Myasthenia gravis presenting as a unilateral abducens nerve palsy.

A 48-year-old man with no significant medical history presented to the emergency department of a large, urban, tertiary-care hospital complaining of double vision and unsteady gait. Physical examination was remarkable for an isolated, unilateral sixth nerve palsy. After comprehensive testing, a final diagnosis of myasthenia gravis was made. The patient's unsteady gait was a manifestation of sensory distortion from the diplopia and corrected when the patient closed his eyes. The presentation of myasthenia gravis as an isolated sixth nerve palsy is unprecedented in the emergency medicine literature.

A multicenter, prospective, randomized trial evaluating a new hemostatic agent for spinal surgery.

STUDY DESIGN: A prospective, randomized trial comparing Proceed, a gelatin-based hemostatic sealant (treatment), with Gelfoam-thrombin (control) in stopping intraoperative bleeding during spinal surgery. OBJECTIVES: To determine the effectiveness and safety of Proceed. SUMMARY OF BACKGROUND DATA: Proceed has been tested in animal models to determine its safety and effectiveness as a hemostatic agent. The current study was conducted under a Food and Drug Administration-approved Investigational Device Exemption to evaluate the effectiveness and safety of Proceed in humans. METHODS: For this study, 127 patients undergoing spinal surgery were randomized into either the treatment or control group after standard surgical means to control bleeding had failed. The bleeding site was evaluated at 1, 2, 3, 6, and 10 minutes after the hemostatic agent was applied. The application was considered successful if the bleeding stopped within 10 minutes. Follow-up evaluation was performed at 12 to 36 hours, then at 6 to 8 weeks after surgery. RESULTS: Proceed stopped bleeding in 98% of the patients (first bleeding site only) within 10 minutes, as compared with 90% of the control patients (P = 0.001). At 3 minutes, successful hemostasis had been achieved in 97% of the Proceed group, as compared with 71% of the control group (P = 0.0001). There was no difference in the adverse event profile between the two groups. CONCLUSIONS: A significantly larger number of bleeding sites had achieved hemostasis with Proceed than with Gelfoam-thrombin at 1, 2, and 3 minutes after application. Proceed was as safe as Gelfoam-thrombin when used for hemostasis during spinal surgery procedures.

Premonitory neurologic signs in a patient with an acute vertex epidural hematoma.

A case of an acute vertex epidural hematoma with delayed neurologic deterioration is presented. Prior to the onset of signs of midbrain compression, the patient developed an excrutiating headache, a movement disorder, and upper motor neuron signs. A review of the literature and this case suggest that the presence of a severe, unrelenting headache and upper motor neuron signs in a victim of head trauma may be secondary to compression of the parasagittal brain region by a vertex hematoma.

Management of acute spine and spinal cord injuries. Old and new concepts.

The modern, positive approach to treatment of injuries of the cervical spine and spinal cord has produced excellent long-term survival, but less progress has been made in reversal of the neurologic defect. Injuries to the spinal column are of four types: flexion-dislocation, hyperextension, vertical compression, and rotation. Those to the spinal cord also involve four categories: morphologic damage, hemorrhage and vascular damage, structural changes, and biochemical response. Experimental work has explored new adjuncts to conservative treatment, such as norepinephrine antagonists, other drugs, and hypothermia. These results, and those of surgery on the experimental lesions, have been hopeful, but not definitive. Controversy surrounds the surgical vs nonsurgical treatment of clinical spinal cord injury. Operation is indicated for roentgenographic evidence of bone fragments in the spinal canal, for worsening neurological symptoms, and, possibly, if experimental evidence is to be followed, for surgical decompression in the very early minutes or hours after injury.

[The clinical significance of abnormalities of bronchial anatomy (author's transl)]. / Die klinische Bedeutung von Bronchusanomalien - Eine Untersuchung an Angehörgin der Nationalen Volksarmee

Abnormalities of the bronchi were found in 0.7-1.4% in patients examined by bronchoscopy or thoracotomy. In most cases there are no clinical symptoms. Anatomical abnormalities of the bronchi are the favoured localization for deformities, chronic inflammations and bronchial neoplasms. The altered topography must be considered if surgery is necessary. Case studies of 12 patients, 1 with bronchus trachealis, 7 with deformities of the lobus superior and 4 of the lobus inferior were analyzed and selected cases are described.