Mivacurium in special patient groups

In special patient groups, drug response may be different from that in the healthy adult patient. Mivacurium dose requirements vary with age, and children require larger doses to obtain any given degree of block, but the elderly often require smaller doses. However, the dose requirements of the neonate do not necessarily differ greatly from those of the adult. There is a relationship between the duration of action of a bolus dose – as well as infusion requirements to maintain block – and the plasma cholinesterase activity. Patients with renal disease may have a decreased cholinesterase activity and may require smaller doses of mivacurium. Patients with severe liver disease may have a marked decrease in cholinesterase activity, and in these patients a substantially smaller dose of the drug may be needed to obtain and maintain any given degree of block. If the variation in dose requirements is kept in mind and the degree of block appropriately monitored, mivacurium may be used with safety in special patient groups, such as children, the elderly, or those with renal or hepatic impairment.     

Hip spine syndrome: management of coexisting radiculopathy and arthritis of the lower extremity.

BACKGROUND CONTEXT: Significant lumbar spinal stenosis and lower extremity arthritis may coexist in the elderly. This combination of lumbar stenosis with radiculopathy and lower extremity arthritis may lead to diagnostic uncertainty. PURPOSE: To describe the findings of hip spine syndrome, a constellation of symptoms with extensive overlap of radiculopathy and lower extremity arthritis. CONCLUSIONS: Evaluation of the patient with lower extremity pain in consideration for total joint arthroplasty should include functional inquiry of the spinal nerves. Diagnostic tests and injections may allow an informative weighting of the patient's symptoms, leading to a better understanding of the patient's pain syndrome. There is a group of patients who have a total hip arthroplasty and then develop or may continue to have pain of groin and buttock, secondary to sciatica of lumbar spinal stenosis. For the patient undergoing total hip arthroplasty with asymptomatic spinal stenosis, there may be increased neurological risk at surgery, related to the stenosis. The patient with both conditions may require surgical decompression of the lumbar stenosis as well as joint arthroplasty of the arthritic joint.     

Optic neuritis: The role of disease-modifying therapy disease-modifying therapy in this clinically isolated syndrome

Opinion statement Optic neuritis (ON) is an important clinical entity, which may herald the diagnosis of multiple sclerosis (MS). Patients with acute monosymptomatic ON generally have a good visual prognosis, and the speed of recovery may be hastened with intravenous methylprednisolone. The question of whether disease-modifying therapy should be initiated after ON as a clinically isolated syndrome is a controversial topic, and factors specific to the patient should be taken into consideration before weighing in favor or against this therapeutic option. A significant proportion of patients with ON will go on to develop MS, and early initiation of therapy may delay this diagnosis. In addition, disease-modifying therapies also may reduce the disabling effects of MS among patients, but this is unknown. There are approved therapies currently available for patients with ON and an abnormal baseline cranial MRI scan, which predict a greater risk of future MS. Patients with a higher baseline MRI burden of disease, multifocal symptomatology (including sensory complaints) at onset, a high relapse rate, and a rapid accumulation of disability within the first few years of diagnosis may benefit from early and aggressive therapy with the disease-modifying drugs that are currently available. ON patients with few or no lesions on their baseline MRI scans and those with low rates of clinical relapse may be selected for careful clinical follow-up and monitored for signs of disease activity before the role of disease-modifying therapy is determined. ON patients with no light perception vision at presentation, marked optic disc swelling, and other atypical clinical features (including peripapillary hemorrhages or retinal exudates) may have a reduced risk of future MS, and for these patients, disease-modifying therapy may be deferred until it is deemed necessary by the patient and the treating physician.     

Perioperative planning for two- and three-plane deformities

Primary multiplanar external fixation is efficacious for a variety of fractures and may avoid a salvage situation. Complex deformity in conjunction with fractures, nonunions, and malunions can be measured and corrected with the Taylor Spatial Frame using the chronic and especially the total residual correction methods. Distal referencing-characterizing a deformed proximal fragment with respect to a normal distal fragment-is very useful in most lower-limb salvage cases. Corrections may be performed in stages using way points, and additional total residual corrections may be performed as needed. The same frame and analysis used for gradual correction may be used in conjunction with intramedullary nailing or plating in some cases.     

Psychopathologic patterns in obesity

The problem of relationship between obesity and psychological distress is debated in the literature wherein a lot of studies exists with controversial results. The phenomenon of obesity is actually considered with criteria aimed to evaluate almost exclusively the weight excess. Even if such criteria have the advantage to permit a scientific communicability, in the clinical settings the focus of obesity involves medical as well psychiatric aspects. The psychological aspects that may have a relevant role in the development of obesity must be recognized and distinguished from those that may be a direct consequence of obesity itself. In fact, certain obese subjects (no-binge obese) may not experience any psychological distress during lifetime whereas other obese subjects (binge obese) may have a significant and highly distressing psychological suffering. Therefore, obese persons seem to represent a heterogeneous population with different adaptive characteristics who may show several and complex psychological mechanisms and distresses. A psychotherapeutic approach seems to be essential to treat such psychological distress that may heavily concur to the development and the maintenance of obesity.     

Palmar radiocarpal dislocation resulting in ulnar radiocarpal translocation and multidirectional instability

Posttraumatic ulnar radiocarpal translation is a rare, often subtle, highly unstable, and potentially devastating manifestation of severe "proximal radiocarpal ligamentous instability. Radiocarpal dislocation should alert the treating physician to the risks of the spectrum of radiocarpal instabilities. Radiocarpal instability may initially be masked or unappreciated owing to presentation without radiocarpal dislocation, local pain and swelling, initially normal standard wrist radiographs, lack of recognition, or delay in the appearance of a static lesion. The specificity, sequence, and extent of extrinsic radiocarpal and ulnocarpal ligament traumatic disruptions are not fully understood, vary with injury severity, and may differ in instances of dorsal as opposed to palmar subluxation or dislocation. Multidirectional (global) wrist instability typically accompanies this ulnar radiocarpal instability in its most severe form and consequences may be dire. The carpus may be difficult to reduce or maintain owing to marked instability, compressive forces across the wrist, and soft tissue or bony fragment interposition. Additional local distal radioulnar joint or intercarpal injuries may further confound stability and require their own specific and simultaneous treatment. Radiocarpal reduction and repair of the radioscaphocapitate ligament and radiolunate ligaments may be sufficient treatment for acute isolated palmar radiocarpal instability. Temporary K-wire fixation may be added as a precaution to prevent palmar carpal subluxation during the time of ligament healing. Radiocarpal reduction, palmar and dorsal soft-tissue repair, and temporary K-wire fixation comprise one method of treatment for early recognized cases of post-traumatic ligamentous ulnar radiocarpal transposition. Halikis et al have recommended radiolunate arthrodesis. Rayhack et al have suggested that limited or complete wrist arthrodesis may be indicated for patients with delayed presentation or in acute cases with extreme instability. Wrist arthrodesis is one means of management for patients with severe radiocarpal instability confounded by distal radioulnar joint or intercarpal instability, as seen in our patient. Damaged ligaments may have a poor blood supply and often may not hold sutures or heal well. Bone anchor sutures or some type of ligament augmentation may help to restore joint stability in some patients. Loss of stability may occur later owing to ligamentous laxity or inadequate soft-tissue healing. Radiolunate, radiocarpal, or complete wrist arthrodesis may be necessary to relieve pain, restore wrist alignment and stability, and reestablish extremity function for patients with chronic radiocarpal instability. Wrist symptoms, age, general health, hand dominance, and occupation may be among the factors that influence the necessity for and timing of reconstruction. Rayhack et al have also postulated that negative ulnar variance may accommodate the occurrence of ulnar radiocarpal translocation and confound repair owing to lack of buttress at the ulnocarpal joint. They further speculated that a joint leveling procedure might improve the support for ligamentous repair or reconstruction in these cases. Permanent functional impairment must be anticipated in patients with ulnar radiocarpal instability. Impairment has typically been commensurate with the extent of the initial lesion, additional confounding local lesions, and length of follow-up.     

Perioperative management of patients with musculoskeletal disease and for the burns patient

Musculoskeletal disease may present as isolated joint disease, a severe multisystem disorder or a neuromuscular disorder affecting the musculoskeletal system. Thorough preoperative assessment is essential to plan the surgical management of this group of patients. Assessment of the severity of cardiorespiratory disease may be difficult with severely limited mobility. The airway and neck may be involved so early anaesthetic opinion is essential. Drug therapy may need to be modified or stopped perioperatively. Intraoperative positioning and thermoregulation can be difficult to achieve and postoperative analgesia needs to be carefully planned to avoid respiratory depression in a vulnerable group.Patients with burns may present in the emergency department for urgent assessment or for early surgery to excise the burn and graft the defect. There may be an inhalational injury which if severe will require urgent treatment often with intubation and ICU care. A major burn is also a multisystem disorder and again there are challenges with airway management positioning and thermoregulation. These patients present for repeated surgeries and can suffer extreme emotional and psychological strain as a result of the burn insult.     

FK506 nephrotoxicity.

Tacolimus (FK506) is a potent immunosuppressive agent with significant nephrotoxic properties. FK506 is complexed with an intracellular binding protein FKBP-12. Both the immunosuppressive and nephrotoxic effects may be linked to the inhibitory effect of this complex on calcineurin. The initial phase of FK506 nephrotoxicity is associated with a reduction in renal blood flow and glomerular filtration rate. More significant microvascular injury may follow with endothelial damage. Tubular epithelial cell vacuolation, atrophy and micocalcification may be associated with the development of irreversible interstitial fibrosis. At times, mesangial cell proliferation adds to the glomerular abnormalities. These effects may be mediated by the inhibitory effect on calcineurin and its role in regulating cellular calcium channels. FK506 stimulates several inflammatory cytokines, such as transforming growth factor-beta, with potential deleterious effects. Also abnormalities in the reninangiotensin system, endothelin, renal prostaglandins, adrenergic receptors may all play a role in the nephrotoxic effects.     

Occult respiratory and autonomic dysfunction in craniovertebral anomalies and upper cervical spinal disease

Sudden unexplained death may be seen with treatment of craniovertebral anomalies and surgery of the upper cervical spine. Death is due to sleep-induced apnea, premonitored by periods of confusion, lethargy, and asthenia. There may be associated hypotension, bradycardia, hyponatremia, hypothermia, inappropriate antidiuretic hormone secretion, and difficulty in micturition. The potential for respiratory failure may be predicted if a CO2 response test demonstrates an attenuated or abnormal response. Apnea during sleep may be reversed by arousal or may require ventilatory support for a period of time. The condition is self-limiting, but remains the major life-threatening complication. Both apnea and autonomic dysfunction are treatable and curable with appropriate diagnosis and management.     

Lymphoid interstitial pneumonitis associated with common variable hypogammaglobulinaemia treated with cyclosporin A

Lymphoid interstitial pneumonitis (LIP) is a rare clinicopathological entity that may be associated with common variable immune deficiency (CVID) and may lead to respiratory failure and death. Some patients may respond to prolonged corticosteroid treatment. We hypothesised that, in view of the predominant T cell nature of LIP, cyclosporin A would be a more appropriate choice of immunosuppressive agent and report the first case of its successful use in a woman with LIP associated with CVID.     

Use of a Dental Roll Coated with Flavored Viscous Lidocaine for Nasal Mucosal Surgery

BACKGROUND: Nasal mucosal surgery may be unpleasant for patients for a variety of reasons. Injection of local anesthetic into this region may be exquisitely tender, and patients may complain of the taste or passage of anesthetic or other secretions down the nasopharynx. In addition the odor of electrocautery may also be disturbing to some patients. OBJECTIVE: The objective was to decrease patient discomfort during extensive nasal surgery. METHODS: A dental roll coated with flavored viscous lidocaine may be placed in the nasal cavity 5 min before injecting local anesthetic and left in place during extensive nasal surgery. Flavored lidocaine may also be simply applied to the mucosal surface and will help anesthetize the area as well as mask the odor of electocautery. RESULTS: We propose that use of a lidocaine-coated dental roll during extensive nasal surgery will reduce the pain of subsequent local anesthetic injections, disguise the taste of anesthetic and other secretions that may drain down the nasopharynx, and help mask the odor of electrocautery. CONCLUSION: The use of a dental roll coated with flavored viscous lidocaine appears to be a simple way to improve patient comfort during extensive nasal surgery. This form of lidocaine may also be used to improve patient comfort during steel and laser surgery on the oral and nasal mucosas as well as placement of intraoral nerve blocks. Viscous lidocaine can be compounded with flavor at a pharmacy or in the office.     

Solitary chondromas and osteochondromas of the spine provoking myeloradicular compression. Apropos of 6 cases treated surgically

3 spinal chondromas and 3 spinal osteochondromas are described and the relevant literature is reviewed. These oncotypes may remain symptomless or may present as a hard paravertebral swelling or with pain or, more rarely, with a slowly-developing neurological syndrome. Chondromas may appear et any age whereas osteochondromas are more likely to occur during the age of skeletal growth. Both have a predilection for males. Standard Xrays may be diagnostic in osteochondromas but do not always visualise chondromas, which may simulate malignant osteolytic lesions or giant cell tumors and their variants. Computed tomography is indispensable for defining the size of the lesion and its relationships with surrounding structures, for planning surgical treatment, and for following-up its evolution. For both oncotypes treatment is surgical. Recurrence is very rare even after subtotal removal. Malignant degeneration is likewise rare. Operative mortality is nil and neurological recovery is the rule.     

Posttraumatic elbow stiffness

Early posttraumatic elbow contractures may be treated with a combination of manipulation with the patient under anesthesia followed by bracing.Extrinsic contractures of the elbow may be treated with open or arthroscopic release, whereas intrinsic and combined contractures may require tissue release as well as partial or total arthroplasty.     

Combination therapy in benign prostatic hyperplasia (BPH)

Because of the constant progress in our understanding of the physiopathology of benign prostatic hyperplasia, it is now possible to propose a more rational use of combination therapy, which is often used empirically, though not recommended, in routine practice. This chronic disorder, which is in fact more complex than it appears, may benefit in theory from a combination of molecules with different complementary action mechanisms. Prostatic obstruction may be treated either by alphablockers with their peripheral muscle-relaxant action on the smooth muscle fibers of the prostate and bladder neck, or by 5-alpha-reductase inhibitors for their reducing effect on gland volume. Irritative bladder symptoms involving the detrusor may be treated by antimuscarinics and to a lesser extent by alphablockers. Currently available data from recent studies suggest that a combination of an alphablocker and a 5-alpha-reductase inhibitor may be useful in patients with symptomatic BPH and a prostate of more than 40 grams with PSA > 1.6 ng/ml. Combinations including an antimuscarinic are effective in patients with BPH with marked irritative symptoms. Finally, the combination of an alphablocker and a phosphodiesterase type 5 inhibitor may be useful in patients with lower urinary tract symptoms (LUTS) associated with erectile dysfunction.     

Transrectal ultrasound in monitoring response to treatment of prostate disease

Transrectal ultrasound provides a safe method for repeated assessments of the prostate gland in the follow-up of prostatic cancer. Changes in the echo pattern of the gland may be observed following treatment, but these may be difficult to interpret. The capsule may be restored; the tumor may appear smaller, and in some cases, ultrasound identification of the tumor may become impossible. The total gland volume decreases with chemotherapy and hormonal manipulation (subcapsular orchidectomy or drug-induced). The volume generally decreases after radiotherapy but may show a transient increase if there is some associated radiation proctitis. The rate of decrease of total prostatic volume has not been established as a reliable indicator of the subsequent prognosis. Future studies should assess whether sequential measurements of the tumor volume rather than the total prostatic volume may be a more useful guide to prognosis.     

FK506 Nephrotoxicity

Tacolimus (FK506) is a potent immunosuppressive agent with significant nephrotoxic properties. FK506 is completed with an intracellular binding protein FKBP-12. Both the immunosuppressive and nephrotoxic effects may be linked to the inhibitory effect of this complex on calcineurin. The initial phase of FK506 nephrotoxicity is associated with a reduction in renal blood flow and glomerular filtration rate. More significant microvascular injury may follow with endothelial damage. Tubular epithelial cell vacuolation, atrophy and micocalcification may be associated with the development of irreversible interstitial fibrosis. At times, mesangial cell proliferation adds to the glomerular abnormalities.

These effects may be mediated by the inhibitory effect on calcineurin and its role in regulating cellular calcium channels. FK506 stimulates several inflammatory cytokines, such as transforming growth factor-beta, with potential deleterious effects. Also abnormalities in the reninangiotensin system, endothelin, renal prostaglandins, adrenergic receptors may all play a role in the nephrotoxic effects.     

The treatment of hypertension in pregnancy

Hypertension in pregnancy is a leading cause of maternal death. It may represent pre-existing essential or secondary hypertension. Alternatively, it may have been induced by the pregnancy. Pregnancy-induced hypertension may develop after 20 weeks’ gestation, is not associated with proteinuria and generally resolves 6 weeks postpartum. In genetically-predisposed mothers, pregnancy-induced hypertension may take the form of pre-eclampsia, a condition characterized by hypertension, oedema and proteinuria. Antihypertensive drugs palliate this condition but the definitive treatment is delivery of the fetus. Antihypertensive drugs administered during the first trimester of pregnancy may have teratogenic effects, the period of greatest risk being from the third to the eleventh week of pregnancy. Drugs given later in pregnancy may adversely affect fetal growth and development. Those given close to term may impair labour or may have adverse effects on the neonate. An appendix to the British National Formulary lists the risks associated with the use of antihypertensive drugs during the various trimesters of pregnancy. Antihypertensive drugs commonly used in pregnant women include methyldopa (a drug that gives rise to a false sympathomimetic neurotransmitter), hydralazine (a vasodilator that may interfere with the intracellular release of calcium ions), labetalol (an antagonist at α₁- and β₁-adrenoceptors with partial agonist activity at β₂-adrenoceptors), nifedipine (an inhibitor of calcium ion influx through L-type channels) doxazosin and prazosin (antagonists at α₁-adrenoceptors) and antagonists at β-adrenoceptors. Magnesium sulphate is useful for the prevention and treatment of seizures associated with eclampsia but its co-administration with nifedipine is best avoided.     

Late problems at the proximal aortic neck: migration and dilation

Migration is a late-term complication of endovascular aneurysm repair (EVAR) evidenced by downward slippage of the endograft. The etiology of migration may be inherent to problems with endograft fixation, although aortic neck dilation may also play a role. Devices with active fixation (ie, hooks and barbs) possess an additional mechanism of fixation and may better resist migration. Aortic neck dilation after EVAR is significant in a subset of patients and may be related to neck degeneration. Excessive oversizing of endografts may contribute to dilation and migration and is, therefore, not recommended. Migration should be treated when the overlap between the endograft and aortic neck is less than 10 mm or when associated with clinically significant events such as type I endoleak or aneurysm expansion. Failure to treat migration could lead to repressurization and subsequent rupture of the aneurysm.     

Transapical mitral valve-in-valve procedure with elective venoarterial ECMO in a patient with severe kyphoscoliosis

Transcatheter mitral valve-in-valve replacement (TMVR) is a feasible alternative in high-risk patients requiring reoperation for failing mitral bioprosthesis. Such patients may present with hemodynamic instability or sudden complications, which may jeopardize the outcomes. We report a successful transapical TMVR in a patient, with severe kyphoscoliosis and on prolonged mechanical ventilation, with prophylactic extracorporeal membrane oxygenator support. This combined procedure may be helpful to reduce the complications of TMVR in critically ill subjects.     

Molecular biology of esophageal cancer

Several mechanisms of resistance to chemotherapy have been identified among the agents that are commonly used in the systemic treatment of patients with esophageal cancer: paclitaxel, platinum, and 5-FU. A recent study from our laboratory evaluated the initial endoscopic biopsy material from patients who subsequently underwent trimodality therapy, including chemotherapy with cisplatin and 5-FU, radiation therapy, and surgery. IHC analysis was performed on seven markers of chemotherapy or radiation therapy resistance: P-gp, GST-pi, MT (platinum inhibitors); EGF-R, TGF-alpha, erb-B2 (activation of cell growth cascade); and p53 (interferes with chemotherapy-induced apoptosis). In this study, elevated expression of GST-pi and P-gp were associated with decreased survival and may be markers of treatment resistance. Expression of erb-B2 was associated with enhanced survival and may be a marker of treatment sensitivity. Assessment of the probability of chemoresistance of a particular tumor using the expression of molecular biologic markers may allow for the selection of a more favorable chemotherapeutic agent. Furthermore, understanding the mechanisms of resistance, including the mechanisms of DNA repair, may provide insight into mechanisms to reverse or to inhibit resistance to chemotherapy. DNA repair mechanisms are used by cells to protect themselves against mutagens and carcinogens. DNA repair inhibitors may increase the mutagenicity associated with DNA damage and may prove to be an ineffective oncologic treatment strategy; however, the possibility exists that DNA repair inhibition may improve the efficacy of anticancer agents, and this should be tested. The value of this strategy may be in allowing treatment doses to be decreased and lessening side effects while maintaining therapeutic efficacy.