Care of the surgical intensive care nursery graduate. The primary care pediatrician's perspective

Care of the intensive care nursery graduate may be quite challenging. It is important that primary care pediatricians become familiar with the complications unique to surgical patients so that they may properly prepare and educate parents and provide appropriate long-term follow-up for these often complex patients. Maintenance of a close relationship with the pediatric surgeon with an open line of communication regarding the approach to various surgical problems facilitates the effective integration of the intensive care nursery graduate into the primary care pediatrician's practice and provides the foundation for a successful clinical outcome.     

Abdominoplasty assessed by survey, with emphasis on complications

Some 958 surgeons replied to a survey designed to determine the complications of abdominoplasties. The results appear in this paper. We believe that the patient contemplating an abdominoplasty and the surgeon planning it should be aware of the unpleasant reality of these complications, which range from the annoying to the lethal. It is of some solace, however, that despite the inevitability of readily visible scars, nearly all of these patients are quite satisfied with their results.     

Neurologic manifestations of primary Gougerot-Sj?gren syndrome

Primary Sj?gren's syndrome is one of the commonest autoimmune connective tissue diseases. Neurological complications occur in about 20 p. 100 of primary Sj?gren's syndrome patients. It most frequently involves the peripheral nervous system, predominantly sensorimotor and sensory polyneuropathy. Sensory neuronopathy and trigeminal nerve involvement are less frequent but quite suggestive of primary Sj?gren's syndrome. Among central nervous system involvements, focal or multifocal lesions of the brain or the spinal cord are the most frequent. Diffuse encephalic involvement may present either as an aseptic meningoencephalitis or as a cognitive impairment. It is not clear whether psychiatric manifestations (mostly mood and personality disturbances) have an organic substratum or are the psychological consequence of the disability induced by a chronic disease such as Sj?gren's syndrome. The response to corticosteroids or immunosuppressive therapy is unpredictable in neurological complications of primary Sj?gren's syndrome. The pathophysiology of these complications remains unknown. Different mechanisms could be assumed depending on the neurological manifestations: vasculitis in polyneuropathies and multiple mononeuropathies, humoral and/or cellular mediated immune response against neurones in sensory neuronopathy. In central nervous system involvement, each of these mechanisms could occur.     

Thrombosis and hemorrhage in oncology patients

As outlined in this review, patients with cancer may harbor many alterations of hemostasis. These are multifaceted and must be considered when trying to control hemorrhage or thrombosis in cancer patients. Also, hemorrhage or thrombosis is often the final fatal event in many patients with metastatic solid tumor or hematologic malignancies. Patients with malignancy present a major clinical challenge in this new era of oncologic awareness and more aggressive care, which has led to prolonged survival for patients and a longer time frame during which these complications may develop. Therefore, these complications are occurring more commonly. It is important to realize that these alterations of hemostasis exist and must be approached in a sequential and logical manner with respect to diagnosis; only in this way can responsible, efficacious, and rational therapy be delivered to patients. By far the most common alteration of hemostasis in malignancy is that of hemorrhage associated with thrombocytopenia, either drug-induced, or radiation-induced, or from bone marrow invasion. Hemorrhage resulting from DIC, however, is also quite common and may present as hemorrhage, thrombosis, thromboembolus, or any combination thereof. Many antineoplastic drugs and radiation therapy may lead to or significantly enhance hemorrhage in patients with malignancy. Thrombosis, also commonly seen in patients with malignancy, is often a manifestation of low-grade DIC. When approaching the patient with malignancy and either hemorrhage or thrombosis, all the potential defects in hemostasis must be considered, defined from the laboratory standpoint, and treated in as precise and logical manner as possible.     

Serious complications of acute sinusitis

Acute sinusitis is common and usually the result of edema around the sinus ostia from the common cold. Chronic sinusitis and recurrent sinusitis are common complications of untreated or undertreated infection. Serious and life-threatening complications are uncommon but demand a high index of suspicion, accurate diagnosis, and rapid intervention by medical and surgical methods. Immediate parenteral administration of antibiotics may be necessary to prevent permanent disabilities or death, and early consultation with an otolaryngologist or neurosurgeon is prudent. Computed tomography is the imaging method of choice for detection of serious intracranial complications of acute sinusitis. Increasing numbers of immunocompromised patients and seriously ill hospitalized patients with problems related to complications of acute sinusitis are being seen.     

Abciximab. An updated review of its use in ischaemic heart disease

Abciximab is a glycoprotein IIb/IIIa receptor antagonist that has proven to be of significant clinical value in improving patient outcome after percutaneous coronary revascularisation. Primarily, the drug inhibits platelet aggregation, but it may also have anticoagulant activity and other beneficial effects, such as inhibiting migration and promoting apoptosis of smooth muscle cells. Large well designed studies have found administration of abciximab (as an adjunct to heparin and aspirin) during percutaneous coronary revascularisation to significantly reduce the incidence of ischaemic complications occurring in the 30 days after the procedure. Significant benefit, particularly on the incidence of myocardial infarction, was still evident after 6 months in 2 of 4 major trials. Abciximab provides particular benefit in patients with unstable angina or myocardial infarction who are undergoing percutaneous coronary revascularisation. The benefits of the drug are additive to those achieved with coronary stenting. Very preliminary data suggest that abciximab may improve coronary blood flow after myocardial infarction and allow reperfusion to be achieved with reduced thrombolytic doses. Caution is required to minimise the risk of bleeding complications with the use of abciximab in combination with heparin and aspirin. Careful patient selection, use of an appropriate heparin regimen, early vascular sheath removal and meticulous femoral artery access site care are recommended. Thrombocytopenia can occur with abciximab treatment, but severe cases are uncommon (< 2% of patients) and can be treated with platelet transfusions. The high acquisition cost of abciximab may be partly or fully offset by the costs averted by the reduced incidence of ischaemic complications and need for urgent and/or repeat revascularisation in high risk patients who receive the drug. However, if bleeding complications occur, this adds to treatment costs. Cost effectiveness analyses generally support the use of abciximab in high risk patients. CONCLUSIONS: Abciximab can be recommended for the prevention of acute ischaemic events in most patients undergoing percutaneous coronary revascularisation, but careful patient selection and strict adherence to the recommended treatment protocol are required to reduce the risk of bleeding complications and thrombocytopenia. Its use in high risk patients is largely supported by pharmacoeconomic data. Further pharmacoeconomic information is needed to establish the drug as a standard of care for all patient groups. The indications for abciximab are likely to expand as more data on its use in acute coronary syndromes become available.     

Metrizamide cisternography with hypocycloidal tomography: preliminary results

Metrizamide (Amipaque), a nonionic water soluble contrast agent, has been shown to be safe and efficacious for lumbar myelography. Clinical trials of cervical, thoracic, and even intracranial examinations have produced good results. Despite an inherent neurotoxicity, significant complications have been quite rare, and patient tolerance in general is remarkably good. Preliminary results of metrizamide cisternograms using hypocycloidal tomography are presented to illustrate the anatomic detail which can be demonstrated using this technique.     

Renal side-effects of non-steroidal antirheumatic drugs

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAID) are increasingly used for analgesia, as antirheumatics and to inhibit platelet aggregation. Renal side effects occur mainly in patients at risk, e.g. those with pre-existing renal insufficiency, or when used together with diuretics or a second NSAID. PATIENTS: In these patients, reversible impairment of renal function, disturbance of electrolyte homeostasis, edema and hypertension are quite common. Nephrotic syndrome with or without interstitial nephritis and renal failure is a rare complication of long-term NSAID therapy. Analgesic nephropathy may result from chronic NSAID use. These three renal complications are exemplified by case reports. CONCLUSIONS: Since side effects of NSAIDs are initially reversible, careful observation of patients can prevent chronic illness. Only rarely dialysis or treatment with glucocorticoids is indicated in patients with interstitial nephritis. Given the large number of patients taking NSAIDs, however, renal side effects are rare, and usually have no long-term consequences. Nevertheless, early detection of side effects is of importance for the prevention of long-term medical complications.     

COX-2 inhibition versus gastroprotection with dual COX inhibitors: an evidence-based approach

Highly selective inhibitors of cyclooxygenase-2 (COX-2i) were introduced to minimize peptic ulcers and their complications caused by dual COX inhibitors (COXi). Co-prescribing a (generally cheap) dual COXi with a gastroprotectant is an alternative strategy, proven to reduce the incidence of NSAID-associated endoscopic ulcers. This review compares the efficacies of these two strategies and makes some estimates of their relative cost-effectiveness. In standard risk patients, endoscopic ulcers are reduced to about the same extent (around 70-80%) by either co-prescribing omeprazole or lansoprazole with a dual COXi or preferring a COX-2i alone. COX-2i reduced ulcer complications by a weighted mean of around 60% in comparative studies with dual COXi. There is little information about the influence of PPI on this endpoint, although one study using H. pylori treatment as a possible surrogate for placebo intervention found 77% protection against recurrent upper gastrointestinal bleeding by co-administered omeprazole. One direct comparison of the two strategies in high-risk patients (recent ulcer bleed) found quite high rates of re-presentation with bleeding ulcer using either strategy, and the differences between them were not significant. Drug costs in four Western countries were compared for each strategy. In one, the costs were similar, but in the others the combination of a cheap dual COXi with omeprazole was usually more expensive than using a COX-2i. The safest strategy in highest risk patients may be to co-prescribe a gastroprotectant with a COX-2i, with resulting higher drug costs but possibly offset by savings in other health costs. The efficacy and cost-benefit of this alternative approach warrants investigation.     

Early endoscopic findings of the upper respiratory and digestive tract in patients undergoing translaryngeal intubation for more than 24 hours

The large number of patients undergoing translaryngeal intubation justifies acquiring full knowledge of the complications that this invasive procedure may produce. The short-term problems that cause immediate complications (esophageal intubation, cuff rupture) are severe and do not escape notice. However, less immediate problems often pass undetected, although their presence may worsen the patient's outcome. Endoscopy allows the condition of the upper respiratory and digestive tract to be examined in order to detect and correct such problems. In this preliminary study, risk factors are analyzed and the lesions are described, classified, and quantified. Forty-seven adult patients were studied prospectively. In the first 24 to 48 hours of intubation, rigid endoscopy was performed under sedation using 0 degree and 30 degrees rigid endoscopes. The high rate of glottic edema (63.8%) was noteworthy because knowledge of this condition can be vital for preventing extubation failure.     

Early atherosclerosis in human hypertension

The detection of preclinical atherosclerosis may contribute to better identifying hypertensive subjects at high risk of complications. Three alterations can be diagnosed noninvasively: calcification, thickening, and stiffening of the arterial wall. Their prevalence is increased in asymptomatic hypertensives and their presence may have important prognostic significance, especially with respect to coronary artery disease. They are also ideal targets to test the efficacy of hypertensive therapy on the arterial wall. Finally, the detection of early atherosclerosis may help to improve the clinical management of hypertensive patients.     

Hemorrhoidectomy with circular stapler in advanced hemorrhoid pathology

The Authors refer their early experience with the treatment of 4th grade haemorrhoids and 4th grade with mucosal prolapse using a circular stapler. The operation is quite easy with a short learning period, with no short term complications and low post-operative pain. The good results need to be confirmed on a large number of cases and a longer follow-up.     

Is there a future for antiarrhythmic drug therapy?

Drug therapy has traditionally been the mainstay of treatment for both ventricular and supraventricular arrhythmias. However, increasing knowledge about the potentially significant adverse effects of these medications, together with the emergence of new, nonpharmacological approaches to the treatment of arrhythmias, has led some to question the future of antiarrhythmic drug therapy. Antiarrhythmic drugs are quite effective in terminating a variety of arrhythmias, including atrioventricular (AV) node re-entrant and AV tachycardias (particularly calcium antagonists and adenosine), atrial flutter (class III agents) and atrial fibrillation (class IA and IC drugs. The chronic use of antiarrhythmic drugs has been increasingly limited by a fear of adverse effects (especially proarrhythmia) and the availability of highly effective nonpharmacological alternatives (particularly ablation for re-entrant tachycardias involving the AV node and bypass tracts and cardiovertor/defibrillators for malignant ventricular arrhythmias. Atrial fibrillation (AF) continues to be a therapeutic challenge for which there is no safe and curative nonpharmacological therapy. Antiarrhythmic drugs of classes IA, IC and III show efficacy in preventing recurrence of AF but there are concerns about possible pro-arrhythmic complications. In the future, antiarrhythmic agents will continue to be used acutely to terminate a broad range of sustained arrhythmias. Chronic use is likely to depend on the development of safer and/or more effective compounds, as well as on improved ways of predicting which patients are likely to develop pro-arrhythmic reactions. The development of molecular electrophysiology will allow for the identification of agents with selected ion channel blocking profiles which may prove efficacious with a lower risk of complications. Finally, an improved understanding of arrhythmia substrates may permit the identification of therapy that prevents arrhythmias by acting on the underlying substrate, rather than simply trying to modify the electrical end product.     

Topical diclofenac/hyaluronic acid gel in the treatment of solar keratoses

Infection remains a major cause of morbidity and mortality among transplant recipients. Aspergillus infections in particular are associated with a high mortality rate. The diagnosis of Aspergillus among transplant recipients may be difficult, because many patients have multiple complications. This article presents a case of Aspergillus in a heart transplant recipient. The discussion provides an overview of the presentation, diagnosis, and treatment of Aspergillus infections.     

Effects of phospholipid base analogues on the subcellular membrane ether composition of suspension cultured LM cells

Morbidity and mortality from pulmonary complications following urinary tract operations can be reduced by preoperative identification of the high risk patient. Pulmonary function tests and arterial blood gases are necessary to identify these patients and to delineate the severity of their pulmonary disease. Respiratory complications can be prevented in many patients with the proper use of pre- and postoperative chest physical therapy and oxygen therapy. Despite the most careful pulmonary management, some patients develop acute respiratory failure following urologic operations. Respiratory failure results from a combination of physiologic abnormalities which impair alveolar ventilation and oxygenation. Utilizing controlled ventilation, supplemental oxygen, and a physiologic approach to treating the underlying cause of respiratory failure, three fourths of urologic patients in respiratory failure may be expected to survive.     

Urinary complications of the resectable cancers of the cervix uteri (author's transl)

The authors studied the urinary complications following 721 operations performed between 1960 and 1974 for cervix uterin carcinoma. The surgical method was the one used at the Fondation Curie according to the protocol of treatment. They have noted that: --first, the surgical act as primary treatment (672 cases) was innocuous, as this series showed only 0,6% of the severe complications; in contrast, when the surgery is performed for a recurrence after a total dose irradiation, the severe complications raised to 8%; --secondly, the uretero-hydronephroses following this type of surgery are relatively frequent on the systematic urograms, but most of them are quite asymptomatic and without later sequelae only 0,3% of them required a surgical treatment. The authors analyse the factors influencing the ureteral stenoses, especially the extent of lymphadenectomy and the associated external irradiation. They studied too the ureteral stenoses due to a local recurrence.     

Diagnostic framework of nonpalpable lesions of the breast

Mammography is the most sensitive test for non-palpable lesions, but its specificity is quite limited. When a decision for biopsy is based only on the mammographic appearance the benign/malignant biopsy ratio (B/M) is around 3:1. The B/M varies according to the radiological pattern being favourable for stellate opacities, high for regular opacities, and intermediate for distortions and microcalcifications. Aspiration cytology of non-palpable lesions, either sonographically or stereotaxically guided, is highly accurate. When the decision for surgical biopsy is taken also on the basis of cytology, B/M may be reduced by up to 0.5:1. As false negatives are expected for cytology, lesions which are strongly suspicious at mammography must be biopsied anyway. Sonography guided aspiration is possible in about a half of mammographically detected non-palpable lesions, particularly for opacities, whereas distortions and microcalcification are seldom visualized at sonography. Cytology should be routinely performed in the presence of questionable non-palpable lesions.     

Management of diabetic pregnancy complicated by coronary artery disease and neuropathy

Various manifestations of diabetic neuropathy may complicate pregnancies of young diabetic patients. Of all forms of diabetic neuropathy, autonomic neuropathy, and, in particular, gastropathy, may cause the most devastating complications. Because neuropathy is a common abnormality in young asymptomatic diabetic women, screening for this disorder may be advisable and can be accomplished by relatively simple and noninvasive tests. Screening is best performed before conception or early in pregnancy, because pregnancy itself and its possible complications later modify the autonomic nervous function tests and make testing unreliable. Practitioners and obstetricians who provide care and counseling to young diabetic patients should be familiar with the risks and consequences to maternal and fetal health that may be imposed by the different forms of neuropathy. Moderate-to-severe autonomic dysfunction may be considered a relative contraindication to pregnancy, especially if gastropathy is part of the clinical presentation. The management dilemmas and high mortality and morbidity associated with symptomatic diabetic neuropathy may justify the addition of a new independent class, class N (neuropathy), to the current classification systems for diabetes in pregnancy.     

Clinical quality measurement. Comparing chart review and automated methodologies

OBJECTIVES: This study investigates the use of data from automated systems within a large managed care plan to create indicators of clinical quality. METHODS: Measures from the first year of Health Plan Employer Data and Information Set, HEDIS 2.0, are used to compare chart review and automated analysis methodologies. The contributions of various data systems in creating clinical quality measures are evaluated. RESULTS: Chart review data usually are better for creating clinical quality indicators, although the level of agreement between the two methodologies often is quite high. Computerized patient record systems are found to be the most reliable automated data source, and automated claims are found to be the least reliable. This study's findings suggest that automated encounter systems may provide relatively reliable data. CONCLUSIONS: Managed care plans may not want to rely on automated data alone for clinical quality measurement. The results reported here support the use of combined methodologies such as the "hybrid" method, which utilizes both automated and chart-review data.     

Glucose effectiveness, peripheral and hepatic insulin sensitivity, in obese and lean prepubertal children

Vascular injuries in lumbar disk surgery, although rare, are serious complications which may be overlooked due to a broad range of clinical manifestations. It is important that surgeons and radiologists be aware of these potentially fatal complications and develop an appropriate symptom-based diagnostic paradigm. We reviewed 8099 consecutive cases of lumbar disk surgery, performed over a 14-year period at a single institution, for postoperative vascular complications. We identified four patients (0.05%) with lumbar disk surgery-related vascular complications: intraoperative lacerations of the abdominal aorta and median sacral artery, an arteriovenous fistula between the left common iliac artery and vein detected 19 days postdiskectomy, and a partially thrombosed aortic aneurysm with an arteriovenous fistula between the aneurysm and the inferior vena cava, diagnosed 11 months after surgery. The majority of cases in the literature of vascular injury in lumbar disk surgery were reported prior to 1965. Diagnostic approaches described in that period do not reflect the great range of diagnostic techniques available today. Angiography remains the gold standard for diagnosis and guidance as to surgical repair. However, a high index of suspicion based on clinical signs and/or the use of sonography or CT is important in the detection of these complications.