Multidisciplinary Interventions in Motor Neuron Disease.

Motor neuron disease is a neurodegenerative disease characterized by loss of upper motor neuron in the motor cortex and lower motor neurons in the brain stem and spinal cord. Death occurs 2-4 years after the onset of the disease. A complex interplay of cellular processes such as mitochondrial dysfunction, oxidative stress, excitotoxicity, and impaired axonal transport are proposed pathogenetic processes underlying neuronal cell loss. Currently evidence exists for the use of riluzole as a disease modifying drug; multidisciplinary team care approach to patient management; noninvasive ventilation for respiratory management; botulinum toxin B for sialorrhoea treatment; palliative care throughout the course of the disease; and Modafinil use for fatigue treatment. Further research is needed in management of dysphagia, bronchial secretion, pseudobulbar affect, spasticity, cramps, insomnia, cognitive impairment, and communication in motor neuron disease.

Disease Modifying Therapy in Multiple Sclerosis.

Multiple sclerosis is an autoimmune disease of the central nervous system characterized by inflammatory demyelination and axonal degeneration. It is the commonest cause of permanent disability in young adults. Environmental and genetic factors have been suggested in its etiology. Currently available disease modifying drugs are only effective in controlling inflammation but not prevention of neurodegeneration or accumulation of disability. Search for an effective neuroprotective therapy is at the forefront of multiple sclerosis research.

Prognosis and outcome of acute stroke in the University College Hospital Ibadan, Nigeria.

BACKGROUND: Many factors influence the outcome of acute stroke, the third leading cause of morbidity and mortality globally. OBJECTIVE: To identify the determinants of outcome of acute stroke. MATERIALS AND METHODS: A prospectively study of 66 adult patients who presented to the medical emergency unit of University College Hospital (U.C.H), Ibadan, in coma from acute stroke, from August 2004 to March 2005, was undertaken after obtaining ethical clearance and written consent of the patients' relations. RESULT: Acute stroke constituted 33% of medical coma, 3.2% of hospital emergencies, 1.0% of total hospital admissions, and 7.3% of medical deaths during the study period. The stroke subtypes were intracerebral hemorrhage (78.8%) and large cerebral infarction (21.2%) with respective case fatalities of 69.7% and 13.6% at 4 weeks. Males constituted 75.8% of the patient population with sex-specific mortality of 68.2%. The highest age specific mortality of 65.2% was in the 40-59 years group. The common risk factors were systemic hypertension, obesity, alcohol/substance abuse, and diabetes mellitus. Co-morbidities included aspiration pneumonia, recurrent seizures, hyperglycemia, and sepsis. CONCLUSION: Age above 39 years, male gender, systemic hypertension, early onset of coma after stroke, and presence of co-morbidities were associated with poor stroke outcome.

Causes of medical coma in adult patients at the University College Hospital, Ibadan Nigeria.

AIMS AND OBJECTIVES: Diseases of medical origin leading to coma account for 3-15% of emergency hospital admissions in developed countries. There is dearth of data on causes of medical coma in adults in Nigeria in particular and Africa in general. This study is to determine the causes of coma in adult patients admitted at the medical emergency unit and wards of the University College Hospital (UCH) Ibadan. PATIENTS AND METHODS: A prospective study of two hundred consecutive adult unconscious patients seen at the medical emergency unit of UCH, Ibadan, from August 2004 to March 2005, was undertaken using a structured clinical history and physical examination protocol, and results of relevant diagnostic investigations, including post-mortem. RESULTS: Medical causes of coma constituted 10% of all emergencies and 3% of total hospital admissions respectively during the 8-month period. Sixty six percent were males. The age group 20-59 years were affected most (76.5%). Four commonest causes were: Acute stroke 33%), diabetic emergencies (12.5%), uraemic encephalopathy and meningitides (11% each). Four least causes were cerebral malaria (1.0%), hypertensive encephalopathy, alcohol and gamalline poisoning (0.5% each). Four common predisposing factors which also had significant male predominance were systemic hypertension (38.5%), diabetes mellitus (14%), alcohol and substance abuse (12.5%), and HIV/AIDS (11.5%). CONCLUSIONS: Hypertensive stroke and diabetic coma constituted the commonest medical causes of coma. Thus preventive measures such as public health enlightenment campaigns for lifestyle modifications, routine blood pressure and glucose examinations are necessary to avert their disastrous consequences.

Footcare practices among Nigerian diabetic patients presenting with foot gangrene

Diabetic foot ulceration and gangrene is a major cause of morbidity andmortality. This study has examined potential preventive footcare practices in a cohort of diabetic patients presenting with foot gangrene. One hundred and two (102) diabetic emergencies presented during the study period. Diabetic foot gangrene accounted for 27 (26%) of these cases. There were 18 males and 9 females (M:F = 2:1), with a mean age of 52+13 years. The mean duration of ulceration was 4±3 weeks and mean ulcer­gangrene interval was 1.2±0.5 weeks. Only 9 patients (33%) had been exposed to any form of footcare education, 15 patients (55%) treated their ulcers by unorthodox means, and 63% of the patients practiced no significant footcare. More widespread education and awareness is needed to prevent the continuing and serious problem of diabetic foot gangrene and consequent lower limb amputation

Risk of aortocoronary bypass surgery in a low-volume inner city hospital.

Incidence of coronary heart disease deaths has been reported to be higher in low socioeconomic groups compared to affluent subjects. In addition, a higher mortality rate has been reported at centers doing fewer open heart surgeries. This article presents evidence in variance with these convictions. We report a single team's experience with coronary artery surgery on 76 low socioeconomic, predominantly black patients (84%) over a period of 8 years. The volume of open heart surgery per year was less than 20. The overall mortality rate of 5.3%, infection rate of 1.3%, and perioperative infarction rate of 7.9% are not significantly different from the reported experience of high-volume surgical centers on similar patients during the same period. Thus, it is possible to obtain comparable results of myocardial revascularization surgery in low-volume, socioeconomically disadvantaged, inner city minority populations.

Unusually low mortality of penetrating wounds of the chest. Twelve years' experience.

Within a 12-year period ending in March 1984, 1109 patients with penetrating thoracic injuries were treated at King-Drew Medical Center located in south central Los Angeles. The average age of the patients was 28.1 years. There were 607 stab wounds and 502 gunshot wounds. Antibiotic prophylaxis was prescribed only for the 428 patients who had laparotomy, thoracotomy, and pulmonary contusion with hemoptysis. Of the 1109 patients, 105 had cardiac injuries. All patients with cardiac trauma underwent thoracotomy, and the mortality rate was 18.1%. Specifically, the mortality rate of gunshot wound of the heart 24.5% and that of stab wound of the heart, 11.5%. In contrast, of the 1004 patients without cardiac injuries, only 115 required thoracotomy and the mortality rate in this group was 0.8% (8/1004). The mortality rate was 69.6% in patients who had a thoracotomy in the emergency room but only 2.8% in patients who had a thoracotomy in the operating room within the first 24 hours after admission. In the 242 patients who had associated abdominal injuries, the mortality rate was 2.1% (5/242), as compared with 2.5% (22/867) for those who had isolated chest injuries. In the entire group, the incidence of complications was 5.1%, of which 1.8% were infectious complications. The presence of associated abdominal injuries did not influence the outcome. The mortality rate in noncardiac thoracic injuries is very low compared with that of cardiac injury. Because of the complexity of the injury, gunshot wound of the heart has the highest mortality rate.

Outcome of thoracic esophageal carcinoma in blacks in the inner city.

This report is based on 45 cases of cancer of the thoracic esophagus in blacks residing in a socioeconomically depressed area of the inner city of South-Central Los Angeles. There were 30 men and 15 women, ranging in age from 26 to 89 years. Preoperative management, contraindications of surgery, and overall results are specified. The operative mortality rate was 14%. As a means of restoring continuity of the alimentary tract after resection of esophageal carcinoma, the stomach was preferred, although the colon was used in two instances. Five-year survival in this series was 14% in the operative group and 13% in the radiotherapy group; one of the surgical patients is still alive, and another one survived for 72 months. In the radiation group, no such incidence occurred. It is therefore concluded that surgery is the optimal palliation if there is an acceptable risk of mortality. When operative risks are unacceptable radiation therapy is used.

A "wandering bullet" in the thoracic esophagus.

This paper describes a patient with a perforation of the thoracic esophagus that was not recognized for 30 hours. Curiously, this patient did well without surgical intervention. Therapeutic considerations for thoracic and cervical esophageal perforations are discusses.

Localized benign mesothelioma of the pleura associated with a hypoglycemic episode.

A patient had severe, episodic hypoglycemia with a mass occupying almost the entire left hemithorax. This mass was initially thought to be an inoperable intrathoracic malignant neoplasm. The findings during operation and the histologic appearance, however, were of a unique, localized benign mesothelioma.

Bilateral chylothorax associated with sclerosing mediastinitis.

A 14-year-old female developed a sequential bilateral chylothorax from a complication of idiopathic mediastinal fibrosis. To the best of our knowledge, there has not been a published report of idiopathic mediastinal fibrosis followed by chylothorax. The recurrent bilateral chylothorax was treated successfully with a closed thoracostomy.

Surgical and nonsurgical treatment of penetrating injuries to the cervical esophagus.

We presented two patients with gunshot wounds and one patient with a stab wound of the cervical esophagus, managed conservatively, which resulted in no deaths. Results of eight studies of cervical esophageal injuries are reviewed and presented in Table I. One must consider both the surgical and conservative methods of management in planning treatment for the given patient.

Reliability of two-dimensional echocardiography in diagnosing fungal endocarditis.

Although the techniques of M-mode and two-dimensional (2D) echocardiography (echo) have been found to be useful in patients with bacterial endocarditis, the 2D findings of fungal endocarditis are not known. In this report, we present the case of a young female narcotic addict with Candida albicans endocarditis in whom we diagnosed a large vegetation by 2D echo. Decision for surgery was made solely on the basis of the 2D-echo findings. We feel that 2D-echo findings are reliable in diagnosing fungal endocarditis because, with this technique, the size, shape, mobility, and exact location of the vegetation can be better identified than by the M-mode echo. In addition, early diagnosis of fungal endocarditis helps in treating the patients with medical and surgical therapy which may result in lower mortality.

Tissue levels of doxycycline in the human lung and pleura.

Antibiotic concentrations in the human lung and pleural tissue were measured following intravenous administration of doxycycline. The average serum levels were 9.3, 7.0 and 3.0 micrograms/ml at 1, 2, and 3 hours; correspondingly, the lung tissue levels were 6.8, 3.5 and 2.3 micrograms/g. The pleural tissue antibiotic concentrations at the same time intervals were 2.5, 1.5, and 1.5 micrograms/g. This suggests that doxycycline is retained well by the lung and the pleura, well above the minimal inhibitory concentration of most of the common bacterial pathogens of the lung, and may be used in the treatment of lung infections caused by susceptible organisms.

Experience in the management of 50 consecutive penetrating wounds of the heart.

Fifty patients with penetrating wounds of the heart were grouped into three categories, based on the clinical severity of the injuries. Gunshot wounds consistently resulted in a higher mortality than knife wounds. Central venous pressure (CVP) was the single most important means of determining cardiac tamponade. The survival rates in the respective groups were 6, 79 and 100 per cent. The improved survival in our series was due to a rapid transportation system, increased awareness of the significance of cardiac injuries and an aggressive surgical approach.

Early thoracotomy for stab wounds of the heart.

Fifteen consecutive patients with stab wounds of the heart are reviewed. The left ventricle was stabbed in six patients and right ventricle in four. Sinus tachycardia was present in 54% and hypotension in 67% of cases. Central venous pressure recorded in ten patients was elevated in all but one. Generalized ST segment elevation was the rule among the available preoperative recordings. One patient had right bundle branch block. Thirteen of the fifteen patients had a thoracotomy and two had pericardiocentesis only. Sixty nine percent of the thoracotomies were performed within two hours of the injury. There was only one death of a patient who arrived with no blood pressure or heart sounds. An average follow-up of 20 months revealed long-term sequela of an asymptomatic ventricular aneurysm in one patient. Our unusually gratifying results support the approach of emergency thoracotomy in patients with penetrating cardiac trauma.

Traumatic thoracobiliary (pleurobiliary and bronchobiliary) fistulas: clinical and review study.

Thoracobiliary fistulas are rare complications of thoracoabdominal trauma, with high morbidity and potentially high mortality. Our experience with four cases and 12 other cases collected from the literature are reviewed. All patients were male and average age was 25 years. Five had blunt trauma, three had stab wounds, and eight, gunshot wounds. All had diaphragmatic and hepatic injuries. Bronchobiliary fistulas with biliptysis developed in seven patients. Fever, cough, chest and RUQ pains were the most common presenting symptoms. Pleural effusion and elevated right hemidiaphragm were the most common X-ray findings. Bile empyema developed in 2/3 of the patients. Early diagnosis, tube thoracostomy with adequate drainage of all subphrenic billious collections, and secure closure of all diaphragmatic perforations are essential in successful management of most of these fistulas. Thoracotomy, however, is indicated in chronic and complicated fistulas, and should not be delayed beyond 3 weeks. Judicious use of appropriate antibiotics is a necessary adjunct to adequate surgical management of these fistulas. All 16 patients survived.

Penetrating gunshot wounds of the chest in civilian practice: experience with 250 consecutive cases.

Our experience indicates a continued rising incidence of gunshot wounds of the chest in the United States. During the past 4 1/2 years, 250 consecutive cases were treated at the King-Drew Medical Center in Los Angeles. Ninety per cent presented with a haemothorax or haemopneumothorax. Pneumothorax alone was present in only 3 per cent of cases. Twenty per cent had associated intra-abdominal injuries, involving mostly the diaphragm, liver, spleen and the gastrointestinal tract. Eighty per cent were treated with tube thoracostomy and among these there were 2 deaths, neither being related to the chest injury. About 16 per cent underwent thoracotomy with a mortality of 12.8 per cent, all the deaths being caused by severe cardiac wounds. The overall mortality was 2.8 per cent. The complication rate was 5.3 per cent, most complications occurring in patients with associated intra-abdominal and spinal cord injuries. The average period of hospitalization was 6.5 days. The management plan and the indications for the two courses of therapy are discussed.

Penetrating stab wounds of the chest: experience with 200 consecutive cases.

The incidence of penetrating wounds of the chest is rising rapidly. Opinions continue to differ on their management. Our experience with 200 consecutive cases of stab wounds of the chest between 1972 and 1975 were reviewed. There were 176 males and 24 females. The average age was 31 years; about two-thirds of the patients were under 30. About 74% presented with hemothorax or hemopneumothorax; 21 presented with pneumothorax. Eleven per cent had associated intra-abdominal injuries. Seventy-nine per cent were successfully treated with tube thoracostomy. About 15% underwent thoracotomy, with three deaths (mortality, 10%); the mortality for cardiac wounds was 16%; overall mortality was 1.5%. The overall complication rate was 5.5%, most occurring in patients with cardiac wounds and associated intra-abdominal injuries. The average period of hospitalization was 6.5 days. Treatment was individualized. Indications for each course of therapy are discussed.