Cerebral ventricular shunts.

Cerebral ventricular shunts are siphoning devices used to treat hydrocephalus. They are placed within cerebral ventricles and peripheral cavities such as the ventricular atrium or peritoneal cavity. Complications include obstruction of cerebral spinal fluid (malfunction) and infection. Morbidity and mortality rates are high when shunt malfunction and infection are not treated emergently. This report summarizes the physical examination of patients with ventricular shunts, reviews the type of shunts commonly used, discusses shunt malfunctions (causing overshunting or undershunting of cerebrospinal fluid) and infections, and makes recommendations concerning empiric antibiotic therapy for shunt infection. The technique of tapping a shunt is presented for management of patients with elevated intracranial pressure that does not respond to non-invasive maneuvers to lower the pressure.

Speech-language pathology and dysphagia in multiple sclerosis.

Dysarthria occurs in approximately 40% of all patients with MS. When speech and voice disturbances do occur, they usually present as a spastic-ataxic dysarthria with disorders of voice intensity, voice quality, articulation, and intonation. While language disturbances such as aphasia, auditory agnosia, anomia, dysgraphia, and dyslexia are very rare in MS, cognitive deficits and swallowing disorders are common. Treating dysarthria, dysphagia, and cognitive deficits in MS patients is effective for reestablishing functional daily activities. The types, severity, and rates of deterioration in MS are highly variable; complete restoration to normal functioning is therefore not always expected. For these reasons, careful documentation of clinical-treatment outcomes and the factors influencing these outcomes should be regularly collected and reported.

Raynaud's phenomenon in the emergency department.

Raynaud's phenomenon manifests as triphasic color changes of the digits, induced by exposure to low temperature or emotional stress. It is a relatively common disorder, estimated to affect 5% to 10% of the general population and 25% to 30% of otherwise healthy women. Although usually self-limiting, it can be severely painful and debilitating, and complicated by ulcerations and tissue necrosis. For the emergency physician treating a patient with an acute presentation of the phenomenon, the main challenges are to achieve adequate pain control, reverse vasospasm, and maintain viable tissue. Emergency treatment can also extend to patient education and arrangement of appropriate referrals and follow-up care.

Urinary thromboxane A2 metabolites in patients presenting in the emergency room with acute chest pain.

OBJECTIVES: The diagnosis of acute myocardial infarction (MI) is difficult in emergency rooms where large groups of patients present with chest pain. Confirmation of the diagnosis of MI based on the myocardial band of creatine phosphokinase may take a day. A more rapid diagnostic screening procedure is desirable and for this reason we evaluated urine thromboxane. DESIGN: The study consisted of patients presenting with chest pain. Urine samples were obtained in the emergency room and on the following 5 days for those patients who were admitted to the hospital. The urine samples were used to determine the levels of immunoreactive 11-dehydro-thromboxane B2 (i-11-dehydro-TXB2) and 2,3-dinor-thromboxane B2 (i-2,3-dinor-TXB2). Myocardial infarction was defined as an increase in the myocardial band fraction of plasma creatine phosphokinase (> 5% of the total) and changes in the electrocardiogram. The patients' diagnoses were retrospectively correlated with thromboxane metabolite levels. SETTING: The present study took place in the emergency rooms of two major hospitals: Georgetown University Medical Center, Washington DC, and Fairfax Hospital, Virginia, USA. SUBJECTS: The study comprised 369 patients presenting with acute chest pain and consisted of 247 men and 122 women aged 30-94 years. MAIN OUTCOME MEASURES: The outcome measure of this study was the predictive value of i-11-dehydro TXB2 and i-2,3-dinor-TXB2, for the diagnosis of MI, in patients presenting in the emergency room with chest pain. RESULTS: Patients undergoing an MI had significantly higher levels of both thromboxane metabolites in their urine in the emergency room, when compared to patients undergoing a cardiac event other than an MI or to patients with unstable angina. Thromboxane metabolite levels rapidly returned to normal on the days following admission to the hospital. Aspirin intake appeared to significantly decrease the levels of i-11-dehydro-TXB2, but not that of i-2,3-dinor-TXB2. CONCLUSIONS: The measurement of thromboxane metabolites in the urine may provide a more rapid, accurate and cost-effective means of diagnosing MIs in patients presenting with chest pain.

A method for the treatment of abductor spasmodic dysphonia with botulinum toxin injections: a preliminary report.

A preliminary technical report of the effective treatment of abductor spasmodic dysphonia with botulinum toxin is presented. Our technique attempts to place the toxin close to the posterior cricoarytenoid muscle to allow diffusion of the material to the PCA. Our pilot study demonstrates that botulinum toxin is an effective approach for reducing or eliminating the abductor glottal spasms during phonation and, thereby, providing functional speech communication.

Double-blind controlled study of botulinum toxin in adductor spasmodic dysphonia.

The treatment of adductor spasmodic dysphonia using botulinum toxin A was conducted in 13 patients as a double-blind, placebo-controlled study. Patients were diagnosed independently by an interdisciplinary team consisting of speech pathologists, an otolaryngologist, and a neurologist. The toxin or saline was injected into each thyroarytenoid muscle under electromyographic and laryngoscopic guidance. Botulinum toxin A markedly reduced perturbation, decreased fundamental frequency range, and improved the spectrographic characteristics of the voice. Fundamental frequency and phonation time remained unchanged. Patients injected with botulinum toxin A noticed significant improvement in their voices in comparison with the placebo-treated group. Excessive breathiness of the voice occurred in two patients, and mild bleeding in one patient in the botulinum toxin A-treated group. Injection with saline resulted in edema of the vocal cord in one patient. Botulinum toxin A proved to be an effective and safe treatment of adductor spasmodic dysphonia.

Quantitative and objective evaluation of vocal cord function.

Objective and quantitative evaluation of vocal cord function is a goal that has been difficult for voice clinicians to obtain. To be useful as a clinical screening tool it must be easy to perform, it must produce numerical storable data, it must have a high degree of accuracy, and it must be cost-effective. The results of this study have shown that using the perturbation factor and the equipment described, a successful rate of greater than 93% can be obtained in evaluating vocal cord dysfunction. The results further indicate that this equipment can be used much in the same way as an audiogram to follow-up and clinically evaluate on an objective basis the function of the vocal cords.

Accidental beta radiation burns from an electron accelerator.

A 61-year-old man presented to the emergency department after accidental exposure to beta radiation and low dose x radiation from an industrial linear electron accelerator. Over 40 days he developed burns on the extremities, abdomen, and face which eventually healed with topical silver sulfadiazine treatment, but suffered no acute x or gamma radiation symptoms. Beta burns and other radiation effects are discussed.

Vocal cord dysfunction - an industrial health hazard.

Vocal cord dysfunction has a definite incidence of association with high environmental noise levels. Our study has shown roughly an 8% incidence of vocal cord dysfunction (vocal cord nodules, vocal cord polyps and chronic laryngitis) in individuals working in high noise environments. In addition, those individuals who have surgery for vocal cord nodules and who work in high noise environments will have over a 30% incidence of recurrent vocal cord dysfunction following surgery. Our study indicates that females tend to be more at risk in high noise environments than males.

Voice spectrography in the evaluation of myasthenia gravis of the larynx.

Myasthenia gravis is a neuromuscular disorder that affects striated muscles especially those innervated by the cranial nerves. The standard diagnostic regimen is to find a reversal of symptoms by acetylcholine esterase administration. The permanent and objective recording of this effect is the key to an accurate assessment of this test. The voice spectrograph is a noninvasive means of evaluating the voice. It has been used successfully to make a clear and specific diagnosis of myasthenia gravis as it affects the larynx. The test can be used to distinguish myasthenia gravis from other functional, anatomical and neuromuscular laryngeal disorders.

The use of spectrograms in the evaluation of vocal cord injection.

The utilization of voice spectrography can be an important adjunct to the assessment of vocal cord function by both laryngologists and speech pathologists. It is especially useful in determining the effectiveness of vocal cord Teflon paste injection procedures. Dysphonic characteristics are made visible, and their improvement can be monitored. As such, spectrographic analysis should be considered as a useful tool for the laryngologist.