Rehabilitation after total shoulder arthroplasty.

Physical therapy constitutes an essential determinant of clinical outcome after total shoulder arthroplasty. We reviewed our results in 81 shoulders at a minimum of 2 years' follow-up, with specific focus on the maintenance of motion and the development of soft tissue healing problems. Our findings show that our graduated rehabilitation program allows most patients to obtain motion comparable to that possible intraoperatively with few complications. Of patients, 70% maintained their elevation, and 90% maintained external rotation. Patients with a diagnosis of rheumatoid arthritis, traumatic arthritis, and osteonecrosis were identified as being at risk for failure to regain motion and for tendon healing complications.

A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients.

The issue of symptom management at the end of life and the need to use sedation has become a controversial topic. This debate has been intensified by the suggestion that sedation may correlate with 'slow euthanasia'. The need to have more facts and less anecdote was a motivating factor in this multicentre study. Four palliative care programmes in Israel, South Africa, and Spain agreed to participate. The target population was palliative care patients in an inpatient setting. Information was collected on demographics, major symptom distress, and intent and need to use sedatives in the last week of life. Further data on level of consciousness, adequacy of symptom control, and opioids and psychotropic agents used during the final week of life was recorded. As the final week of life can be difficult to predict, treating physicians were asked to complete the data at the time of death. The data available for analysis included 100 patients each from Israel and Madrid, 94 patients from Durban, and 93 patients from Cape Town. More than 90% of patients required medical management for pain, dyspnoea, delirium and/or nausea in the final week of life. The intent to sedate varied from 15% to 36%, with delirium being the most common problem requiring sedation. There were variations in the need to sedate patients for dyspnoea, and existential and family distress. Midazolam was the most common medication prescribed to achieve sedation. The diversity in symptom distress, intent to sedate and use of sedatives, provides further knowledge in characterizing and describing the use of deliberate pharmacological sedation for problematic symptoms at the end of life. The international nature of the patient population studied enhances our understanding of potential differences in definition of symptom issues, variation of clinical practice, and cultural and psychosocial influences.

Schistosoma mansoni in mice: the pattern of primary cercarial exposure determines whether a secondary infection post-chemotherapy elicits a T helper 1- or a T helper 2-associated immune response.

Reinfection with Schistosoma mansoni following chemotherapy often results in an ameliorated granulomatous reaction and hence a mild disease. This study examined some of the immunological mechanisms that could be associated with this residual protection. BALB/c mice were infected with either a single dose (group A) of 100 S. mansoni cercariae or with 10 doses of 10 cercariae each (group B) given at 3-day intervals. The mice were treated with praziquantel 8 weeks postinfection and, 2 weeks later, together with another group of naive mice (group C), they were infected with a single dose of 100 cercariae each. All the animals were killed 8 weeks later and schistosome egg antigen (SEA)- and soluble adult worm antigen preparation (SWAP)-induced cytokine recall responses in splenocytes, as well as serum immunoglobulin levels, were quantified and hepatic granuloma sizes measured. Group A animals had higher levels of SEA-induced interferon-gamma (IFN-gamma) but lower levels of interleukin (IL)-5 than groups B and C (P < 0.01). Group B animals had low SEA-induced IFN-gamma levels and elevated IL-5 levels, although these were lower than group C. SEA-induced IL-10 was low in both groups A and B as compared to group C (P < 0.01). SWAP was less effective as an inducer of splenocyte cytokine production than SEA but both SWAP-induced IFN-gamma and IL-5 were detected in groups A and C. SEA- and SWAP-specific immunoglobulin E (IgE) and immunoglobulin G (IgG) titres were not significantly different between the three groups. Granuloma diameters were larger in group C (mean 297 +/- 51.3 microm) as compared to groups A (174 +/- 49 microm, P < 0.01) and B (247.5 +/- 44 microm, P < 0.05). Taken together, these results demonstrate that granuloma size is reduced during a reinfection exposure compared with a primary infection. This reduction is associated with a T helper 1 response in mice exposed to a single large dose of cercariae in the primary infection and with a predominantly T helper 2 response in those infected with multiple small doses.

Physical modalities for complex regional pain syndrome.

Hand therapy is the backbone of a treatment program for complex regional pain syndrome. Various treatment techniques and physical modalities are described in the framework of a clear set of treatment goals. Hand therapy is often the only treatment necessary for simple cases. Adjunct treatments, such as injections or other pharmacologic agents, may be needed when pain control is problematic.

Sudden death in a child following jellyfish envenomation by Chiropsalmus quadrumanus. Case report and autopsy findings.

Sudden death following coelenterate envenomation is not uncommon in Australia where the Pacific box jellyfish is indigenous. However, few cases of sudden fatal reactions have been reported in the Northern Hemisphere, and those that have occurred have all been attributed to the Portuguese man-of-war, Physalia physalis. We report the case of a child who died within 40 minutes of accidental envenomation with tentacles of a jellyfish, Chiropsalmus quadrumanus, and describe the findings at autopsy. This coelenterate may be of special danger to small children.

Sorption of amiodarone to polyvinyl chloride infusion bags and administration sets.

The loss of amiodarone from i.v. admixtures to flexible polyvinyl chloride (PVC) infusion bags and i.v. administration sets was studied. Admixtures containing amiodarone hydrochloride 600 micrograms/mL and either 5% dextrose injection or 0.9% sodium chloride injection were stored at room temperature in glass bottles (both with and without contact of the drug solution with the rubber bottle closure), in flexible PVC bags, or in rigid PVC bottles. After 120 hours, the contents of each flexible PVC bag were emptied and replaced by methanol, which was allowed to remain in the bag for an additional 120 hours and was then analyzed for amiodarone content. To determine availability of amiodarone after infusion through a 1.8-m PVC i.v. administration set, solutions stored in glass containers were run through the set at 0.5 mL/min for 90 minutes. Samples of drug solutions were collected at appropriate intervals and analyzed by a stability-indicating high-performance liquid chromatography (HPLC) assay. Admixtures containing 0.9% sodium chloride injection were not stable; visual incompatibility was evident after 24 hours of storage in glass bottles, and no further testing was performed. In admixtures containing 5% dextrose injection that were stored in 50-mL flexible PVC bags, 60% of the initial amiodarone concentration remained after 120 hours; approximately half of the lost drug was recovered with the methanol. In effluent collected from the PVC administration set, 82% of the initial amiodarone concentration remained. Amiodarone concentrations did not decrease appreciably, after storage in glass or rigid PVC bottles, indicating that drug loss was probably affected by the plasticizer, di-2-ethylhexyl phthalate.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative effects of long-term ethanol consumption and forebrain lesions on maze learning and active avoidance behavior in rats.

Male rats consumed a liquid diet containing 10.7% ethanol as their only source of food and fluid for 6.5 months, beginning at 2 months of age. During withdrawal, there were no differences between the alcohol group and their pair-fed or free-fed controls on EEG, body temperature, irritability and tremor measures. In behavioral tests begun 4-5 weeks after withdrawal, the rats that had consumed alcohol acquired accurate spatial behavior in a cross maze task more slowly than controls, but were unimpaired in shuttle-avoidance learning. In concurrent studies with groups of rats that had sustained lesions of the dorsal hippocampus, the mamillary bodies (MMB), or the mediodorsal thalamus, the pattern of behavioral deficits after MMB lesions was found to be qualitatively similar to that observed after the cessation of long-term alcohol consumption. These findings provide renewed hope that a useful rodent model for studying the neuropsychology of cognitive deficits associated with human alcoholism can be developed.