Chronic deep posterior compartment syndrome of the leg in athletes: postoperative results of fasciotomy.

The present study evaluates the efficacy of two treatment regimens in individuals possibly suffering from chronic exercise induced compartment syndrome (CECS) of the deep posterior compartment of the leg. We hypothesised that the current method of fasciotomy of the deep posterior compartment of the leg is a procedure with a limited success rate. Dynamic intra-compartmental pressure measurements were applied to 46 patients that had symptomatology of a posterior CECS. Only those patients that met predefined pressure criteria, the "high-pressure group" (27 patients), were offered surgical treatment in the form of fasciotomy. The other 19 patients, "low-pressure group", received conservative treatment, consisting of inlays and physiotherapy. In addition, these patients were examined more closely in order to exclude different pathology. Efficacy of both approaches was evaluated by a questionnaire after a mean three-year follow-up. Fifty-two percent of the high-pressure group judged their operation successful, whereas 48 % did not. The majority of the low-pressure group (84 %) was free of symptoms, after conservative treatment as well as following treatment of other pathology. The present study shows that the success rate of patients surgically treated for posterior CECS is relatively low (52 %). The established cut-off points for the compartment pressure to deselect patients for an operation are justified based on the long-term success rate of the low-pressure group.

[Double-sided juvenile osteochondritis dissecans of the lateral femoral condyle in a 15-year-old boy]. / Dubbelzijdige juveniele osteochondritis dissecans van de laterale femurcondyl bij een 15-jarige jongen.

A 15-year-old boy of Turkish origin presented with a painful swollen left knee. An X-ray revealed osteochondritis dissecans of the lateral femoral condyle. Arthrotomy was performed and the fragment was fixated with tissue glue and 2 absorbable pins. Eight months later, a large recurrent osteochondral fragment of the lateral femoral condyle was seen on X-ray. The patient was re-operated, during which operation the fragment was found and fixated with three compression screws. One year after the first operation the patient developed similar complaints in the contralateral knee; this knee also contained osteochondral fragments necessitating surgery. Osteochondritis dissecans of the knee is a multifactorial disease in which part of the cartilage of the femoral condyle becomes unattached from the subchondral stratum, usually on the lateral side of the medial femoral condyle. Initially, an inflammatory reaction was thought to be the cause of osteochondritis dissecans. Because of the lack of white blood cells, a previous trauma is a better explanation for the ultimate loosening of the cartilage. The treatments that are described for osteochondritis dissecans are conservative treatment, operative fixation, with or without subsequent chondrocyte transplantation or osteochondral autograft transplantation, and finally microfracturing.

Embolism of the popliteal artery after anterior cruciate ligament reconstruction: a case report and literature review.

Arterial complications after anterior cruciate ligament reconstruction (ACLR) are rare. We present a case report of a 44-year-old male patient with a subtotal occlusion of the popliteal artery, with sensory loss in the foot, 17 days after ACLR. Embolectomy and anticoagulant therapy led to full recovery of the peripheral arterial circulation. The sensory loss of the foot also fully recovered. To our knowledge, this is the first case report of an embolus of the popliteal artery after ACLR without relation to graft fixation. A literature review on vascular complications after ACLR is presented.

Supramaximal flow in asthmatic patients.

In normal subjects supramaximal flows (SF) are known to be correlated with flow limitation. To further understand the mechanisms involved in SF this correlation and the influence of salbutamol and methacholine administration on SF have been investigated in asthmatic subjects. Protocol A involved obtaining basal maximal expiratory flow/volume curves and interrupted curves through a fast valve from 36 asthmatic patients. Maximal flow at 50% of forced vital capacity (V'max50) increase (deltaV'max50) was compared between basal curves and envelope curves passing through SF peaks obtained after each interruption. Protocol B involved the study of 33 asthmatic patients after salbutamol administration and 12 asthmatic patients after methacholine challenge. DeltaV'max50 between basal versus interrupted curves were analysed (deltaV'max50B). Similar procedures were performed after salbutamol (deltaV'max50S) and after methacholine administration (deltaV'max50M). A significant negative correlation between forced expiratory volume in one second and deltaV'max50 was observed. SF decreased significantly after salbutamol administration and increased significantly after methacholine. The results of this study suggest that in asthmatic patients participation of "pendelluft" in SF increases as airflow limitation increases.

[Argentine consensus on sleep-related respiratory disorders]. / Consenso Argentino de trastornos respiratorios vinculados al sueño.

Due to the increased interest of the medical community in sleep disorders an experts meeting was called to establish common criteria for diagnosis, treatment and management of these disorders. Adult prevalence of sleep apnea/hypopnea syndrome (SA/HS) is about 2-4% and increases in the elderly. Snoring and excessive daytime somnolence (EDS) are habitual symptoms. Increased risk to cardiovascular disorders and traffic accidents are the major complications. Increased upper airways resistance syndrome is a recently described syndrome which also involves EDS. A standardized questionnaire was developed and its use was recommended in order to evaluate patients with respiratory sleep disorders (RSD). Polysomnography was established as gold standard in the diagnosis of RSD. Minimal requirement of split night studies and screening studies was also standardized and specific indications were summarized. Medical treatment of obesity in relationship to RSD was analyzed. Nasal continuous positive airways pressure (CPAP) was established as the first choice treatment of SA/HS. Titration of CPAP was standardized. Oral appliances with mandibular advancement could be considered in the treatment of snoring patients without SA/HS and in patients with increased upper airways resistance syndrome. Uvulopalatopharingoplasty can only be performed in snoring patients in whom the presence of SA/HS has been dismissed by polysomnography. Management of patients must include periodic clinical control. EDS must be determined by Epworth test. In order to evaluate CPAP compliance the use of time-controlled devices is highly recommended.

Consenso Argentino de trastornos respiratorios vinculados al sueño. / [Argentine consensus on sleep-related respiratory disorders]

Due to the increased interest of the medical community in sleep disorders an experts meeting was called to establish common criteria for diagnosis, treatment and management of these disorders. Adult prevalence of sleep apnea/hypopnea syndrome (SA/HS) is about 2-4

and increases in the elderly. Snoring and excessive daytime somnolence (EDS) are habitual symptoms. Increased risk to cardiovascular disorders and traffic accidents are the major complications. Increased upper airways resistance syndrome is a recently described syndrome which also involves EDS. A standardized questionnaire was developed and its use was recommended in order to evaluate patients with respiratory sleep disorders (RSD). Polysomnography was established as gold standard in the diagnosis of RSD. Minimal requirement of split night studies and screening studies was also standardized and specific indications were summarized. Medical treatment of obesity in relationship to RSD was analyzed. Nasal continuous positive airways pressure (CPAP) was established as the first choice treatment of SA/HS. Titration of CPAP was standardized. Oral appliances with mandibular advancement could be considered in the treatment of snoring patients without SA/HS and in patients with increased upper airways resistance syndrome. Uvulopalatopharingoplasty can only be performed in snoring patients in whom the presence of SA/HS has been dismissed by polysomnography. Management of patients must include periodic clinical control. EDS must be determined by Epworth test. In order to evaluate CPAP compliance the use of time-controlled devices is highly recommended.

Relationship between supramaximal flows and flow-limiting mechanisms.

The aim of this study was to evaluate the relationship between supramaximal flows (SF) and indices of airway mechanics. We studied 26 asymptomatic young subjects (13 smokers, mean +/- SD 15.9 +/- 6.6 pack-years. Subjects performed maximal expiratory flow-volume (MEFV) curves, according to the American Thoracic Society (ATS) criteria, on a rolling-seal spirometer and then repeated them through a specially devised valve, which occluded the mouthpiece either 3 or 6 times.s-1 with a ratio of open:closed time of 3:1. Envelope MEFV curves for 3 and 6 Hz occlusions were constructed passing through the SF obtained after each occlusion, and the increment in flow at 50% of vital capacity was measured with respect to the basal curve (delta V' max50). We found that the delta V' max50 at 3 and 6 Hz correlated to the baseline forced mid-expiratory flow (FEF25-75) in % of predicted value (r = -0.73 and r = -0.55, respectively). our results suggest that inhomogeneities within the lung are an important mechanism in the occurrence of supramaximal flow in normal subjects.

Propuesta para la estandardización de la espirometría en la ciudad de Buenos Aires / A proposal for spirometry standardization in the city of Buenos Aires

Se trata de un estudio multicéntrico que abarcó 8 Hospitales de Buenos Aires, referido al Control de Calidad de 17 espirómetros (9 volumétricos, 5 neumotacómetros y 3 medidores de FEFmx) de uso corriente en ellos. Se realizó mediante un Simulador de Espirometría por Descompresión Explosiva. Este instrumento portátil proporciona un flujo aéreo similar a una espiración forzada, cuyos CVF, VEF1 y FEF25-75 se conocen con precisión. Aplicándolo a los espirómetros se pudo comprobar si la exactitud de sus mediciones se ajustaba, o no a las recondaciones de la American Thoracic Society. Sólo el 42// (6/14) de los aparatos logró medir corectamente los parámetros básicos (CVF y VEF1, observándose que los de registro volumétrico presentaban mejor rendimiento que los que miden primariamente el flujo. Si bien la magnitud de los errores (igual o menor del 11//) no parece excesiva, en realidad sí lo es, ya que representa la mitad del rango de variación de los valores teóricos. Se concluye que los Controles de Calidad mensuales recondados por el American College of Chest Physicians constituyen una sugerencia bien fundamentada

Propuesta para la estandardización de la espirometría en la ciudad de Buenos Aires / A proposal for spirometry standardization in the city of Buenos Aires

Se trata de un estudio multicéntrico que abarcó 8 Hospitales de Buenos Aires, referido al Control de Calidad de 17 espirómetros (9 volumétricos, 5 neumotacómetros y 3 medidores de FEFmx) de uso corriente en ellos. Se realizó mediante un Simulador de Espirometría por Descompresión Explosiva. Este instrumento portátil proporciona un flujo aéreo similar a una espiración forzada, cuyos CVF, VEF1 y FEF25-75 se conocen con precisión. Aplicándolo a los espirómetros se pudo comprobar si la exactitud de sus mediciones se ajustaba, o no a las recondaciones de la American Thoracic Society. Sólo el 42// (6/14) de los aparatos logró medir corectamente los parámetros básicos (CVF y VEF1, observándose que los de registro volumétrico presentaban mejor rendimiento que los que miden primariamente el flujo. Si bien la magnitud de los errores (igual o menor del 11//) no parece excesiva, en realidad sí lo es, ya que representa la mitad del rango de variación de los valores teóricos. Se concluye que los Controles de Calidad mensuales recondados por el American College of Chest Physicians constituyen una sugerencia bien fundamentada (AU)

Effects of inhaled platelet activating factor on bronchial responsiveness in patients with symptomatic and asymptomatic pulmonary embolism.

To determine the possible role of platelet-activating factor (PAF) in pulmonary embolism (PE), the reactivity of the airways to inhaled PAF, using doses ranging from 6.25 to 400 micrograms, was examined in 24 patients with a past episode of PE. Twelve of these patients had experienced acute respiratory insufficiency during the episode (with or without additional symptoms). None of the remaining 12 patients had experienced any respiratory symptoms during the PE episode. Diagnosis was established by means of a ventilation-perfusion lung scan performed when admitted to the hospital because of deep venous thrombosis (DVT) in the lower limbs. Nonspecific bronchial reactivity as measured by the response to bronchoprovocation testing with methacholine showed no significant differences between both groups. PAF caused a dose-dependent bronchoconstriction defined by at least a 35 percent decrease in specific airway conductance (SGaw) in all patients. The average dose of PAF needed to decrease SGaw 35 percent was significantly lower in patients who had had a symptomatic PE than in those with asymptomatic PE (p = 0.011). This finding suggests that patients who suffered from symptomatic PE may present a greater airway reactivity to inhaled PAF. This different behavior might explain the existence of some of the respiratory symptoms of PE, which could be attributed to PAF-related effects. However, additional studies are needed to evaluate the role of PAF in PE.

Hygroscopic condenser humidifier as a solution to nasal dryness due to nasal CPAP treatment for obstructive sleep apnea syndrome.

We report an apparent solution to nasal dryness for patients with obstructive sleep apnea syndrome treated with nasal continuous positive airway pressure (CPAP) when a hygroscopic condenser humidifier is introduced into the CPAP circuit. Six patients underwent a 5-h test period of nasal CPAP therapy with a mask containing a hygroscopic humidifier. The water vapor showed a statistically significant increase in both inspired and expired gases. The relative humidity of the inspired gases increased significantly. The levels of O2 and CO2 in the respired gases did not change. When patients were asked about nasal dryness at the end of the test, all of them reported marked improvement.

Captopril and bronchial reactivity.

In order to assess the effect of captopril on bronchial reactivity, 16 consecutive patients with asthma and hypertension were randomized in a double-blind crossover study, with increasing doses of placebo or captopril for 4 week periods. Forced expiratory flow (FEV1) and a dose-response curve with methacholine (PD20) were measured before and after treatment . Effective control of hypertension was achieved in all patients on captopril (P less than 0.05), while no changes in FEV1 and PD20 were observed. We conclude that captopril can be used as a first step in the treatment of asthmatic patients with hypertension.

Evaluation of a new piston-type spirometer.

A new dry spirometer (DS) incorporating a microcomputer for automatic calculation and direct read-out of spirometric parameters was compared to a calibrated Fleisch pneumotachograph (PT). Twenty-eight volunteers, including healthy subjects, obstructive and non-obstructive patients, performed a total of 48 spirometric tests with the two apparatuses randomly alternated. DS values for FVC were lower than those of the PT with a mean difference of 0.177 1 +/- 0.171 SD (p less than 0.0001). Mean FEV1 values were very similar in both apparatuses with a non significant difference of 0.003 1 +/- 0.182 FEF25-75 values were higher with the DS, showing a mean difference with the PT of 0.407 1 . s-1 +/- 0.324 (p less than 0.00001). The DS also gave slightly higher PEFR values than the PT, with a mean difference of 0.310 1 . s-1 +/- 0.830 (p less than 0.02). Differences in FVC readings between DS and PT were greater in severely obstructed patients (0.350 1 +/- 0.084, p less than 0.0001) than among healthy subjects (0.120 1 +/- 0.051, p less than 0.0002). On the contrary, in absolute figures DS values for FEF25-75 showed a greater difference with those of the PT in normals (0.547 1 . s-1 +/- 0.320, p less than 0.001) than in obstructed patients (0.288 1 . s-1 +/- 0.244, p less than 0.05). DS flow resistance was 2.67 cmH2). s. 1-1 for a flow of 8.8 1. s-1. Based on the spirometric differences observed, and on the high flow resistance and volume limitation imposed by its 6 1 capacity, we concluded that the apparatus tested cannot be recommended for clinical spirometry.