Surgical patients with surprising laboratory data.

Preoperative laboratory tests were performed on elective ambulant orthopaedic patients (n = 26) on the afternoon after their arrival in hospital and on the next morning before the operation. Significantly lower concentrations of leukocytes, albumin, total protein, platelets, and total calcium were observed in samples taken in the morning. Posture and chronobiological rhythms may be responsible for these changes. An overnight change in laboratory values may lead to unnecessary further investigations and postponement of surgery. The clinician should be aware of the effects of preanalytical factors on laboratory data.

Hyperostosis and osteoarthritis in patients surviving after tetanus.

Twenty patients (12 men and 8 women) who had survived tetanus were examined for bone and joint abnormalities, 1-9 years after the disease. The radiographic findings in the elbows were abnormal in 13 out of 20 patients, as were the shoulders of all 3 patients examined. Insertion hyperostoses were found at the elbow and/or in the shoulder region in 5 (25%) of the patients. The hyperostoses were bilateral in 3 patients. One of the patients with hyperostoses also had calcifications in the soft tissue of the elbow. The abnormalities were associated with mild clinical symptoms. Trauma to the periosteum caused by repeated traction of muscular contractions is possibly the causative mechanism. Twelve patients (60%) had osteoarthritis of the elbow joint presumably secondary to the violent stress to the joint.

Tetanus of immunized children.

Five children aged five to 15 years contracted tetanus in Finland between 1969 and 1985, together with 101 adults. Four of the five had been adequately immunized against tetanus. The clinical picture of tetanus was mild or moderate, and none of the children needed respirator treatment. Epilepsy, meningitis and psychogenic symptoms were considered in the differential diagnosis. The course of tetanus in immunized patients is atypical and often benign, but the diagnosis is problematic--in contrast to affected children in developing countries, whose populations are not adequately immunized and where neonatal tetanus is common and often fatal.

Unusual and iatrogenic sources of tetanus.

In order to successfully treat tetanus one has to be aware of its causes. Therefore, sources of tetanus were examined in a series of 106 patients with tetanus diagnosed in Finland during the period 1969-1985. The primary injuries which were identified in 100 (94.3%) of them included puncture wound, minor injury, excoriation, animal bite, cut wound, open fracture, burn, undefined wound and other sources. The latter group included nine patients in two of whom tetanus was caused by an operation on a closed injury and in one patient by a decubitus ulcer during hospital care. Six patients had an unusual source of tetanus: frostbite, poor teeth, ulceration in the gum under a denture, infected molluscum contagiosum, a scratched atheroma cutis and an infected granuloma pyogenicum. Two of these nine patients died; the mortality in the whole series was 12 patients (11.3%). It is important to be aware of even the rare sources of tetanus, as the rarity or absence of a primary injury may delay the diagnosis and treatment of tetanus and worsen the prognosis of the patients.

Tetanus caused by occupational accidents.

The role of occupational accidents as a source of tetanus is poorly known. In Finland, during the period 1969-1985, 28 (26%) of the 106 cases of tetanus were caused by occupational accidents, 16 of which occurred in agriculture and forestry. Twenty-one of the patients were men and seven were women. The mean annual incidence of tetanus was 1 per 100,000 occupational accidents during the study period. The cases were concentrated in summer and autumn. Most of the primary injuries were minor, 61% of the injuries occurring in the hands and fingers. Forty-three percent of the patients had not been immunized against tetanus, and 46% were unaware of their state of immunization. The systematic immunization of the population against tetanus is important because the disease is often caused by slight injuries not requiring treatment by health care personnel. This need is emphasized for work in agriculture, forestry, and other branches in which contact with soil or animals occurs.

Polyneuropathy caused by chlorprothixene.

Seven chronic psychiatric patients developed signs of polyneuropathy mainly in the lower limbs after receiving chlorprothixene (500-1800 mg/d) from 3 to more than 24 months. The most prominent electroneuromyographic findings were decreased or not measurable motor conduction velocities of the peroneal nerves. Electromyography showed signs of denervation in the leg muscles in all the patients, and also in the upper limbs in 4 of them. The signs of polyneuropathy gradually subsided after withdrawal of chlorprothixene. Thus, chlorprothixene may cause a toxic, dose-dependent, reversible polyneuropathy.

Tetanus in Finland: diagnostic problems and complications.

In a 16-year nationwide study in Finland 106 patients were diagnosed as having tetanus. Tetanus was diagnosed on the first visit to a doctor in half the patients, it was suspected in 28% but not considered in 22%. Diagnosis of tetanus may be delayed if a patient is elderly or has no known primary lesion. Abnormal EEGs and CSF findings with increased protein level were unexpectedly common (76% and 24% respectively). The most significant complications were cardiac arrhythmias (34%), blood pressure lability (32%), an increased haemorrhagic tendency (28%), an increase in thrombosis (8%) and/or of anoxic periods (16%) and death (11%). Intensive care has markedly improved the prognosis of tetanus; the main problems at present are difficulty of early diagnosis and treatment of complications of the most serious cases.

Outcome and neurological sequelae of patients after tetanus.

From 1969-1985, 106 people contracted tetanus in Finland. The outcome of the disease was good in 78 cases (returned to work), poor in 27 (12 died, 5 institutionalized and 10 retired) and unknown in 1. Poor outcome was the result of a disease requiring respirator treatment. Other clinical factors significantly correlated with poor outcome were blood pressure lability, hyperglycemia, hyperthermia, tachycardia and anticoagulation therapy. Forty people who were representative of the whole series with regard to sex, age and severity of disease attended a follow-up study on average 7 years and 4 months later. Forty age- and sex-matched controls had the same examinations, and compared with them, the 40 patients still had significantly more muscle fatigue and cramps, nervousness, decreased mental capacity and difficulties in balance, speech and memory. They also had more clinical findings, such as peripheral paresis, muscular atrophy, decreased or absent tendon reflexes and decreased mental capacity than the controls.

Electroneuromyographic sequelae of tetanus, a controlled study of 40 patients.

To assess the peripheral nervous system involvement caused by tetanus 40 patients recovered from tetanus and their sex and age matched referents were submitted to electroneuromyography (ENMG). Clinical symptoms and signs of peripheral neuropathy were found in 6 patients, 3 of whom had other obvious aetiology than tetanus. EMG was examined of the masseters and three muscles in the extremities. Motor conduction velocities (MCVs) were examined of the median, ulnar and peroneal nerves, distal sensory conduction velocity (dSCV) of the median, ulnar and radial nerves and the sensory conduction velocity (SCV) of the median nerve. Repetitive stimulation was done to study the neuromuscular transmission. The patients had significantly longer motor distal latencies (DLs) and slower dSCVs and more frequent ENMG findings compatible with mono- or polyneuropathy than their referents. There was no systematical difference in the MCVs. These findings suggest that tetanus may cause toxic axonal polyneuropathy, sequels of which appear to be slight or subclinical and can be seen at a group level.

Electroencephalography in tetanus.

To assess the brain involvement caused by tetanus, we examined the EEGs of 39 patients recovered from tetanus and those of 39 sex- and age-matched controls. The patients had significantly more frequent and more severe EEG abnormalities than their controls. The most marked difference was in the occurrence of diffuse EEG abnormalities (P less than 0.05). Twenty patients had normal EEGs. EEGs of 14 patients (5 of whom in this follow-up) during acute tetanus showed abnormalities in 10 patients, marked in degree in 3 of those. EEG abnormalities started to improve after the acute phase of tetanus. It is concluded that EEGs of patients with tetanus are often abnormal and that EEG is helpful in revealing brain involvement in patients after tetanus.

Epidemiology of tetanus in Finland from 1969 to 1985.

During the period 1969-85, tetanus caused the hospitalization of 106 patients (63 men and 43 women) in Finland. 12 (11.3%) of them died, most of the causes of death being unexpected complications during the intensive care. The majority of the patients were more than 50 years old and had not been fully vaccinated against tetanus. There was a clear seasonal variation, most of the cases occurring during the months when there is no snow on the ground. Half of the primary lesions were minor injuries to hands and fingers. Only half of the primary lesions had needed medical treatment and usually the patients had received antibiotics and tetanus vaccination but not immunoglobulin. To diagnose tetanus is more difficult today than previously, because few doctors nowadays encounter tetanus cases and the diagnosis is based entirely on clinical criteria, and because abortive mild forms of tetanus may occur, especially in patients with partial immunity.

Neuropsychological methods in the differentiation of organic solvent intoxication from certain neurological conditions.

Neuropsychological impairment and the subjective symptoms of 21 patients with organic solvent intoxication were compared with those of patients with vertebrobasilar insufficiency (n = 16), cerebral trauma (n = 16), and headache (n = 15). The aim was to study the diagnostic efficiency of psychological methods in the neuropsychological assessment of patients with suspected solvent intoxications. Our results suggest that it is possible to differentiate between the four groups at group level; however, because of the variance in each group, no specific rule for individual diagnostics can be given. At group level, a combination of three test variables and three symptom scales yielded the most effective discrimination. Instead of the raw scores, subscores for the individual tests as well as detailed use of the symptom questionnaire were informative when the groups were compared. This approach may also be applicable to individual diagnostics.

Cerebrospinal fluid cells and proteins in patients occupationally exposed to organic solvents.

Cerebrospinal fluid (CSF) cells and proteins were determined for 33 patients exposed to industrial organic solvents. A lymphoid reaction, i.e., a pathologically elevated number or percentage of enlarged lymphoid cells was observed in one-third of the patients, more often in patients with chronic intoxication (40%) than in those currently exposed to organic solvents (32%). An almost significant decrease of small lymphocytes in the CSF was observed among patients who had a past history of chronic solvent intoxication but no recent exposure. No cytological evidence of tissue destruction was found. Signs of slight blood--CSF barrier damage occurred in 5 (23%) of the currently exposed patients, but intrathecal IgG synthesis was not observed. Increased cellular activity in the CSF was also accentuated in principal component analysis. The results suggest slight nonspecific immunoactivation in the central nervous system of subjects exposed to organic solvents.

Dantrolene sodium in chronic spasticity of varying etiology. A double-blind study.

Seventeen patients, 13 males and 4 females, with moderate to severe spasticity caused by varying neurological disorders attended a double-blind, placebo-controlled trial to determine the efficacy and safety of dantrolene sodium. Three patients discontinued, two because of side effects and one because of a laboratory abnormality. In the fourteen subjects who completed the trial there was a statistically significant decrease in resistance to passive stretch, clonus and hyperreflexia without significant reduction of muscle strength. A positive clinical effect was observed in ten patients while a very slight or no effect was seen in four cases. All patients reported adverse reactions during the dantrolene period, six patients during the placebo treatment. Six patients wanted to go on with dantrolene after the trial. On many occasions the urine of the patients turned bright yellow with high doses of dantrolene. It is concluded that dantrolene sodium is an effective antispastic drug in about one-third of patients who suffer from spasticity of varying etiology.

Neurological picture of organic solvent poisoning in industry. A retrospective clinical study of 37 patients.

A retrospective evaluation of neurological, neuroradiological, neurophysiological, psychological, and laboratory findings on 37 patients, remitted to the Institute of Occupational Health, Helsinki because of suspected poisoning due to organic solvents, was performed. Patient selection was made on the basis of performed pneumoencephalography (PEG). Most of the patients had been exposed to a mixture of solvents (19 cases). Carbon disulphide exposure had occurred in six cases, trichloroethylene in five cases, and the rest of the patients had been exposed to styrene (one case), thinner (two cases), toluene (1 case), methanol (1 case), and carbon tetrachloride (two cases). Clinical neurological findings comprised slight psycho-organic alteration, cerebellar dysfunction, and peripheral neuropathy. The PEG showed changes suggesting brain atrophy in 63% of the patients. Slight asymmetric central atrophy and localized cortical atrophy were the most frequent findings. The main electroencephalographic finding was slight diffuse slow-wave. Electroneuromyography showed slight changes suggesting peripheral neuropathy in 23 of the 28 patients examined. Psychological alterations were seen in all patients: personality changes and psychomotor disturbances were the most common findings. Because individual constitutional differences existed, no clear-cut exposure-effect relationship could be established. Thus, neurological evaluation of all those exposed to neurotoxic agents who present symptoms, regardless of the degree of current exposure, is important.