Iatrogenic lesions of peripheral nerves.

Iatrogenic nerve lesions (INLs) are an integral part of peripheral neurology and require dedicated neurologists to manage them. INLs of peripheral nerves are most frequently caused by surgery, immobilization, injections, radiation, or drugs. Early recognition and diagnosis is important not to delay appropriate therapeutic measures and to improve the outcome. Treatment can be causative or symptomatic, conservative, or surgical. Rehabilitative measures play a key role in the conservative treatment, but the point at which an INL requires surgical intervention should not be missed or delayed. This is why INLs require close multiprofessional monitoring and continuous re-evaluation of the therapeutic effect. With increasing number of surgical interventions and increasing number of drugs applied, it is quite likely that the prevalence of INLs will further increase. To provide an optimal management, more studies about the frequency of the various INLs and studies evaluating therapies need to be conducted. Management of INLs can be particularly improved if those confronted with INLs get state-of-the-art education and advanced training about INLs. Management and outcome of INLs can be further improved if the multiprofessional interplay is optimized and adapted to the needs of the patient, the healthcare system, and those responsible for sustaining medical infrastructure.

Inflammatory activation after experimental cardiac tamponade.

BACKGROUND/PURPOSE: Cardiac tamponade is a medical emergency situation associated with a high rate of life-threatening complications, even after immediate interventions. Our aim was to characterize the acute inflammatory consequences of this event in a clinically relevant large animal model. METHODS: Cardiac tamponade was induced for 60 min in anesthetized, ventilated and thoracotomized minipigs by intrapericardial fluid administration, the mean arterial pressure (MAP) being maintained in the interval of 40-45 mm Hg (n = 8). A further group (n = 7) served as sham-operated control. The global macrohemodynamics, including the right- and left-heart end-diastolic volumes (RHEDV and LHEDV), the pulmonary vascular resistance index (PVRI) and the superior mesenteric artery (SMA) flow, were monitored for 240 min, and the intestinal microcirculatory changes (pCO2 gap) were evaluated by indirect tonometry. Blood samples were taken for the determination of cardiac troponin T and vasoactive inflammatory mediators, including histamine, nitrite/nitrate, big-endothelin, superoxide and high-mobility group box protein-1 levels in association with intestinal leukocyte and complement activation. RESULTS: The cardiac tamponade induced significant decreases in MAP, cardiac output, LHEDV and SMA flow, while the PVRI and the pCO2 gap increased significantly. After the removal of fluid from the pericardial sac, the MAP and the LHEDV were decreased, while the PVRI and the pCO2 gap remained elevated when compared with those in the sham-operated group. In the posttamponade period, the abrupt release of inflammatory mediators was accompanied by a significant splanchnic leukocyte accumulation and complement activation. CONCLUSIONS: The macrocirculatory and splanchnic microcirculatory disturbances were accompanied by a significant proinflammatory reaction; endothelin and the complement system may be significant components of the inflammatory cascade that is activated in this porcine model of pericardial tamponade.

Circulatory consequences of reduced endogenous nitric oxide production during small-volume resuscitation.

Hypertonic small-volume resuscitation transiently restores the cardiovascular function during various circulatory disturbances. Nitric oxide (NO) is an important mediator of flow-induced peripheral and central hemodynamic changes, and therefore, we hypothesized that a decreased endogenous NO production could influence the consequences and the effectiveness of hypertonic fluid therapy. The main goal of this study was to outline and compare the circulatory effects small volume hypertonic saline-dextran (HSD, 7.5% NaCl-10% dextran; 4 ml/kg iv) infusion with (n=7) or without (n=7) artificially diminished NO production in normovolemic anesthetized dogs. HSD administration significantly increased cardiac index (CI), coronary flow (CF) and myocardial contractility, and elevated plasma nitrite/nitrate (NOx) and endothelin-1 (ET-1) levels. However, the late (2 h) postinfusion period was characterized by significantly decreased myocardial NO synthase (NOS) and enhanced myeloperoxidase activities. Pre-treatment with the non-selective NOS inhibitor N-nitro-L-arginine (NNA, 4 mg/kg) immediately increased cardiac contractility, and the HSD-induced CI and CF elevations and the positive inotropy were absent. Additionally, plasma ET-1 levels increased and NOx levels were significantly decreased. In conclusion, our results demonstrate that HSD infusion leads to preponderant vasoconstriction when endogenous NO synthesis is diminished, and this could explain the loss of effectiveness of HSD resuscitation in NO-deficient states.

People with dementia and their relatives: personal experiences of Alzheimer's and of the provision of care.

Little is known about the experiences of people with dementia, as there has been relatively little research carried out that includes their perspectives. In the past, user perspectives on experiences of dementia and on services have mostly been solicited from family carers, rather than from people with dementia themselves. It has been suggested that these studies may lack information and insight into the experiences of people with dementia. This study aimed at eliciting the views and feelings of people in all stages of dementia, as well as those of their relatives, on care services and on experiences of dementia. Twenty-seven people with dementia from residential and day care settings were interviewed and their daily lives videotaped. Interviews were also conducted with next of kin. This article reports on findings and issues arising from the study.

Ultrasonography in the diagnosis and monitoring of ascites in acute abdominal attacks of hereditary angioneurotic oedema.

BACKGROUND: Hereditary angioneurotic oedema (HAE) is a rare cause of ascites. As acute abdominal attacks of the disease can mimic surgical emergencies, prompt and accurate diagnosis is essential. This study was undertaken to evaluate the usefulness of serial abdominal ultrasound (US) examinations. PATIENTS AND METHODS: Seventy patients with HAE were followed up for almost a decade. All patients presenting with an acute oedematous attack underwent abdominal US, which was then repeated 24 and 48 h after appropriate therapy. RESULTS: Twenty-two acute oedematous attacks with abdominal complaints severe enough to justify hospital admission occurred in the study population. Abdominal US performed during the attack showed oedematous thickening of the intestinal wall in 80% of cases and invariably demonstrated the presence of free peritoneal fluid in all patients. Rapid symptomatic relief achieved by treatment was accompanied by the significant regression of US abnormalities. CONCLUSIONS: Transitory ascites demonstrated by abdominal US is a clue to the diagnosis of an acute abdominal attack of HAE. The possibility of HAE should always be considered whenever unexplained abdominal pain recurs with or without ascites.

Endogenous fragment of hemoglobin, neokyotorphin, as cell growth factor.

It is shown that neokyotorphin (the alpha-globin fragment 137-141) stimulates proliferation of normal cells (murine embryonic fibroblasts, red bone marrow and spleen cells) and tumor cells (murine melanoma and transformed fibroblasts L929) in the absence or in the presence of fetal bovine serum. In contrast to serum deprivation conditions, the ability to potentiate L929 cell growth in the presence of fetal serum is strongly cell density dependent. The peptide also enhances the viability of L929 cells, murine embryonic fibroblasts and of the primary cultures of murine red bone marrow cells and splenocytes under serum-deprivation conditions for at least 72 h. The results of flow cytometry analysis suggest that the effect of neokyotorphin on survival of L929 cells in serum-free culture medium is due to maintenance of cell proliferation in the absence of growth factors. Along with cell cycle progression the peptide induces reversible reduction of L929 cell size.

[The clinical value of coronary flow reserve in ischemic heart disease as measured by dipyridamole stress transesophageal echocardiography]. / A dipyridamol-terheléses transoesophagealis echokardiográfia segítségével számított coronaria-áramlási rezerv klinikai értéke ischaemiás szívbetegségben.

The relationship between coronary flow reserve and the result of coronarography was examined. 152 patients were investigated by stress transoesophageal echocardiography and coronary angiography. The value of coronary flow reserve was significantly lower in cases of significant coronary stenosis than in those patients who had a normal coronarography (in patients with left anterior descending coronary artery stenosis: 1.77 +/- 0.47 vs in cases with normal coronary angiogram: 3.19 +/- 1.15). There was no difference in the value of CFR in those cases where not only LAD stenosis but CX or RC stenosis was also found. The value of coronary flow reserve was significantly higher in RC or CX patients than that of LAD patients. In patients with positive stress and negative coronarography (X syndrome) the coronary flow reserve was 1.23 +/- 0.2, which value was significantly lower as compared to patients with significant coronary stenosis.

[Skin malignancies of the head and neck: numbers and surgical concepts]. / Hautmalignome im Kopf-Hals-Bereich: Zahlen und chirurgisches Konzept.

OBJECTIVE: A surgical concept for the excision of skin malignancies as applied in our department for years is presented and reevaluated. METHODS: A retrospective study analysed 82 patients treated surgically for basalioma and spinalioma of the head and neck between January 1997 and September 1999. The data are compared with three former studies. RESULTS: A high percentage of malignant skin tumours was primarily non-in-sano resected. Compared with the three former studies the number of skin malignancies is increasing. The statistics of Canton St. Gallen/Appenzell show the same trend. CONCLUSION: Comparing the one-stage procedure with the two-stage procedure, no significant difference was found regarding the incidence of residual tumor. This surgical concept allows reliable histological control of the tumour margins and precise resection of any residual tumour, and does not comprise the result of any plastic surgery to close the wound.

Mutation analyses of a series of TNT-related compounds using the CHO-hprt assay.

Trinitrotoluene (TNT) and related compounds were tested for induction of mutation in the CHO-hprt mutation assay. The parent compound, TNT, was consistently found to be mutagenic at concentrations above 40 microg ml(-1), whether or not S9 activating enzymes were added. Five TNT metabolites gave statistically significant but small increases in mutation frequency over solvent controls: 4-amino-2,6 dinitrotoluene, 2,4',6,6'-tetranitro-2',4-azoxytoluene, 2,2',6,6'-tetranitro-4,4'-azoxytoluene, 2',4,6,6'-tetranitro-2,4'-azoxytoluene and triaminotoluene. Clear dose-response relationships could not be established for the mutagenic response of these compounds. They are considered as very weak mutagens in this mammalian test system. Five compounds did not produce statistically significant mutation frequencies at the levels tested: 2-amino-4,6-dinitrotoluene, 2,4-diamino-6-nitrotoluene, 1,3,5-trinitrobenzene, 2,6-diamino-4-nitrotoluene and 4,4',6,6'-tetranitro-2,2'-azoxytoluene. The results indicate that none of the TNT metabolites tested pose a significant mutational health risk, at least as judged by the CHO-hprt assay.

Marked elevation of serum creatine kinase associated with olanzapine therapy.

OBJECTIVE: To report a case of marked elevation of serum creatine kinase (CK) associated with olanzapine therapy. CASE SUMMARY: A 39-year-old white Jewish schizophrenic man treated with olanzapine developed an elevated serum CK concentration with a peak concentration of 4000 IU/L (normal < 230). No other diagnostic criteria for neuroleptic malignant syndrome (NMS) were present. On discontinuation of the drug, serum CK concentrations returned to normal within eight days. DISCUSSION: Olanzapine, like other atypical antipsychotic drugs, may cause muscle injury with concomitant elevations of serum CK of muscle origin. We suggest that in patients treated with olanzapine, CK concentrations should be checked on initiation of therapy, within the first 48 hours, and weekly thereafter for at least one month. In addition, patients with clinical signs suggestive of NMS should be monitored more carefully. For those patients with a history of NMS, or even of isolated serum CK elevation during antipsychotic therapy, follow-up should be stricter. CONCLUSIONS: Marked elevation of serum CK may be a possible complication of olanzapine therapy.

Differentiation of microorganisms based on pyrolysis-ion trap mass spectrometry using chemical ionization.

The ability to differentiate microorganisms using pyrolysision trap mass spectrometry was demonstrated for five Gram-negative disease-causing organisms: Brucella melitensis, Brucella suis, Vibrio cholera, Yersinia pestis, and Francisella tularensis. Bacterial profiles were generated for gamma-irradiated bacterial samples using pyrolytic methylation and compared for electron ionization and chemical ionization using several liquid reagents with increasing proton affinities. Electron ionization combined with pyrolysis caused extensive fragmentation, resulting in a high abundance of lower mass ions and diminishing the diagnostic value of the technique for compound identification and bacterial profiling. Chemical ionization reduced the amount of fragmentation due to ionization while enhancing the molecular ion region of the fatty acids. As the proton affinity of the reagent increased, the protonated molecular ions of the fatty acids became the predominant ions observed in the mass spectrum. As a result, chemical ionization was shown to be more effective than electron ionization in bacterial profiling. Whereas the bacteria could be distinguished at the Genera level using electron ionization, further differentiation to the subspecies level was possible using chemical ionization. The greatest separation among the five test organisms, in terms of Euclidean distances, was obtained using ethanol as the chemical ionization reagent and using pooled masses representing specific fatty acid biomarkers rather than total ion profiles.

[Is transposition of the ulnar nerve in ulnar nerve sulcus syndrome really indicated?]. / Ist eine Vorverlagerung des N. ulnaris beim Sulcus nervi ulnaris-Syndrom wirklich indiziert?

Anterior transposition of the ulnar nerve in cubital tunnel syndrome requires ligation of the segmental epineural vessels over 8 to 10 cm in order to free up and mobilize the nerve along its new course. As a result, the blood supply of ulnar nerves already compromised by entrapment is likely to be harmed even more. For the past three years we chose to perform simple decompression of the nerve with or without external/internal neurolysis on 33 patients (34 arms). After a follow-up time of six months to three years (mean 12 months), the outcome was evaluated by complete examination of hand function and by electrophysiologic studies. Four patients were excluded from the analysis due to short follow-up times. Four underwent decompression for mild entrapment symptoms, six for moderate symptoms, and 19 for severe symptoms. The functional outcome was rated as excellent in 26.7% (eight patients) and as good in 33.3% (ten patients). In group 3 (severe entrapment symptoms), seven patients (23.3%) showed moderate results and in four patients (13.3%) the outcome was poor. Considering that most of our patients had severe entrapment with advanced muscle atrophy, the overall outcome of decompression was satisfactory.

[Significance of double crush in carpal tunnel syndrome]. / Die Bedeutung des Double Crush beim Karpaltunnelsyndrom.

From June 1992 to October 1995, 224 patients were operated on carpal tunnel syndrome. We treated 71 male and 153 female patients. During our investigations, we found that one third of the patients suffered from a double crush syndrome. 84% of the patients suffered from one or more predisposing accompanying diseases. In most of them (42%) we found rheumatic diseases, 19% diabetes mellitus, 8% hyperuricaemia, and 6% hypothyreosis. In 33%, we observed a very short history and a bilateral carpal tunnel syndrome. According to the preoperative tests, four different groups of patients regarding electrophysiological parameters and the graduation of thenar atrophy were differentiated. The fourth group was composed of patients with double crush syndrome, who continued to complain of considerable pain despite surgery, the operated hand remaining both weak and awkward in its movements. Inspired by the prospective study by Dellon (1992) and our results, we will perform a retrospective analysis of the longterm effect of carpal tunnel release in diabetic neuropathy.