[Benzodiazepine withdrawal presenting as pseudo-surgical abdominal pain]. / Sevrage en benzodiazépines révélé par un syndrome douloureux abdominal pseudochirurgical.

A 39-year-old patient was admitted to the emergency department for acute abdominal pain. Physical examination showed a peritoneal syndrome. However, CT-scan, Doppler and blood analysis were unremarkable. As the patient had a history of auto-medication with benzodiazepines at high doses, a withdrawal syndrome was considered. An intravenous administration of 3 mg of midazolam determined the relief of all symptoms in a few minutes.

Liver disease in extrahepatic malignancy.

The various causes of liver disease in malignancy have been reviewed. Metastatic lesions, hepatotoxicity from oncotherapeutic agents, infections, and vascular complications must all be considered. A systematic approach beginning with a detailed history and physical examination usually provides clinicians with early clues as to the etiology of the liver disease in malignancy. The advent of new laboratory tests and the technologic advances in abdominal imaging have provided powerful new tools for the diagnosis and management of patients with liver disease. Understanding how these tests could be properly used will enhance the likelihood that important liver disease will not be missed in patients with malignancies.

The effectiveness of seat belt legislation in reducing various driver-involved injury rates in California.

This study makes use of econometric models to examine the impact of seat belt laws on various driver-involved injury rates in California in both single- and multiple-vehicle accidents. The study makes use of a large data set from the U.S. D.O.T. State Traffic Accident Files and accounts for the general impact of seat belt laws as well as their dynamic effects on injury rates. The models adjust for a wide range of additional contributing factors to injury rates, including the influence of unemployment rates, speed limits, companion effects, and others. Robust results are obtained for the efficacy of seat belt legislation on reducing (moderate to fatal) injury rates in California.

The wrist: field evaluation and treatment.

A poorly diagnosed and treated wrist injury could become a career-ending injury. Optimal treatment begins on the playing field, not the operative field. A careful, thorough field evaluation is mandatory to ensure prompt recognition of a potentially debilitating injury. Suspected fractures or ligamentous disruption require immediate referral to a physician for definitive early treatment. When the trainer and physician work as a team, early diagnosis, treatment, and rehabilitation of wrist injuries can be instituted to reach the goal of maintaining functional healthy wrists for future athletic endeavors.

The hand: field evaluation and treatment.

A careful field evaluation is mandatory to ensure prompt recognition of a potentially debilitating hand injury. The major responsibility of the examination is to rule out any possible serious injury prior to returning the athlete to competition. This article deals with both on-the-field evaluation and recognition and sideline management of injuries to the hand.

Core decompression of the distal femur for avascular necrosis of the knee.

From 1974 to 1981, we performed 28 core decompressions of the distal femur for pathologically confirmed avascular necrosis. At a mean follow-up of 54 months (range 20 to 140 months) and using the Ficat stages, all seven cases in stage I and stage II had good results. Of 21 cases in stage III, 11 cases had good results, four had poor results, and six needed total knee replacement. There were no significant orthopaedic complications. The procedure is worthwhile and will be more accurate with new methods of imaging.

Choledochal cyst.

A 16-year-old girl with recurrent pain in the right upper quadrant and abnormal results of liver function tests was found to have a large choledochal cyst filled with stones. Computerized tomography and endoscopic retrograde cholangiopancreatography showed the large cyst with innumerable primary cyst stones and an anomalous pancreaticobiliary duct junction.

Pedestrian tibial injuries.

From August 1980 through May 1984, 102 adult pedestrian patients with 130 tibial fractures were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. We reviewed their records for admission status, procedures performed, and results: 32 patients who died, underwent primary amputation, or were lost to followup were excluded, leaving 70 patients with 86 tibial fractures as the base study group. We grouped the data by year of admission and analyzed it in terms of the effects of changes in the treatment protocol on results, specifically the time to union. For the first year, the existing treatment protocol included: antibiotics, debridement and irrigation with a bulb syringe, stabilization according to wound size and surgeon preference, split-thickness skin graft, and bone grafting in response to delayed or nonunion. The average time to union for Grade III fractures was 58.39 weeks; average time overall was 53.95 weeks. In the fourth year, the altered treatment protocol included: antibiotics, debridement and jet lavage, scheduled rebridement, external fixation for open fractures, judicious use of open reduction/internal fixation for closed fractures, early free flap soft-tissue coverage, and early bone grafting by history and fracture pattern. The average time to union for Grade III fractures was 37.65 weeks; average time overall was 34.46 weeks. From the first to the fourth year, time to union for Grade III fractures decreased by 64.5% and time to union overall decreased by 63.9%. We feel the decrease is a direct result of early bone grafting, the fixator construct used, and judicious use of open reduction/internal fixation.

Massive colonic dilatation as initial presentation of mesenteric vein thrombosis.

The case of a patient with primary mesenteric venous thrombosis presenting with massive dilatation of almost the entire colon is described. The differential diagnosis suggested by this presentation is briefly discussed with special attention to the diagnosis of acute colonic pseudoobstruction. Possible reasons for the atypical presentation of acute mesenteric venous thrombosis should, therefore, be considered in the differential diagnosis of all patients presenting with colonic distention and pseudoobstruction.

Methadone dose decreases and anxiety reduction.

This research evaluated the efficacy of an Anxiety Reduction program designed to reduce anxiety early in methadone detoxification and thereby facilitate dose reduction. Major outcome variables were methadone dose, alcohol and illicit drug use, and withdrawal symptomatology. Fifty-three subjects were recruited and randomly assigned to Anxiety Reduction or Control conditions, and were followed for 48 weeks after study start. Statistically significant differences in dose between Anxiety Reduction subjects and Controls occurred early in treatment, and could only be interpreted when initial dose and initial mood disturbance were taken into account. The differences were not of sufficient magnitude to be of clinical importance, and reflected differences in the small number of subjects who changed dose, rather than overall group trends. Anxiety Reduction subjects reported less alcohol use at treatment termination and at follow-ups, and fewer withdrawal symptoms at termination. They were also less likely to be dropped from treatment for disciplinary reasons. High initial anxiety about detoxification was related to minimal dose reduction in both conditions. Also, in both conditions, anxiety increased with decreasing dose.

Colloid osmotic pressure at birth. Effect of sample site, type, and mode of delivery.

Colloid osmotic pressure was measured at birth in 102 newborns. Umbilical vein plasma colloid osmotic pressure correlated with total serum protein, birth weight, and gestational age. Mean colloid osmotic pressure of 11 infants who were small for gestational age was less than, and that of seven infants who were large for gestational age was more than, that of average-sized infants of similar gestation. For infants weighing 1,501 to 3,000 g, mean (+/- SD) colloid osmotic pressure following cesarean section (15.1 +/- 1.6 mm Hg) was lower than that following vaginal delivery (18.4 +/- 2.2 mm Hg). This may reflect the fact that use of maternal fluid therapy preceding cesarean section was greater than before vaginal delivery. The definition of normative values for neonatal plasma colloid osmotic pressure makes it possible to investigate changes in relation to disease, therapy, and subsequent outcome in sick neonates.

Oral cholecystography in the early phase of acute alcoholic pancreatitis. A prospective, randomized comparison of Telepaque and Bilopaque.

Biliary tract disease is a major cause of acute pancreatitis. However, with traditionally employed Telepaque, radiographic visualization of the gallbladder during acute pancreatitis remains unreliable, even in patients with apparently normal gallbladders. Therefore, oral cholecystography has customarily been deferred for such patients for several weeks. Recently, successful oral cholecystography has been described during the acute episode of pancreatitis, using Bilopaque, a more water-soluble cholecystopaque. The relative intestinal absorption of Telepaque and Bilopaque and the ability of these agents to produce diagnostic oral cholecystograms of fasting patients with acute alcoholic pancreatitis were compared. Forty-five hospitalized patients were studied within 96 hours of admission. Mean peak plasma contrast concentrations for Bilopaque exceeded those for Telepaque. Thirty-one percent of the Bilopaque group achieved diagnostic single-dose oral cholecystograms, compared with to 11% of the Telepaque group (P less than 0.05).

Acute and subacute pancreatitis. Role of surgery and endoscopic retrograde cholangiopancreatography.

Six of seven patients with acute pancreatitis who were intractable to prolonged medical therapy underwent successful endoscopic retrograde cholangiopancreatography (ERCP) followed by immediate operative therapy. All of these patients had surgically correctable lesions consistent with chronic pancreatitis. There was one associated mortality and no morbidity. The conditions of the surviving six patients were significantly improved in the immediate postoperative period, and long-term follow-up has been encouraging. Pancreaticojejunostomy and conservative resection appeared to have good results. The timing of the operation immediately after ERCP in patients with acute pancreatic pathology eliminated problems with exacerbation or sepsis. Patients whose clinical conditions do not improve with aggressive medical therapy for acute pancreatitis may have both chronic and acute disease that is amenable to operative therapy.