Asthma exacerbations . 4: Prevention

Asthma exacerbations are common. They account for a significant morbidity and contribute a disproportionate amount to the cost of asthma management. The optimal strategies for the prevention of asthma exacerbations include the early introduction of anti-inflammatory treatment-most commonly, low dose inhaled corticosteroids. This should be coupled with a structured education programme which has a written action plan as an integral component. Where patients continue to be poorly controlled, the addition of a long acting beta agonist should be considered. The latter should not be used as monotherapy and should always be used with inhaled corticosteroids. Atopic patients with a history of repeated exacerbations, especially if they are steroid dependent and with a raised IgE, may be considered as potential candidates for omalizumab. In the early stages of an asthma exacerbation, doubling the dose of inhaled corticosteroids has been shown to be ineffective. The ideal strategy for the management of worsening asthma in patients on combination treatment, especially salmeterol and fluticasone, is uncertain. There is an emerging body of evidence for strategies on how to prevent progression to an exacerbation in patients taking a combination of budesonide and formoterol.     

Micturition neuropharmacology

Applying the basic principles, therapy guides to our hypothetical cases can be constructed. The 60 year old man with postoperative abdominal perineal resection with hypertension and parkinsonism may well need a transurethral resection of the prostate; however, other options include decreasing his anticholinergic-type medications, such as antiparkinsonism medications, changing his hypertensive therapy from beta blockers such as propranolol and metoprolol to alpha blockers such as methyldopa and prazosin. Bethanacol would seldom be helpful alone, but with an alpha blocker could help if not contraindicated by the presence of vascular disease. The second example, a 45 year old woman with stress incontinence, may be assisted with improved storage by an anticholinergic agent, an alpha enhancer, a mucosal enhancer, and if pertinent, switching hypertensive therapy from an alpha blocker to a beta blocker. The last example, a T10 paraplegic with a spastic, hyperreflexic bladder, can have improved storage with anticholinergics, decreased sphincter tone with alpha blockers, as well as decreased sphincter tone with alpha blockers, as well as decreased spasms through suppression of hyperactive spinal cord activity with baclofen.     

Guidelines for the clinical use of transmyocardial laser revascularization

Patients with chronic, severe angina refractory to medical therapy who cannot be completely revascularized with either percutaneous catheter intervention or coronary artery bypass graft surgery (CABG) are clinically challenging. Transmyocardial laser revascularization (TMR), as sole therapy or as an adjunct to CABG, may be appropriate therapy for these patients. The recommendations are based on a review of the available evidence including expert consensus opinions. The author follows the format of the American Heart Association and the American College of Cardiology guidelines for diagnostic and therapeutic procedures. There are class I indications for sole therapy TMR and class IIA indications for TMR as an adjunct to CABG. TMR is indicated for selected patients: as sole therapy for a subset of patients with refractory angina. It also may be effective as an adjunct to CABG for a subset of patients with angina who cannot be completely revascularized surgically.     

Editorial Commentary: Is It Time to Take a Stand? When Arthroscopic Bankart Repair Is No Longer a Viable Option for Anterior Shoulder Instability

Recurrent anterior instability remains a challenging pathology to treat effectively. Arthroscopic Bankart repair, with its low invasiveness and complication rates, is readily the first, as well as most commonly, used procedure. However, some outcomes studies have reported an unacceptably high failure rate. As such, the ideal candidate for an arthroscopic repair has yet to be fully defined, mainly because of the multiple risk factors for failure after arthroscopic instability repair. Among those factors, recurrence of an instability event is clearly a risk factor for worse outcomes after arthroscopic instability repair. This may be due to an association between recurrent instability and an increase in glenoid bone loss, humeral bone loss, and more extensive labral tears, as well as more capsular, ligamentous, and rotator cuff injuries. Patients who present with 2 preoperative dislocations and a duration of instability symptoms of more than 6 months, as well as off-track Hill-Sachs lesions, may not be ideal candidates for arthroscopic instability repair. There is a “cost” to waiting on surgery after a first dislocation.     

Pathologie und Pathophysiologie des Kreislaufschocks mit besonderer Berücksichtigung der Schocklunge

The circulatory shock presents an acute generalized failure of the circulation, in particular of the lesser peripheral circulation, and may possibly but not necessarily be accompanied by a decrease in blood pressure and damage to the tissue due to a lack of oxygen. The main question concerning the causal pathogenesis of shock is still unsettled, but an interaction between a lack of oxygen as well as of other factors, like endotoxin, complements and vasoactive amines, and the presence of a microthrombosis must be held responsible for the appearance of this condition. In modern intensive medicine the lung must be considered as the preferential area for the manifestation of shock. The clinical picture of shock lung may be described as acute respiratory deficiency accompanied by an impaired diffusion of oxygen, an increase in dead-space ventilation together with an increased shunt volume and intensified respiratory activity. The pathology of shock lung shows two phases and has its onset in exudative alveolitis followed by alveolar fibrosis which can hardly be controlled by therapy. The early phase of shock lung manifesting itself by exudative alveolitis is decisive with regard to diagnosis and further therapeutic measurements. If the condition can be brought under control at this stage there is a chance that the patient may survive.     

Protriptyline as an alternative stimulant medication in patients with brain injury: A series of case reports

The results of a series of eight individual case reports in which protriptyline, an activating tricyclic antidepressant, was used as a 'stimulant' medication are presented. For some patients with head injury, traditional stimulants, such as methylphenidate, or dopaminergic stimulants, such as levodopa-carbidopa, amantadine, or bromocriptine, may be partially or totally ineffective or not tolerated. Protriptyline can be a very effective alternative and, for some patients, may be the most effective stimulant tried. In low to moderate doses, protriptyline should be considered for trials as an activating/stimulant medication in patients with head injury.     

Biomechanics of intramedullary nailing and its interlocking

Mechanically an intramedullary nail cannot be conceived of as a nail but rather as a bendable feather subject to longitudinal tension and, to a lesser degree, to transverse pressure. Reaming the medullary canal is necessary for centralizing of the nail as well as for increasing the area of contact with the bone. However, this procedure is detrimental to the bone metabolism, thus reducing its elasticity against torsional forces. The dynamic locking nail-system is more biologic than conventional nailing, with rotatory instability being reduced by additional components, such as transverse screws. By applying static locking only true static weight bearing with crutches, will be ensured but no dynamic mobilisation. Nails with conventional strength and in trefoil leaf formation are superior to other designs. However, an improved angle in the proximal locking is suggested, as this will allow the weight bearing to be increased three to four times.     

The use and abuse of external incisions in rhinoplasties

The author emphasizes his basic opposition to the use of external incisions in surgical rhinoplasty with only a few minor exceptions. External incisions are justifiable in only a limited number of cases, and when they are published these cases should be exceptional indeed and not suggested as an alternative technique or as an innovation to be used on a routine basis. The endonasal approach should be used in the vast majority of aesthetic rhinoplasties with only a few exceptions mentioned here.     

Age and admission weight as predictors of mortality in gastro-enteritis

The age and weight of 2,095 children admitted to the Ga-Rankuwa Hospital outpatient rehydration unit were analysed with regard to death as an outcome. Age was not a good predictor of death as an outcome. Weight, expressed as a percentage of expected weight for age, was a good predictor of death and should be utilised as an important inpatient admission criterion.     

Foam sclerotherapy for the treatment of varicose veins

Treatment of venous insufficiency with liquid sclerotherapy is considered by some to be an unfulfilled promise. It was heralded in the first half of the last century to be a replacement for surgery, but as recurrences of varicose veins appeared in limbs treated with injection techniques, surgery reappeared and was dominant in the last half of the century. Just as saphenous stripping was proved to be superior to proximal ligation, both were replaced by use of electromagnetic energy, such as radiofrequency and laser venous ablation, as a means of taking the saphenous veins out of the circulation. Now reports of recurrent varices in 20 to 50% of operated cases are making some physicians look to alternatives in treating varicose veins. Foam sclerotherapy must be looked upon as an entirely new method of treatment. It is useful in all types of varices and is proven to be safe, simple, cheap, reliable, and repeatable.     

Etiology and assessment of hypercoagulability with lessons from heparin-induced thrombocytopenia

Hypercoagulability, or thrombophilia, is a condition associated with an abnormally increased tendency toward blood clotting. Affected individuals are prone to developing venous or arterial thrombosis and often require thromboprophylaxis. Hypercoagulability can be generally classified as either an inherited or acquired condition. Patients with an inherited thrombophilia have genetic variances that alter the quality or quantity of proteins involved with hemostasis. Hypercoagulability may also be acquired and develop as an exaggeration of normal physiologic responses to major tissue injury, or an abnormal response to various prothrombotic clinical factors. Careful assessment for hypercoagulability is important because effective management strategies, often involving anticoagulation, may be available. Heparin-induced thrombocytopenia is an example of an acquired hypercoagulable state that has been well studied and, when recognized, responds to appropriate therapy. In this article, we review the etiology, risks, and assessment of thrombophilia, with emphasis on the clinical lessons learned from heparin-induced thrombocytopenia.     

Duplex ultrasound of the superficial femoral artery is a better screening tool than ankle-brachial index to identify at risk patients with lower extremity atherosclerosis

OBJECTIVES: The purpose of vascular disease screening is early identification of atherosclerotic disease and the aim of an ankle-brachial index (ABI) is to identify lower extremity (LE) atherosclerosis as a marker for coronary artery disease (CAD). However, early evidence of atherosclerosis may be present in the superficial femoral artery (SFA) with a normal resting ABI. This study was performed to determine if SFA duplex ultrasound (DUS) could detect more patients with LE atherosclerosis than an ABI; be performed in the same or less time as the ABI measurement; and be associated with similar vascular disease markers as the ABI. METHODS: From January through November 2006, 585 patients were screened for peripheral arterial disease. SFA DUS was included in this Institutional Review Board approved program and demographic/ultrasound data were collected prospectively. SFA DUS findings were divided into six categories. Plaque w/o color change or worse and ABI <0.90 or >1.20 were considered to be abnormal. Data were evaluated using decision matrix and logistical regression analysis. RESULTS: Sensitivity and specificity of SFA DUS using the ABI as the benchmark was 100% and 88%, respectively. Sensitivity and specificity of ABI was 17% and 100%, respectively, using DUS as the standard. DUS detected atherosclerotic disease in 143 SFAs (93 patients) in which the ipsilateral ABI was normal, and there were no false negative SFA DUS studies. Multivariate logistic regression analysis demonstrated the following variables to be significantly and independently associated with an abnormal SFA DUS as well as an abnormal ABI: history of claudication, history of myocardial infarction, and an abnormal carotid DUS. Additional variables (current or past smoker and age >55) were also independently associated with an abnormal SFA DUS but not with an abnormal ABI. Mean time to complete bilateral testing was essentially the same for both tests. CONCLUSIONS: SFA DUS is an accurate screening tool and can be utilized in screening protocols in place of the time-honored ABI without prolonging the examination. Traditional vascular disease markers that are found in patients with an abnormal ABI are also associated with an abnormal SFA DUS. SFA DUS identifies more patients with early LE atherosclerosis than does ABI without missing significant popliteal/tibial artery occlusive disease. Finally, an abnormal SFA DUS can be used as an indirect marker to identify more potentially at risk patients with CAD.     

The reproducibility and significance of carbon dioxide urethral profilometry.

Infusion urethral profilometry using carbon dioxide as a medium is an interesting study with a wide range of variability from day to day in a single individual, a fact that considerably reduces the value of a single measurement as a diagnostic tool. Presently, all forms of infusion profilometry must be considered to be interpretable only within the framework of the entire neurourologic evaluation. The study may be useful to make the clinician more secure about a particular diagnosis and as an objective measurement for medico-legal documentation. It also may be useful in predicting and objectively demonstrating treatment results if normal variability can be excluded. However, a high level of skepticism should be maintained regarding the value of the profile in those situations in which its interpretation does not correlate with the impression formed from the remainder of the neurourologic evaluation.     

Ethical issues surrounding high-risk kidney recipients: implications for the living donor

Evaulating patients for living kidney donor transplantation involving a recipient with significant medical issues can create an ethical debate about whether to proceed with surgery. Donors must be informed of the surgical risk to proceed with donating a kidney and their decision must be a voluntary one. A detailed informed consent should be obtained from high-risk living kidney donor transplant recipients as well as donors and family members after the high perioperative risk potential has been explained to them. In addition, family members need to be informed of and acknowledge that a living kidney donor transplant recipient with pretransplant extrarenal morbidity has a higher risk of a serious adverse outcome event such as graft failure or recipient death. We review 2 cases involving living kidney donor transplant recipients with significant comorbidity and discuss ethical considerations, donor risk, and the need for an extended informed consent.     

The Society of Thoracic Surgeons practice guideline series: transmyocardial laser revascularization

BACKGROUND: Patients with chronic severe angina refractory to medical therapy who cannot be completely revascularized with either percutaneous catheter intervention or coronary artery bypass graft surgery present clinical challenges. Transmyocardial laser revascularization, either as sole therapy or as an adjunct to coronary artery bypass graft surgery, may be appropriate for some of these patients. Although transmyocardial revascularization has consistently been demonstrated as an efficacious means of relieving angina, the mechanism of its effects are still debated, and criteria for the selection of patients for this novel therapy have not been adequately defined. METHODS: We reviewed the available evidence to allow us to make recommendations for the appropriate therapeutic applications of transmyocardial revascularization following the format of the American Heart Association and the American College of Cardiology guidelines for diagnostic and therapeutic procedures. Our recommendations were classified as class I, IIA, IIB, or III. For each recommendation we defined the level of supporting evidence as A, B, or C. RESULTS: We identified class I indications for transmyocardial revascularization as sole therapy and class IIA indications for transmyocardial revascularization as an adjunct to coronary artery bypass graft surgery with levels of evidence A and B, respectively. CONCLUSIONS: Transmyocardial laser revascularization may be an acceptable form of therapy for selected patients: as sole therapy for a subset of patients with refractory angina and as an adjunct to coronary artery bypass graft surgery for a subset of patients with angina who cannot be completely revascularized surgically.     

Effects of Halothane and Methoxyflurane on Pulmonary Resistance to Gas Flow During Lung Bypass

Lung-mechanics during cardio-pulmonary bypass were studied in 20 patients operated upon for heart disease. Pulmonary resistance to gas flow, pressures and compliance were continuously measured with the aid of a respiratory analogue computer. Measurements were made at constant blood gas tensions in the oxygenator with various combinations of inspired carbon dioxide fractions with oxygen, halothane and methoxyflurane. Oxygen with carbon dioxide proved to be a strong broncho-dilatator as well as oxygen + halothane with decreases in resistance of 15–8% of control values, respectively. This was combined with an increase in compliance of 6–5%. In contrast to halothane and carbon dioxide, the mixture of oxygen + methoxyflurane resulted in an increase of resistance with 6%. Methoxyflurane and carbon dioxide resulted in a decrease of the resistance with 16%. It is concluded that halothans and carbon dioxide have a direct action on bronchial smooth muscles, but that such an effect is lacking for methoxyflurane. If diethyl-ether, which was not tested due to explosive risks, has similar pharmacological properties as methoxyflurane then the beneficial effect of diethyl-ether in bronchoconstrictive conditions ought to be elicited through adrenergic stimulation with the liberation of cathecholamines into the pulmonary circulation. Such an action of diethyl-ether is known to support the myocardial function during anaesthesia. The study of anaesthetic agents on smooth muscles of the bronchial system during conditions of lung bypass is of interest, as conclusions can be drawn as to the most suitable anaesthetics to be given to patients with bronchoconstrictive disease. The results indicate that halothane is such an agent in contrast to methoxyflurane.     

Pancreaticoduodenectomy for benign disease.

Ten cases of pancreaticoduodenectomy (PD) performed for benign disease are reported with all patients alive and well at an average of 7.5 years. A review of the English literature reveals that 52 patients have had a PD for benign disease in which a carcinoma had originally been suspected (incidence of 1%) with an overall surgical mortality of 9.6%. Three hundred and thirty-four cases of PD done for complications of pancreatitis have been reported with an overall mortality of 4.8%. On rare occasion, despite extensive preoperative evaluation, a patient will be explored with true uncertainty as to the diagnosis of a periampullary mass. Under these circumstances, it has been considered good surgical judgement to proceed with resection, considering that the lesion may be benign, as opposed to leaving behind an early resectable malignant lesion. Results of this review support this policy only in that if the PD is done for what turns out to be benign disease, the perioperative mortality is low, and an excellent long-term survival can be expected.     

Is there still a place for conservative treatment of distal radius fractures in the adult?]

Contrary to Colles'opinion which pretended the fracture of the distal radius would heal without sequellae, many studies devoted to this problem showed that complications will affect one third of the cases (malunion, nerve compression, dystrophy, tendon rupture). It is important for the surgeon to know well the different fracture types, the general condition of his patient as well as his osteoarticular state to make the good choice of treatment. Our study shows that the nonoperative treatment will be chosen for any fracture type as far as it concerns an old or crippled patient, especially if there is an osteoporosis. On the contrary, for a young and active patient with a good bone quality, non operative treatment will be chosen as far as the fracture will be reducible and stable. If it is not, an osteosynthesis has to be done. Many studies already published tend to demonstrate that there is a correlation between anatomical and functional results. However, concerning elderly, this correlation tend to disappear with time.     

A “closed fracture” with a neighbouring venous ulcer

This is a case report of a 57-year-old lady that sustained a fracture of her distal tibia and fibula. In close proximity to the fracture was a chronic venous ulcer. She was treated as a closed fracture with an intramedullary nail and subsequently developed an infection, requiring further surgery, a prolonged course of antibiotics and 3 months stay in hospital in an attempt to save her leg. Any soft tissue defect close to a fracture should be treated as a source of contamination and infection and should be treated accordingly to avoid significant complications.     

A rare mass formation of the vulva: giant cavernous hemangioma

OBJECTIVE: Vulvar hemangioma is an extremely rare pathology in adult women causing sexual dysfunction, pain, and cosmetic problems requiring therapeutic intervention. MATERIALS AND METHODS: We present a case of an isolated giant vulvar cavernous hemangioma with a 2-year history that macroscopically seemed to be a vulvar varicosis but was actually detected at the end to be cavernous hemangioma in an adult patient with no history of other disease. RESULTS: The patient was treated with surgical excision because of progressive complaints. Histopathologic evaluation suggested cavernous hemangioma. CONCLUSION: Hemangiomas can undergo spontaneous involution; thus, treatment may be reserved for those lesions of functional or psychological concern. In this case, surgical correction was used both as a diagnostic method and as a therapeutic intervention because of progressive complaints such as pain, feeling of pressure, and sexual dysfunction.