Subclinical peripheral neuropathy in stable middle-aged patients with chronic obstructive pulmonary disease

INTRODUCTION: Presently, there are few studies addressing the subject of peripheral neuropathy in patients with chronic obstructive pulmonary disease (COPD). Consequently, there is a dearth of evidence and awareness of subclinical neuropathy in stable COPD patients with no significant hypoxaemia, particularly in the age group of 40-60 years. The present study was designed to evaluate the subclinical peripheral neuropathy in this study group. METHODS: 60 subjects were included in the study. The COPD group comprised 30 male smokers with stable COPD, aged between 40 and 60 years and with no clinical neuropathy; and 30 age-matched healthy male volunteers served as the control group. The following nerves were evaluated for latency, amplitude and conduction velocity: for motor nerve conduction - median nerve, ulnar nerve, and common peroneal nerves; and for sensory nerve conduction - median nerve, ulnar nerve, and sural nerves. RESULTS: Five out of 30 COPD patients had peripheral nerve impairment on electrophysiological evaluation. In these patients, we found decreased amplitude and conduction velocity in all examined sensory nerves; however, the conduction velocity was found to be more than 70 percent of the predicted value. These findings were suggestive of predominantly sensory (with milder involvement of motor nerves) axonal polyneuropathy. CONCLUSION: We observed five out of 30 COPD patients to have predominantly sensory axonal peripheral neuropathy. These five COPD patients had significantly higher consumption of cigarettes, longer duration of illness and advanced airflow obstruction when compared to COPD patients with no peripheral neuropathy.     

A review of directions of gaze during intraocular anesthetic blocks

Safety of orbital blocks depends on operator and patient factors. Among the patient factors, the direction of gaze is important. Certain ocular structures move when the gaze is shifted. These may veer into the path of the needle, setting the stage for injury. The optic nerve with its accompanying artery swerves medially during abduction, direct up gaze, and superolateral and inferolateral gazes. These gazes are therefore risky for medial compartment blocks. In a superomedial gaze, the optic nerve shifts down and out and is likely to be injured during inferolateral needle blocks. Primary gaze is considered to be the safest for akinetic sharp needle blocks. "Tethering tests" involving extremes of gazes are dangerous. The superomedial, superior, superolateral, and inferomedial routes are perilous in all gazes. The superolateral gaze during classic Steven's sub-Tenon's block brings the optic nerve forward, rendering it vulnerable. Complications can be reduced by avoiding deep blind dissection and posterior injections.     

Patient Initiated Implantable Pacemakers for Paroxysmal Supraventricular Tachycardia

Abstract: Patient initiated implantable pace makers for paroxysmal supraventricular tachycardia. J. Vohra, A. Hamer, H. Mond, G. Sloman and D. Hunt, Aust. N.Z. J. Med., 1981, 11, pp. 27–34. Seven patients with recurrent paroxysmal supraventricular tachycardia (PSVT) resistant to standard drug therapy were treated with patient initiated implantable pacemakers. All patients had required frequent hospital admissions and cardio versions prior to pace maker implantation Two patients had Wolff-Parkinson-White (WPW) syndrome on their surface ECGs and five patients had no ECG evidence of pre excitation. All patients had detailed electrophysiological studies. Three patients had junctional tachycardia, one patient had reciprocating atrial tachycardia and in three, including one with normal surface ECG, retrogradely conducting accessory atrio-ventricular connections (AAVC) formed a part of the tachycardia circuit. Initiation and termination of tachycardia were re-checked at subsequent studies On the basis of these studies, two patients with WPW syndrome had right ventricular endocardial leads and custombuilt, magnet actuated pacemakers capable of delivering right ventricular coupled stimuli at fixed, present intervals of 200 and 400 ins. Both these pacemakers provided inconsistent reversions and proved unsatisfactory In the remaining five patients, a unipolar tined J-shaped right atrial (RA) lead (Medtronic ?? 6991) and a radiofrequency (RF) receiver (Medtronic 5998T) were implanted and enabled patients to overdrive PSVT. The follow-up period in these patients ranged from 14 to 20 months. Several episodes of PSVT have been consistently reverted and none have required hospitalisation or cardio-version. Two patients had transient atrial fibrillation following the application of RF pacemaker. Three have required no antiarrhythmic drugs and in two the drug therapy has been greatly reduced and simplified. The Medtronic 6991 lead provided satisfactory RA stimulation without dislodgement. In carefully selected patients with PSVT, RF pacemakers provide a useful Mode of treatment     

Efficacy of non-surgical periodontal therapy in the management of chronic periodontitis among obese and non-obese patients: a systematic review and meta-analysis

Objective

There is a controversy over the influence of obesity on the periodontal treatment outcome in patients with chronic periodontitis (CP). The aim of the present systematic review was to evaluate the efficacy of non-surgical periodontal therapy (NSPT) in the management of CP among obese and non-obese patients.

Materials and methods

The addressed focused question was “What is the efficacy, of NSPT with respect to clinical, radiographic, biochemical, microbiological, and patient-centered outcomes in obese as compared to non-obese chronic periodontitis patients?” Databases were searched from 1977 up to and including December 2014 using relevant key indexing terms. Unpublished data, experimental studies, letters to the editor, review articles, case reports, and commentaries were excluded. Meta-analysis of three studies was performed.

Results

Five clinical studies were included. The total number of patients ranged between 30 and 260 individuals. The mean age of patients was between 42.5 and 48.8 years. In three studies, the clinical periodontal parameters (plaque index (PI), gingival bleeding index (GBI), periodontal pocket depth (PPD), and clinical attachment loss (CAL)) in obese and non-obese patients following NSPT was comparable. Meta-analysis of PPD and CAL among obese and non-obese subjects showed comparable outcomes (PPD P = 0.91, I ² 67.36 %; CAL P = 0.87, I ² 77.16 %). However, in three studies, NSPT resulted in a significantly better clinical periodontal outcome among non-obese subjects than obese subjects. The difference in the levels of serum pro-inflammatory cytokine levels (IL-1β, IL-6, TNF-α, IFN-γ, leptin, adiponectin, and CRP) among obese and non-obese patients following treatment for CP was inconsistent.

Conclusion

It remains unclear whether NSPT has a significantly higher impact on the clinical periodontal outcomes in obese patients than in non-obese patients with chronic periodontitis, given that the number of selected studies was relatively low and the reported findings were inconsistent.

Clinical relevance

Although the effect of obesity on the outcome of NSPT still remains unclear, nevertheless clinicians are prompted to manage obesity prior to and during periodontal treatment

     

Spontaneous Tracheal Rupture: A Case Report

Background

Upper-airway disruption is a rare but potentially life-threatening phenomenon. It can occur spontaneously, be due to trauma, or be iatrogenically induced. Even more rare are such events reported in the pediatric population.

Objective

This article discusses the presentation, diagnostic difficulties, and management of spontaneous tracheal rupture in a child.

Case Report

A 3-year-old boy was brought by emergency medical services to our emergency department with a presumptive diagnosis of anaphylaxis. With progressive swelling and respiratory distress, the patient quickly deteriorated. He received i.v. epinephrine, chest compressions, and bag-valve mask ventilation. He was intubated without difficulty and with no noted airway edema. Concomitant bilateral needle thoracostomies were performed and subsequent bilateral tube thoracostomies were placed. Immediately after intubation and chest tube placements, the patient's oxygen saturations and heart rate improved. Bronchoscopy failed to demonstrate any evident pathology. However, computed tomography scan revealed a defect in the posterior wall of the trachea proximal to the termination of the endotracheal tube. Cardiothoracic surgery was consulted and performed a primary repair of the tracheal defect. The patient was extubated soon after surgery, and he was discharged home neurologically intact.

Conclusions

The initial presentation of spontaneous tracheal rupture can be misleading and difficult to diagnose. After resuscitation, stabilization, and diagnosis, both surgical repair and nonoperative management have been reported as successful treatment measures for tracheal disruption.