, which confirmed the diagnosis. The patients in this series have consented to the use of their data in the ongoing research into ketamine-induced bladder pathology. RESULTS: Ultrasound demonstrated small bladder volume and wall thickening. CT revealed marked, generalized bladder wall thickening, mucosal enhancement, and perivesical inflammation. Ureteric wall thickening and enhancement were also observed. In advanced cases ureteric narrowing and strictures were identified using both CT and IVU. Correlation of clinical history, radiological and pathological findings was performed to confirm the diagnosis. CONCLUSION: This case series illustrates the harmful effects of ketamine on the urinary tract and the associated radiological findings. Delayed diagnosis can result in irreversible renal tract damage requiring surgical intervention. It is important that radiologists are aware of this emerging clinical entity as early diagnosis and treatment are essential for successful management.

Opening farm gates: community as educator.

This paper presents the experience of five undergraduate Bachelor of Nursing students who undertook a clinical practice placement in a rural community. This, our first engagement with nursing, was a profound learning experience. We did not expect the intense contributions the rural community as a whole would make to our understandings of rural health care in general, and rural nursing in particular. Initially, we felt like outsiders to the rural community as well as the profession of nursing. The interwoven nature of community relationships combined with our acute sense of being highly visible in the township led to us developing a sense of vulnerability. We believed we needed to portray a professional image during all social interactions with the community and this compounded our insecurities during the clinical placement. Before long, we found the rural population embracing and very supportive of our placement. However, we found ourselves questioning whether we would return to a rural community to work as nurses on the basis of our lack of privacy during this time.

Is needle examination always necessary in evaluation of carpal tunnel syndrome?

OBJECTIVE: To investigate whether needle evaluation added any important clinical information to normal nerve conduction studies in the evaluation of carpal tunnel syndromes. DESIGN: Retrospective review of electromyography (EMG) done with the referring diagnosis of possible carpal tunnel syndrome. SETTING: Outpatients seen for EMG evaluation at one university hospital by a single electromyographer. PATIENTS: Consecutive sample of possible carpal tunnel syndrome patients. INTERVENTIONS: None. MAIN OUTCOME MEASURE: We determined whether needle examination was abnormal when nerve conduction studies were normal. RESULTS: In patients in whom only carpal tunnel syndrome was suspected, normal nerve conduction studies predicted that EMG would be normal 89.8% of the time (p = .0494). Testing based on a larger sample size might increase the predictive value. CONCLUSIONS: There may be a subpopulation of patients referred for carpal tunnel syndrome who may be adequately evaluated by nerve conduction studies alone. Additional studies will help evaluate whether this is so.

Ondine's curse and neurally mediated syncope--a new and important association.

A 6-year-old boy with congenital central hypoventilation syndrome (Ondine's curse) presented with presyncope. Investigation revealed a diagnosis of neurally mediated syncope. This previously unreported association provides strong evidence that autonomic dysfunction is implicated in both these conditions.

Surveillance of sentinel occupational mortality in the District of Columbia: 1980 to 1987.

Epidemiological surveillance of sentinel occupationally related deaths commonly relies on computerized analyses of mortality data obtained from vital statistics records. A computer search of death records in the District of Columbia for the period 1980 to 1987 identified 15 cases that noted asbestosis, silicosis, coal worker's pneumoconiosis, or primary cancer of the pleura/mesothelioma as the underlying cause of death. A manual review of the death certificates for the same period identified three times as many cases (n = 48) with any mention of these conditions. Problems with performing surveillance of these events using death certificates include the lack of sufficient information to identify mesotheliomas and the failure to code and computerize all contributing causes of death.

Acquired toxoplasma encephalitis.

Toxoplasma was the cause of encephalitis in a 4 year old boy. He recovered completely after treatment with pyrimethamine and sulphadimidine. Toxoplasma encephalitis has a high mortality, and active treatment is recommended.

Interrupted aortic arch type A associated with congenitally corrected transposition of great arteries and ventricular septal defect. Successful direct aortic anastomosis and pulmonary artery banding in an infant.

A case is described of congenitally corrected transposition of the great arteries (atrioventricular discordance, ventriculoarterial discordance) with interrupted aortic arch, a previously unreported association. Aortic continuity was achieved by direct surgical anastomosis. Pulmonary artery banding was subsequently necessary, because of heart failure associated with a large ventricular septal defect. A possible pathogenetic mechanism is suggested.

Reduction of systemic vascular resistance by competitive alpha adrenergic blockage with thymoxamine after cardiopulmonary bypass for cardiac operations.

Fifteen patients with evidence of excessive systemic vasoconstriction following cardiac operations were studied. Serial hemodynamic measurements were made before and during infusion of thymoxamine, a competitive alpha adrenergic blocking drug. Thymoxamine resulted in a full in systemic resistance together with a rise in cardiac index without reflex tachycardia. When thymoxamine was infused at a rate of 1 mg . kg-1, the desired effect was achieved without sudden profound falls in arterial pressure and there were no significant side effects. During the first few hours after bypass, skin temperature measurements do not give an adequate indication of the circulatory state. Measurement of mixed venous oxygen saturation is a most useful, simple method of monitoring the acute effects of treatment during this period.

An operant procedure for improving vocabulary definition performances in developmentally delayed children.

This report describes a training program in which operant procedures were used to improve the identification and definition of selected vocabulary words in three developmentally delayed children. Generalization from the training words was well established, as determined by responses to untrained vocabulary performance words. The results of this procedure suggest its application with other developmentally delayed children.