Complications of temporomandibular joint arthroscopy: a retrospective analytic study of 670 arthroscopic procedures.

PURPOSE: Temporomandibular joint (TMJ) arthroscopy has been considered a safe surgical procedure in the treatment of TMJ derangement. However, it is not exempt from complications. This study evaluates the complications of arthroscopy in patients with internal derangement of TMJ. PATIENTS AND METHODS: Five hundred consecutive patients (670 joints) with TMJ derangement who underwent arthroscopy between 1995 and 2004 were retrospectively analyzed. All the patients were classified as II to V in the Wilkes classification. Lysis and lavage, electrocautery of the posterior ligament, injection of corticoids, injection of ethanolamine, myotomy of lateral pterygoid muscle attachments, myotomy and electrocautery, motor debridement, injection of sodium hyaluronate, and meniscal suture were performed in different patients. RESULTS: Complications were recognized during or immediately after the surgery. They were observed in 5 of 341 (1.26%) arthroscopies of the right TMJ and 4 of 329 (1.21%) arthroscopies of the left TMJ. A 1.34% complication rate was found in the whole series. No blood clots within the external auditory canal were observed. Bleeding within the superior TMJ space was observed in 57 cases (8.5%), 36 of them in the right TMJ and 21 in the left TMJ, but they were not considered as true complications. Lacerations of the external auditory canal were found in 2 cases (0.3%), with no cases of perforation of the tympanic membrane. Lesion of the auriculotemporal nerve was observed in a case. Paresia of the facial nerve was found in 4 cases (0.6%). Alteration of visual accuracy of the ipsilateral eye was also observed in a patient immediately after the surgery. CONCLUSION: Special care must be taken to reduce complications within the upper joint space by means of an adequate instrumentation and by paying attention to essential points of the arthroscopic technique.     

Overexposure of radiation therapy patients in Panama: problem recognition and follow-up measures.

This report summarizes and analyzes the responses of various organizations that provided assistance to the National Oncology Institute (Instituto Oncológico Nacional, ION) of Panama following the overexposure of 28 radiation therapy patients at the ION in late 2000 and early 2001. The report also looks at the long-term measures that were adopted at the ION in response to the overexposure incident, as well as implications that the incident has for other cancer treatment centers worldwide. In March 2001, the director of the ION was notified of serious overreactions in patients undergoing radiation therapy for cancer treatment. Of the 478 patients treated for pelvic cancers between August 2000 and March 2001, 3 of them had died, possibly from an overdose of radiation. In response, the Government of Panama invited international experts to carry out a full investigation of the situation. Medical physicists from the Pan American Health Organization (PAHO) were among those invited. They ascertained that 56 patients treated with partially blocked teletherapy fields for cancers of the uterine cervix, endometrium, prostate, or rectum, had had their treatment times calculated using a computerized treatment planning system. PAHO's medical physicists calculated the absorbed doses received by the patients and found that, of these 56 patients, only 11 had been treated with acceptable errors of +/-5%. The doses received by 28 of the 56 patients had errors ranging from +10 to +105%. These are the patients identified by ION physicists as overexposed. Twenty-three of the 28 overexposed patients had died by September 2005, with at least 18 of the deaths being from radiation effects, mostly rectal complications. The clinical, psychological, and legal consequences of the overexposures crippled cancer treatments in Panama and prompted PAHO to assess radiation oncology practices in the countries of Latin American and the Caribbean. ION clinicians evaluated the outcome of 125 non-overexposed patients who had been treated in the same time period and for the same cancer sites as the overexposed patients. The clinicians uncovered a larger recurrence of cervical cancers than expected. The finding prompted PAHO to launch an initiative for the accreditation of radiation oncology centers in Latin America and the Caribbean, working in collaboration with professional societies for radiation oncologists, medical physicists, and radiotherapy technologists. The Latin American Association for Radiation Oncology (Asociación Latinoamericana de Terapia Radiante Oncológica) has established an accreditation commission. Accreditation will require that centers implement a comprehensive radiation oncology quality assurance program that follows international guidelines. Statistical data on patient outcomes will be collected in order to document needs in radiotherapy centers in Latin America and the Caribbean and to define future strategies for cancer treatment.     

Determinants of left ventricular systolic function recovery after an acute coronary syndrome.

INTRODUCTION: Ischemic heart disease is a major cause of heart failure in western societies. However, the factors that may influence left ventricular function (LVF) recovery after an acute coronary syndrome (ACS) are still unclear. OBJECTIVE: To identify variables that may influence LVF evolution one year after ACS. METHODS: 104 patients hospitalized with ACS between 7/1/2001 and 12/31/2002 and with systolic dysfunction--defined as an echocardiographic ejection fraction (EF) < or = 45%--were randomly allocated to a planned coronary follow-up program (FUP) or a general cardiology clinic (GC); patients from both groups were also randomly referred to a structured cardiac rehabilitation program (CRP). EF was re-assessed at one year. We compared differences between patients who recovered left ventricular function (EF > 45%; group 1) and those who did not (group 2). RESULTS: One year after discharge, 44.2% of the patients had recovered function. There were no significant differences between the groups in gender (77.7 vs. 76.5% male), age (56 vs. 59 years), hypertension, diabetes, dyslipidemia, smoking habits or family history. A previous history of cardiovascular events was more frequent in group 2 (11.1% vs. 35.3%, p = 0.03). Cardiac catheterization was performed before discharge in 88.8% and 88.2% in groups 1 and 2 respectively (p = NS); no differences were found in coronary anatomy between the two groups. Angioplasty was performed in 54.2% in group 1 and 50% in group 2 (p = NS). There were no differences in the use of angiotensin-converting enzyme inhibitors (83.3% vs. 87.5%), beta-blockers (87.5% vs. 87.5%), nitrates (37.5% vs. 33.3%), aspirin (95.8% vs. 95.8%), statins (79.1% vs. 75%) or diuretics (20.8% vs. 45.8%). There was no significant difference in LVF recovery between patients randomized to FUP or GC (38.5% vs. 54.5%). 87.5% of patients who completed the CRP had normal EF at one year compared to 32.7% of patients not referred to the program (p = 0.009). Although EF improved in both groups, this improvement was greater in patients who completed a CRP (EF 8% vs. 5%, p = 0.003). CONCLUSION: A previous cardiovascular event and completion of a CRP were the only variables that influenced LVF recovery. Thus, enrollment in a CRP, in addition to standard therapy, could be an important therapeutic measure in patients with systolic dysfunction after ACS; our data suggest that these programs should be more widely used.     

Greater efficacy of pulsatile insulin in type I diabetics critically depends on plasma glucagon levels

The aim of this study was to investigate the role of plasma glucagon levels on the blood glucose response to intravenous insulin administered continuously or in a pulsatile manner. Six type I diabetic patients proven to have no residual insulin secretion were investigated. Endogenous glucagon secretion was inhibited by a continuous intravenous infusion of somatostatin (100 micrograms/h) and replaced by exogenous infusions of the hormone at three different rates (7.5, 4.5, and 2.5 micrograms/h), resulting in three different plasma glucagon steady-state levels (i.e., approximately equal to 200, approximately equal to 130, and approximately equal to 75 pg/ml, respectively). Each subject, in random order and on different days, was infused intravenously with regular human insulin either continuously (0.17 mU X kg-1 X min-1) or with the same amount of insulin infused in a pulsatile manner (0.85 mU X kg-1 X min-1 during 2 min followed by 8 min during which no insulin was infused). At plasma glucagon levels approximately equal to 200 pg/ml, blood glucose rose from approximately 10 to approximately 13 mM without any difference between the two modalities of insulin infusion. For plasma glucagon levels approximately equal to 130 pg/ml, plasma glucose remained steady throughout the experiments, but during the last 40 min, plasma glucose levels were significantly lower when insulin was administered intermittently. This greater blood glucose-lowering effect of pulsatile insulin occurred earlier and was more pronounced for plasma glucagon levels averaging 75 pg/ml. We conclude that the greater hypoglycemic effect of insulin administered intravenously in a pulsatile manner in type I diabetics critically depends on plasma glucagon circulating levels.     

The late results after axillo-femoral bypass grafts in patients with leg ischaemia

The late results--up to six years--after axillo-femoral bypass reconstruction are reported for 85 patients with leg ischaemia who were regarded as poor-risk patients for aortic bypass surgery, or who had aortic graft infection. Velour-Dacron grafts and expanded polytetrafluoroethylene (PTFE, Gore-Tex)--grafts have been used. The cumulative patency rate (life table) six years after graft implantation was 64% (PTFE-grafts) and 58% (Velour-Dacron grafts). The corresponding cumulative limb salvage rate six years after graft implantation was 88% when PTFE grafts were used and 77% when Velour-Dacron grafts were used. Our results demonstrate that axillo-femoral reconstruction is a useful procedure with a good patency rate 6 years after implantation. This procedure should be considered when dealing with poor risk patients with severe leg ischaemia.     

First-pass effects of verapamil on the intestinal absorption and liver disposition of fexofenadine in the porcine model.

The aim of this study in pigs was to investigate the local pharmacokinetics of fexofenadine in the intestine and liver by using the pig as a model for drug transport in the entero-hepatobiliary system. A parallel group design included seven pigs (10-12 weeks, 22.2-29.5 kg) in three groups (G1, G2, G3), and a jejunal single-pass perfusion combined with sampling from the bile duct and the portal, hepatic, and superior caval veins was performed. Fexofenadine was perfused through the jejunal segment alone (G1: 120 mg/l, total dose 24 mg) or with two different verapamil doses (G2: 175 mg/l, total dose 35 mg; and G3: 1000 mg/l, total dose 200 mg). The animals were fully anesthetized and monitored throughout the experiment. Fexofenadine had a low liver extraction (E(H); mean +/- S.E.M.), and the given doses of verapamil did not affect the E(H) (0.13 +/- 0.04, 0.16 +/- 0.03, and 0.12 +/- 0.02 for G1, G2, and G3, respectively) or biliary clearance. The E(H) for verapamil and antipyrine agreed well with human in vivo data. Verapamil did not increase the intestinal absorption of fexofenadine, even though the jejunal permeability of fexofenadine, verapamil, and antipyrine showed a tendency to increase in G2. This combined perfusion and hepatobiliary sampling method showed that verapamil did not affect the transport of fexofenadine in the intestine or liver. In this model the E(H) values for both verapamil and antipyrine were similar to the corresponding values in vivo in humans.     

Selective hypersensitivity to boiled razor shell.

Many types of seafood require cooking before ingestion and it has been demonstrated that this cooking process may affect the antigenicity and allergenicity of the food. We describe a case of anaphylaxis caused by selective sensitization to razor shell, a mollusc. In vivo and in vitro studies confirmed sensitization to boiled razor shell. Analysis of the nature of the allergen yielded results that were consistent with the findings of other authors and suggested that allergens involved in seafood allergy are commonly high molecular weight proteins that, in most cases, are heat stable.