Prolonged duodenal paralysis after PEG placement in a patient with traumatic brain injury: a case report.

Percutaneous endoscopic gastrostomy (PEG) has recently become a usual procedure for patients with prolonged disorders of consciousness after brain injuries. Despite a high rate of success and a very low procedure-related mortality, morbidity associated to PEG placement reaches 9.4% in a recent large meta-analysis. This case report describes an uncommon complication of PEG placement in a patient with vegetative state after traumatic brain injury: the development of prolonged duodenal paralysis. This patient was treated by placement of a transient jejunostomy until recovery of duodenal functional activity, to permit adequate nutrition. This procedure-related complication is previously unreported in scientific literature.

Early rehabilitative treatment in patients with traumatic brain injuries: outcome at one-year follow-up.

AIM: The aim of this study was to analyze the outcome at one-year follow-up of patients with traumatic brain injuries (TBI) after 4 years of application of our organizing model and compare our results with the international data in terms of disability (functional independence measure [FIM], disability rating scale [DRS] scores) and social integration (community integration questionnaire [CIQ], work reentry) METHODS: We started a routine based on the presence of the physiatrist in the Intensive Care Unit (ICU) and Neurosurgery 3 times per week to evaluate all patients with TBI, program and control physiotherapeutic treatments and transfers to rehabilitative centers. Data were collected considering 80 TBI patients sequentially discharged from our department, from August 1999 to December 2003. The sample was composed of patients with severe brain injury evaluated at rehabilitation admission, rehabilitation discharge and one-year follow-up. We compared our data with those of the Traumatic Brain Injury Model System Data Base (TBI MSDB) and Gruppo Italiano per lo Studio delle Cerebrolesioni Acquisite Riabilitazione (GISCAR). RESULTS: Disability at one-year follow-up was better than at discharge: increase in FIM value, in DRS value. Social reintegration and return to work were not optimal: CIQ value was 16 and only 38% of patients returned to work at follow-up. Disability and social integration mean scores in our sample were similar to those obtained in TBI MSDB and so were the values of onset-admission interval (OAI) and length of stay (LOS). Differences were found with the Italian GISCAR database where mean OAI and LOS were higher than in our sample (55 and 86 days vs 18 and 37 days). CONCLUSIONS: Our data show that this kind of organizing model for the rehabilitative evolution of TBI patients can positively influence the cost-efficiency rate of rehabilitation process reducing care costs in terms of ICU and rehabilitation LOS without affecting outcome in terms of disability and reintegration.

Persistent anaphylactic reaction after induction with thiopentone and cisatracurium.

A 6-year-old boy presented for surgery for phimosis. The anaesthetic technique included intravenous induction with thiopentone and neuromuscular blockade with cisatracurium. Severe persistent bronchospasm and central cyanosis followed the administration of these drugs. A continuous i.v. infusion of epinephrine at 0.2 microg. kg(-1) x min(-1) was necessary to break the severe refractory bronchial hyperresponsiveness. There was no previous exposure to anaesthetic drugs and no definite family history of allergy. Through increased serum eosinophil cationic protein, tryptase and histamine levels and IgE levels specific to cisatracurium, we demonstrated an IgE-mediated anaphylactic reaction to cisatracurium in the child's first exposure to this new neuromuscular blocking agent. Anaphylactic reactions to new anaesthetic drugs may be challenging to recognize and treat during general anaesthesia in children. The pathogenesis, diagnosis and management of life threatening persistent allergic reactions to intravenous anaesthetics are discussed.

[Rehabilitative strategies in patients with subarachnoid hemorrhage]. / Strategie riabilitative in pazienti con ESA.

The role of rehabilitative treatment in neurological disorders due to subarachnoid haemorrhage is described in acute, intermediate and chronic phases. A fourth phase, defined phase of diagnosis and treatment of cognitive and behavioural "cripto-deficits", is discussed. In each phase, emphasis is put on the organization of rehabilitative work which should always be the result of integrative team approach, to prevent and correct complications and to apply an holistic treatment (physical and cognitive). At present, in neurological rehabilitation, the most important requirement is no longer have the professionals (physiotherapists, speech and occupational therapists, etc.), but have a suitable environment and a good organisation of team planning and work. Neurosurgical centers is warranted. Practice guidelines should be addressed to obtain quality and continuity of management in the early diagnostic phase; intensive global medical approach should be ensured by neuroanesthesists and intensivists to achieve optimal cerebral conditions before surgical or endovascular treatment.

Effects of calcium supplementation and deoxycorticosterone on plasma atrial natriuretic peptide and electrolyte excretion in spontaneously hypertensive rats.

The effects of calcium and the mineralocorticoid deoxycorticosterone (DOC) on blood pressure were studied in four groups of spontaneously hypertensive rats (SHR): (1) control; (2) calcium; (3) deoxycorticosterone and; (4) deoxycorticosterone + calcium. Calcium was given as 1.5% calcium chloride in drinking fluid and deoxycorticosterone by weekly subcutaneous injections (25 mg kg-1). During the nine weeks of treatment the increase in systolic blood pressure was enhanced in the deoxycorticosterone and attenuated in the calcium group, whereas the deoxycorticosterone + calcium group did not deviate from control. Total plasma calcium was elevated in the calcium group. Plasma concentrations of sodium and atrial natriuretic peptide (ANP) were increased by deoxycorticosterone while neither of the calcium-treated groups differed from control in these respects. Urinary excretions of calcium and sodium were increased in both groups receiving calcium, and also the deoxycorticosterone group excreted more calcium into urine than the control. Adrenergic nerve density in a section of the mesenteric artery and the urinary excretion of noradrenaline and adrenaline were similar in all study groups. The results indicate that calcium supplementation can attenuate the development of hypertension and prevent the deoxycorticosterone-induced blood pressure rise in SHR, possibly by influencing sodium metabolism as seen in increased natriuresis, and by preventing the actions of deoxycorticosterone on sodium balance.