Phenytoin impairs the bioavailability of dexamethasone in neurological and neurosurgical patients.

Plasma concentration-time data after oral and intravenous administration of dexamethasone have been subjected to pharmacokinetic analysis in six neurological or neurosurgical patients taking the steroid with phenytoin, and in nine patients (one studied twice) taking dexamethasone without phenytoin. An additional patient was studied before and during phenytoin intake. Apparent volume of distribution was similar in the two groups, but the group treated with phenytoin had an almost statistically significantly shorter dexamethasone mean terminal half-life, an approximately trebled mean plasma clearance, and a mean oral bioavailability of the steroid of only 33%, compared with a mean 84% oral bioavailability in those not receiving phenytoin. To achieve a given plasma dexamethasone concentration, patients treated with the steroid and phenytoin may need oral dexamethasone doses several times those required by patients not receiving phenytoin.     

Cortisol production during high dose dexamethasone therapy in neurological and neurosurgical patients.

Simultaneous plasma dexamethasone and cortisol levels were followed at intervals over 8 hour periods on 40 occasions in 19 subjects who received regular high dosage dexamethasone therapy (rarely less than 12 mg a day) for various neurological and neurosurgical conditions. Lower dexamethasone doses (for example 2 mg daily for 2 days) normally suppress adrenal cortical production of cortisol to below 50 micrograms/l for at least 8 hours. However, in 12 of the 35 studies that did not take place at the first steroid dose or in subjects taking second daily bolus steroid dosage such suppression was not present 8 to 12 hours after dexamethasone intake, though it was shown that dexamethasone could suppress cortisol production in all these cases. Failure of maintained suppression despite the high steroid dose appeared to be related to rapid elimination of dexamethasone. These findings may help explain the relative rarity of adrenal failure in clinical neurological practice after high dosage steroid therapy is ceased.     

Latex allergy in neurosurgical practice

The possibility of latex allergy and the implications of the potential life-threatening allergic reactions among patients (for example those with spina bifida), health care professionals, and latex industry workers are discussed. Latex allergy is becoming increasingly widespread in medical and surgical practice. Although early reports of latex allergy date from 1927, only over the last decade has more attention been paid to this condition. This is due to an increasing number of reported cases of adverse reactions to latex, varying in severity from mild to fatal. Latex allergy has become a major problem in children with spina bifida, who need to undergo many major aggressive diagnostic and therapeutic procedures. Risk groups have been identified and include patients having multiple surgical procedures, such as those with spina bifida. In this review we aim to emphasise some aspects of the current management of surgical patients with latex allergy. Received: 1 March 1999     

The neurological content of general practice.

Of examined patients in medical practice in this study 12.3% presented with neurological disease or health problems involving neurological questions or approach. In acute cases neurological problems (15.5%), occurred more often than in chronic ones. This high neurological workload in general practice has to be taken seriously into consideration in undergraduate and postgraduate medical training.     

Ideal ward round making in neurosurgical practice

The success of a perfect ward round lies in the role of the consultant leading the 'round making group' (RMG) as well as the hallmark of effective questioning and participation of each member. Twelve senior consultants with more than 10 years' experience in neurosurgical practice at three different university hospitals were observed during round making by a participant observer. Observations were made on the group climate of the RMG, the leadership pattern and language expressed by the clinician conducting the round and the effectiveness in his performance as a leader during clinical discussions. The group climate showed evidence of good productivity and flexibility with 92% and 75% consultants, pleasantness of climate was above average with only 50% (6/12) and poor objectivity with 42% (5/12) consultants. Forty two percent of the consultants were not always very well comprehensible, while only 50% (6/12) spoke exactly fitting the occasion. Only 33% (4/12) of the consultants used humour effectively, while 42% (5/12) spoke unnecessarily in between discussion and were poor in introducing the problems of patient to the round making group. Ward round making in neurosurgical practice needs a holistic approach with motivation, planning, leadership skills and structured curriculum to fulfill its objectives.     

Somatoform disorders in neurological practice

PURPOSE OF REVIEW: Patients with medically unexplained symptoms continue to intrigue, fascinate and frustrate clinicians. They are common in general medicine and often present with apparent neurological disorder. This review aims to provide insight into the recent literature that has sought to clarify epidemiology, diagnostic issues, aetiologic understanding and treatment of patients with psychogenic disorders who usually first present to neurologists. RECENT FINDINGS: Somatoform disorders are common in neurological practice. A number of papers have addressed issues of epidemiology and identified that medically unexplained symptoms in neurological populations are higher than originally thought. A number of recent review papers have served to summarize areas of considerable information (e.g. treatments) and areas of rapid growth in knowledge (e.g. neuroimaging). Studies investigating the role of psychological factors are well represented and clarify our psychopathological understanding of somatoform disorders in patients presenting to neurologists. Treatment studies are few and continue to be limited by population sizes and study designs. SUMMARY: Somatoform disorders are common in neurological populations. Comorbidity related to somatoform disorders with known organic neurological conditions requires further study. On account of the limitations of treatment studies, evidence-based clinical management of these patients is awaited.