Effect of graded water immersion on vital capacity and plasma volume in patients with cervical spinal cord injury.

STUDY DESIGN: A case-control study was conducted. OBJECTIVE: The aim of the study was to test the hypothesis that the increase in hydrostatic pressure on the abdominal wall may be the major determinant of vital capacity (VC) improvement in tetraplegic subjects during water immersion, despite the blood volume shifts from the legs and abdomen to the thorax. SETTING: The study was carried out in the Rehabilitation Center, Brasília/DF, Brazil. METHODS: In total, 11 men with tetraplegia (complete motor lesion, C4-7, 30.4 years old) and 12 healthy controls were studied. Hematocrit level and spirometry values were obtained on dry land and at each level of immersion (the pelvis, xiphoid and neck). RESULTS: Baseline spirometry value of tetraplegic subjects showed reduced VC (53.3+/-17.4% of predicted), whereas all control subjects had >80% of predicted values. Neither group showed significant changes in VC at the pelvic and xiphoid levels of immersion. In tetraplegic subjects, VC increased by 27.2% at the neck level (+/-25.8, P<0.008), whereas in healthy subjects it decreased by 6.3% (+/-5.0, P<0.008). Both groups showed significantly increased inspiratory capacity only when immersed to the neck. Hematocrit level of tetraplegic subjects fell significantly with immersion to the xiphoid and neck levels (P<0.017), which occurred in controls only at the xiphoid level (P<0.017). CONCLUSIONS: Hydrostatic compression may be the main contributor to improving VC in tetraplegic subjects immersed in water. This improvement occurs despite increased plasma volume during immersion.

Maximal static mouth respiratory pressure in spinal cord injured patients: correlation with motor level.

STUDY DESIGN: Transversal. OBJECTIVES: The few studies concerning maximal static mouth respiratory pressures in patients with spinal cord lesions suggest a marked reduction. We studied the correlation of these parameters with the motor level of injury. SETTING: Rehabilitation Center, Brasília/DF, Brazil. METHODS: One hundred and thirty-one patients with traumatic spinal cord injury (C4-L3) were recruited. The participants were assessed by standard spirometry and maximal static mouth respiratory pressure. RESULTS: Forced vital capacity was most reduced in tetraplegics (subgroup C4-C5, 49%+/-25 predicted) and increase successively for each descending subgroup (C6-C8, 61%+/-22 predicted; T1-T6, 70%+/-15 predicted), becoming normal in low paraplegia (T7-L3, 84%+/-15 predicted). There is no evidence of an obstructive disturbance throughout all groups. The lowest average percent predicted of maximal static inspiratory pressure (MIP) was in the subgroup C4-C5 (50%+/-23). The average percent predicted of maximal static expiratory pressure (MEP) improved from 19%+/-14 in the C4-C5 subgroup to 51%+/-19 for T7-L3 subgroup. The average percent predicted of all participants for MIP was 74%+/-30 and for MEP was 37%+/-21. In patients with complete motor lesion, the correlation with the level of injury was stronger for MEP (r=0.81, P<0.0001; r (2)=0.65) than for MIP (r=0.62, P=0.004; r (2)=0.38). No correlation was found among incomplete motor lesion patients. CONCLUSIONS: The linear regression equations for the relationship of percent predicted MIP or MEP to level of injury are applicable only to complete motor lesions and may be useful to establish normative association between them.

Cholinergic bronchomotor tone and airway caliber in tetraplegic patients.

STUDY DESIGN: Case-control study. OBJECTIVES: To evaluate the resting airway caliber in subjects with tetraplegia; to define the participation of cholinergic innervation in this condition; and to determine if baclofen modifies this pattern. SETTING: A rehabilitation hospital, Brasília, Brazil. METHODS: We studied 18 tetraplegic patients, with complete motor loss between C4 and C8, and 18 healthy control subjects by measuring airway conductance, before and after inhaled ipratropium bromide. RESULTS: At baseline, the pulmonary function parameters revealed mild-to-moderate restrictive impairment in tetraplegic patients as defined by decreases in total lung capacity and predicted percent of slow vital capacity. The average baseline specific airway conductance (sGaw) was less in tetraplegic patients (0.25+/-0.11) than in the control group (0.41+/-0.10 l/s/cm H(2)O) (P<0.0001). All patients had improved post-bronchodilator sGaw >or=40% compared with only four of the 18 controls (P<0.001). The average increase for tetraplegic patients was 235% (+/-93) versus 25% (+/-24) for controls (P<0.0001). Analysis of variance for repeated measurements showed significant difference in sGaw between the control and spinal cord injury (SCI) groups (P<0.0001) following bronchodilator challenge, but found no difference for total gas volume. No difference for mean basal sGaw and bronchodilator challenge was encountered comparing tetraplegic patients using baclofen to those not using it. CONCLUSIONS: Cervical SCI patients have a reduced baseline conductance compared to controls. Marked improvement occurs after an inhaled anticholinergic drug. This behavior was not affected by the use of baclofen. The study adds support to the hypothesis of an increased cholinergic bronchomotor tone in tetraplegic patients.

Predictive factors of functional gain in long-term stroke survivors admitted to a rehabilitation programme.

PRIMARY OBJECTIVE: To assess factors that may influence functional gain of patients with chronic sequelae of stroke. RESEARCH DESIGN: Prospective study of 290 stroke patients consecutively admitted to a rehabilitation setting. METHODS AND PROCEDURES: Functional Independence Measure Scale (FIM) was used to assess functional capacity. Functional improvement registered during hospitalization (FIM-gain score) was compared to demographic data, stroke sub-type, vascular risk factors, motor deficit, visual hemineglect, aphasia, level of response and sphincter control. FIM-gain score was classified as high-gain (=22) and low-gain (<22). MAIN OUTCOMES AND RESULTS: Two hundred and fifty-two patients who had no prior rehabilitation and were capable of completing the rehabilitation programme were studied (average age 58.4+/-13.9 years; 42.9% women). The mean time from stroke onset to admission was 271.5 days. Average FIM score at admission was 58.8 and at discharge was 81.6. Average FIM Gain was 23.6. The 38% patients admitted later than 6 months after stroke had an average FIM Gain of 19 vs 26 for patients admitted prior to 6 months. Significant predictors of functional improvement were time from stroke onset, age, sitting balance and level of responsiveness. CONCLUSION: The functional improvement scores in persons with stroke beginning a rehabilitation programme at a later stage are 73% of the scores obtained by patients beginning treatment in the first 6 months. FIM score improvement can be predicted by time since stroke onset, age, sitting balance and level of responsiveness.

Schistosoma mansoni myelopathy: clinical and pathologic findings.

Thirteen patients with Schistosoma mansoni myelopathy are reported. Neurologic syndromes included acute areflexic flaccid paraplegia (three), thoracic myelopathy with hyperreflexia and Babinski sign (six), and a cauda equina syndrome (four). Inflammatory granulomas and a schistosome worm in a leptomeningeal vein of the spinal cord were observed in the one patient coming to necropsy.

American trypanosomiasis (Chagas' disease): an unrecognised cause of stroke.

BACKGROUND: American trypanosomiasis, known as Chagas' disease (CD) is a major cause of cardiomyopathy in South America. Irreversible damage to the heart can appear 10 to 20 years after chagasic infection. The frequency of cerebrovascular complications in chronic CD is unknown. OBJECTIVES: To describe a group of patients with chronic or latent CD affected by ischaemic stroke and identify predictive variables for stroke in CD patients. PATIENTS AND METHODS: Retrospective case series of stroke patients with CD was studied using a cross sectional, descriptive design. CD was confirmed by positive immunofluorescence and haemaglutination serology. Data were collected on age, sex, vascular risk factors, previous history of CD, diagnostic stroke subtype, electrocardiograph and echocardiography findings. Frequency of vascular risk factors were compared with a control group of 239 non-chagasic stroke patients. RESULTS: 136 consecutive CD stroke patients, mean age 56 years, 72 women and 64 men were identified. Vascular risk factors were observed in 81.6% of CD patients. Hypertension (70.29% versus 51.47%; p=0.0004), diabetes mellitus (15.9% versus 6.61%; p=0.0143), and tobacco use (53.98% versus 30.88%; p=0.00002) were significantly less frequent in the CD stroke group. Cardiomyopathy was significantly higher in CD stroke patients (45.58% versus 24.69%; p=0.00005). Abnormal electrocardiograms was observed in 82% of chagasic patients (right bundle branch block 39.5%, left anterior fascicular block 35.8%). Left ventricle (LV) diastolic dysfunction (61.47%), LV systolic dysfunction (51.18%), congestive cardiomyopathy (29.92%), and apical aneurysm (15.74%) were the most frequent echocardiographic findings. Aetiologies were cardioembolism (52.2%), undetermined (36.76%), atherothrombotic (8.82%), and small vessel stroke (2.2%). A diagnosis of CD was established after presentation with stroke in 38.23% of the patients. CONCLUSIONS: CD should be included in the differential diagnosis of stroke in patients of South American origin.

Duration of knowledge in general thoracic surgery.

BACKGROUND: Medical knowledge changes rapidly, so current medical education approaches emphasize the development of life-long learning skills ("teaching the learner to learn") as opposed to the simple acquisition of contemporary medical knowledge. Because there are no data on the rapidity of change of general thoracic surgical knowledge, we do not know whether this trend in medical education is appropriate for thoracic surgical trainees. We undertook a study to assess the duration of knowledge in general thoracic surgery. METHODS: The first general thoracic surgery article from each issue of The Annals of Thoracic Surgery between 1965 and 1997 was abstracted into a summary statement. A form, made up of 360 summary statements in random order, was assessed by 6 general thoracic surgeons. They assessed statement validity on a 5-point scale (1 = statement false; 5 = statement true). Average statement validity scores for 30 time intervals were calculated. The relationship between time of publication and statement validity was analyzed. RESULTS: Average validity scores ranged from 2.24 (represents 1965 to 1966) to 4.32 (represents 1969 to 1970). Validity scores increased with time (y = 3.46 + 0.017x, where y is validity score and x is time), and this was significant (r = 0.40; p = 0.027). However, the absolute change in average validity scores over the 33-year study period was only 0.52 or 13.1% of the "modern" era scores. CONCLUSIONS: The assumption that medical knowledge changes quickly may not be true in general thoracic surgery. Although life-long learning skills are important, general thoracic surgery training programs should continue to emphasize fundamental knowledge in the specialty.

Forced oscillation technique to detect and monitor tracheal stenosis in a tetraplegic patient.

STUDY DESIGN: A case report. OBJECTIVES: To demonstrate forced oscillation technique's (FOT) utility in a tetraplegic patient with tracheostenosis. SETTING: A Rehabilitation Hospital, Brasília, Brazil. METHODS: Serial evaluations of spirometry, bronchoscopy and forced oscillation assessment. RESULTS: A 16-year-old male with C7 spinal cord injury, initially required mechanical ventilation and subsequent tracheostomy over a period of 4 weeks. Five months after the accident the onset of tracheostenosis was diagnosed. Flow-volume data were compatible with a fixed tracheal stenosis. FOT showed an obstructed pattern, manifested by high levels of resonance frequency and impedance. The FOT pattern returned to normal after dilatation. The FOT abnormalities recurred with two subsequent broncoscopicaly confirmed episodes of tracheal restenosis without parallel changes in spirometric parameters. CONCLUSION: This case suggests a role for FOT in the non invasive detection and follow up of tracheal stenosis. FOT may be particularly useful in tetraplegic patients, in whom the restriction from muscle weakness may make interpretation of forced expiratory flow-volume data problematic.

The benefit of pulmonary metastectomy for bone and soft tissue sarcomas.

The outcome of patients having metastectomy for pulmonary metastases from locally controlled primary malignancy of bone and soft tissue of the limbs is compared to a similar group deprived of such therapy. Forty patients receiving pulmonary metastectomy and 18 patients who were candidates for, but did not receive, metastectomy were compared by age, sex, histology, number of metastases, synchronous and metachronous presentation of metastases and the use of chemotherapy. The only variable correlated with survival was metastectomy. Surgical mortality was 0%, complications occurred following 11.7% of the procedures. Survival of the 40 metastectomised patients (median 60 months) was better than that of the 18 patients not operated upon (median 28 months; P = 0.02). For osteosarcoma, median survival was 51 months versus 30 months, respectively (P = 0.004). Median survival for patients undergoing pulmonary metastectomy was twice that of those not receiving metastectomy. The number and time of appearance of metastases does not appear to be a deterrent.

Epinephrine decreases postoperative requirements for continuous thoracic epidural fentanyl infusions.

Epidural thoracic fentanyl infusions provide effective preoperative analgesia after thoracotomy; however, side effects can limit the effectiveness of this technique. This study evaluates epinephrine as an adjunct to continuous thoracic epidural fentanyl infusions after thoracotomy. Thirty-eight patients were studied in a prospective, randomized, double-blind trial comparing fentanyl alone to fentanyl with epinephrine 1:300,000. Epidural infusion rates were titrated to equivalent pain relief using a visual analog scale. With the addition of epinephrine, there was a significant reduction in fentanyl requirements (0.82 +/- 0.07 vs 1.19 +/- 0.11 micrograms.kg-1.h-1, P = 0.005, repeated-measures analysis of variance) and in plasma fentanyl concentrations (steady state: 0.91 +/- 0.13 vs 1.65 +/- 0.23 ng/mL, P = 0.007, repeated-measures analysis of variance). There were no differences in pain scores, side effects, spirometry, patient satisfaction scores, or hemodynamic variables. This study demonstrates that adding epinephrine 1:300,000 to continuous thoracic epidural infusions decreases fentanyl requirements titrated for effective analgesia. The reduction in fentanyl requirements was associated with reduced fentanyl plasma concentrations.

Mediastinoscopic treatment of mediastinal cysts.

Selected patients with mediastinal cysts can be managed safely and effectively by mediastinoscopic techniques. Small cysts in favorable locations can be excised partially or nearly completely. Cysts that are intimately associated with vital structures are better suited to mediastinoscopic cystotomy and chemical sclerosis. Three cases are presented and technical aspects are discussed.

Esophageal perforation in recessive dystrophic epidermolysis bullosa.

Recessive dystrophic epidermolysis bullosa is an inherited mechanobullous disease characterized by skin blistering and esophageal bullae. In response to minor trauma, a split in the dermis or esophageal subepithelium occurs. Esophageal perforation is a rare complication. Because the esophagus is diseased in these patients, we believe that esophagectomy rather than repair is the treatment of choice for esophageal perforations. We report a patient for whom early primary repair failed and esophagectomy was required.

Thoracic versus lumbar epidural fentanyl for postthoracotomy pain.

Thirty patients were prospectively randomized to receive either thoracic or lumbar epidural fentanyl infusion for postthoracotomy pain. Epidural catheters were inserted, and placement was confirmed with local anesthetic testing before operation. General anesthesia consisted of nitrous oxide, oxygen, isoflurane, intravenous fentanyl citrate (5 micrograms/kg), and vecuronium bromide. Pain was measured by a visual analogue scale (0 = no pain to 10 = worst pain ever). Postoperatively, patients received epidural fentanyl in titrated doses every 15 minutes until the visual analogue scale score was less than 4 or until a maximum fentanyl dose of 150 micrograms by bolus and an infusion rate of 150 micrograms/h was reached. The visual analogue scale score of patients who received thoracic infusion decreased from 8.8 +/- 0.5 to 5.5 +/- 0.7 (p < or = 0.05) by 15 minutes and to 3.5 +/- 0.4 (p < or = 0.05) by 45 minutes. The corresponding values in the lumbar group were 8.8 +/- 0.6 to 7.8 +/- 0.7 at 15 minutes and 5.3 +/- 0.9 at 45 minutes (p < or = 0.05). The infusion rate needed to maintain a visual analogue scale score of less than 4 was lower in the thoracic group (1.55 +/- 0.13 micrograms.kg-1 x h-1) than in the lumbar group (2.06 +/- 0.19 microgram.kg-1 x h-1) during the first 4 hours after operation (p < or = 0.05). The epidural fentanyl infusion rates could be reduced at 4, 24, and 48 hours after operation without compromising pain relief. Four patients in the lumbar group required naloxone hydrochloride intravenously.(ABSTRACT TRUNCATED AT 250 WORDS)

Pericardioscopy and biopsy.

The diagnosis of malignant pericardial effusion is usually made by pericardial fluid cytology or open pericardial biopsy. A case is reported where diagnostic difficulty warranted flexible pericardioscopy under fluoroscopic guidance. The technique is described.

Plasma cell granuloma of the lung.

Plasma cell granuloma is an uncommon, nonneoplastic pulmonary lesion. An 11-year retrospective review of resected pulmonary tumors yielded six patients with plasma cell granulomas. Fine needle aspiration biopsy results were falsely positive for carcinoma in one patient. Adherence or invasion of the mediastinum was present in three patients. Granuloma in one patient, who underwent two operative procedures, was deemed unresectable at the initial thoracotomy. For both diagnostic and therapeutic reasons, early surgical excision is recommended for plasma cell granulomas of the lung.

Pneumothorax complicating cardiac surgery.

Pneumothorax is an infrequent complication of cardiac surgery. In order to evaluate potential causative or associated factors and to formulate guidelines for prevention and management of this complication, we undertook a retrospective nine-year analysis of our adult cardiac surgical procedures. Twenty-one of 1463 patients suffered a postoperative pneumothorax for an overall incidence of 1.4%. Life threatening pneumothoraces occurred in four patients. Seven of 21 had chronic obstructive pulmonary disease. Eighteen required chest tube insertion. Four patients, including three with chronic obstructive pulmonary disease, required further interventions. These included additional chest tube insertion in three, high constant chest tube suction in three, tetracycline pleurodesis in three, and thoracotomy in one patient. Pneumothoraces following cardiac surgery are often preventable, may be associated with prolonged morbidity, and are potentially life threatening. Conservative management with chest tube drainage is usually successful. Patients with chronic obstructive lung disease are more likely to suffer prolonged morbidity and require thoracotomy.