Hypoglycemic coma, jaundice, and pure RBC aplasia following chlorpropamide therapy

Five weeks following the initiation of chlorpropamide therapy for diabetes mellitus, hypoglycemic coma, cholestatic jaundice, and RBC aplasia developed in a 41-year-old woman. Within 40 days of stopping the drug, she had made a complete recovery. To our knowledge, this is the first case in which these three complications of chlorpropamide have occurred simultaneously.     

Electrocardiographic manifestations following electric injury

Bromomethane (BM) is a fumigant used in agriculture; it readily breaks down to bromide ion. WHO assessed the ADI of BM, at 1 mg/kg, using data on the toxicity of bromide. On the other hand, U.S. EPA used the observation of hyperplasia in the forestomach of rats given BM by gavage and arrived at a value of 0.0014 mg/kg. The validity of EPA's assessment is thus subject to question because of the data involved by (1) direct introduction of this volatile and reactive chemical to the GI by gavage and (2) using lesions in the rat forestomach which is absent in humans.     

Dissociative symptoms in children

Acute nonfatal erysipelas was diagnosed in 4 sows in a 1,000-sow commercial farrow-to-finish operation in Indiana. Sows were pyrexic, lethargic, lame, and had multiple, 1.3- to 7.6-cm, erythematous rhomboid skin lesions. Outbreak was attributed to failure to properly vaccinate pigs. Further morbidity and mortality were prevented by treatment of clinically affected sows and all pigs in close proximity with procaine penicillin G daily for 3 consecutive days and vaccination of all pigs with questionable vaccination status, using bacterin of killed Erysipelothrix rhusiopathiae. Periodic review of herd management protocols is important to ensure that recommended vaccination schedules are being followed and animals are receiving quality vaccinations. Human error can contribute to many production problems and should be included on the differential diagnoses list.     

Use of flumazenil in the diagnosis and treatment of patients with coma of unknown etiology

OBJECTIVES: To evaluate the use of single-dose flumazenil in the diagnosis of coma of unknown etiology, and of continuous flumazenil infusion in the treatment of benzodiazepine-induced coma. DESIGN: Prospective study. SETTING: Emergency room and general medicine ward of a teaching hospital. PATIENTS: A total of 42 comatose adults in whom metabolic, neurologic, or traumatic causes of coma were excluded. INTERVENTIONS: a) Intravenous bolus injections of 0.25 mg flumazenil were given at 1-min intervals, either until improvement by two coma grades or a total dose of 2.0 mg was reached. b) Loading doses as in (a) followed by a maintenance infusion administered as long as indicated by repeated coma grade evaluation. MEASUREMENTS AND MAIN RESULTS: a) Of 34 patients, 28 received only the flumazenil loading dose responded promptly. Twenty-one of 25 available urine samples of the responding patients contained only benzodiazepine metabolites. Four urine samples contained benzodiazepines in combination with other drugs. Six patients did not respond to the flumazenil loading dose. The urine of three patients contained a combination of benzodiazepines and another coma-exerting drug; the remaining three were negative. A total of 24 patients, who initially responded to flumazenil loading, deteriorated to their previous coma state and were admitted to the general medical ward. Six (25%) patients developed complications related to hospitalization and their bedridden state. b) Eight other patients, who deteriorated after an initial loading dose, received a second iv bolus of flumazenil, followed by maintenance infusions over 5 to 24 hrs. Their hospital course was uneventful. CONCLUSIONS: These findings indicate that flumazenil is safe and effective in the diagnosis of benzodiazepine-induced coma. Furthermore, the use of continuous flumazenil maintenance infusion is of considerable therapeutic value in patients who exhibit deterioration after initial response to the single loading dose.     

Obsessive compulsive disorder following head injury

An epithelial ovarian tumor with steroid production was examined in a 70-year-old postmenopausal female. The stromal cells of this tumor were rather dense and occasionally characterized by luteinization or hyperthecosis, which has been associated with steroidogenesis. Subcellular visualization using confocal laser scanning microscopy (CLSM) successfully led to the identification of 3 beta-hydroxysteroid dehydrogenase (HSD) in both mitochondria-like small particles and endoplasmic reticulum-like linear profiles, and P450-aromatase also in endoplasmic reticulum-like linear profiles, on the three-dimensional images.     

Lactate clearance and survival following injury

Previous reports cite optimization of O2 delivery (DO2) to 660 mL/min/m2, O2 consumption (VO2) to 170 mL/min/m2, and cardiac index (CI) of 4.5 L/min as predicting survival. We prospectively evaluated 76 consecutive patients with multiple trauma admitted directly to the ICU from the operating room or emergency department. Patients had serum lactate levels and oxygen transport measured on ICU admission and at 8, 16, 24, 36, and 48 hours. Patients were analyzed with respect to survival (S) versus nonsurvival (NS), lactate clearance to normal (< or = 2 mmol/L) by 24 and 48 hours, hemodynamic optimization as defined above, as well as Injury Severity Score (ISS), ICU stay (LOS), and admission blood pressure. All patients achieved non-flow-dependent VO2. There was no difference in CI, DO2, VO2, or ISS when S was compared with NS. All 27 patients whose lactate level normalized in 24 hours survived. If lactate levels cleared to normal between 24 and 48 hours, the survival rate was 75%. Only 3 of the 22 patients who did not clear their lactate level to normal by 48 hours survived. Ten of the 25 nonsurvivors (40%) achieved the above arbitrary optimization criteria. Fifteen of the survivors never achieved any of these criteria. Optimization alone does not predict survival. However, the time needed to normalize serum lactate levels is an important prognostic factor for survival in severely injured patients.     

Adjustment following spinal cord injury.

Investigated specific coping strategies associated with psychological adjustment following spinal cord injury with a battery of assessments administered to 57 patients (median age 26.5 yrs) participating in a spinal cord injury rehabilitation program. Ss were divided into 3 groups based on degree of psychological distress. High-distress Ss reported using more Wish-Fulfilling Fantasy, Emotional Expression, Self-Blame, and Threat Minimization Coping strategies relative to the low and moderate distress groups. The Self-Blame Coping strategy was significantly correlated with psychological distress over and above age, time since injury, or level of injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The peripheral pulse following arterial injury

There has been little attention paid to the persistence of the pulse following complete forearm arterial transection, and we found no report that has established the etiology or frequency of this phenomenon. Eighteen patients with documented complete radial or ulnar artery transections were evaluated. Nine of the 18 patients had persistently palpable pulse distal to the transections. Seven of the pulses were due to retrograde flow and two were due to transmission from the proximal arterial stump or large collaterals. The Allen test was accurate in demonstrating arterial occlusion in each case. Digital compression of the intact artery eliminated the pulse in those cases due to retrograde flow. Documentation of flow direction and collateral vessels was performed with the Doppler directional velocity meter. The fallibility of the peripheral pulse following complete arterial injury is stressed. The Allen test, digital compression of the intact artery, and Doppler studies should be performed on patients with suspected arterial injuries. The exploration of all wounds in the region of major arteries from which profuse bleeding has occurred is recommended.     

Employment outcomes following spinal cord injury

PURPOSE: We determined the clinical utility of proton MR spectroscopy in defining the extent of disability in benign versus secondary-progressive multiple sclerosis (MS). METHODS: Thirty patients with clinically definite MS, including 16 patients with benign MS and 14 with secondary-progressive MS, and a group of 13 healthy volunteers were studied with combined stimulated-echo acquisition mode proton MR spectroscopy and MR imaging (all patients received contrast material). RESULTS: Acute enhancing lesions of benign and secondary-progressive MS were characterized by a reduction in N-acetylaspartate (NAA)/choline and NAA/creatine and an increase in inositol compounds/creatine as compared with normal white matter. Such variations were also detected in chronic unenhancing lesions in patients with secondary-progressive MS, although they were not found in chronic unenhancing lesions in patients with benign MS. Chronic lesions of the two forms of the disease have significative differences in NAA and inositol signals. CONCLUSION: Proton MR spectroscopy is able to show metabolic changes occurring in the white matter of patients with MS. Such changes differ according to the phase (acute versus chronic) and the clinical form (benign versus secondary-progressive) of the disease.     

Dissociative symptoms in panic disorder

BACKGROUND: Partitioning experiments have been used historically and in the recent past to evaluate space perception in visually normal and disturbed individuals. Specifically, amblyopic patients display notably distorted and/or uncertain spatial localization when assessed by either line or space bisection. METHODS: This investigation was concerned with the comparison of line bisection with space bisection. Normal and amblyopic subjects bisected horizontal lines and spaces extending 1, 2, 3 and 15 deg arc monocularly on a computer screen. Results of the two procedures were compared. RESULTS: Visually normal subjects bisected both lines and spaces without reproducible distortion, within uncertainties approximating 1-3% of their length. No differences were observed between the two procedures. Strabismic amblyopes bisected without constant distortion to either side of the geometrical mean, irrespective of direction or extent of the deviation; their uncertainty at bisecting ranged from 2% to 12%. Again, no distinction between line and space bisection could be made. CONCLUSION: We conclude that the two procedures yield comparable results.     

An arteriovenous fistula following laminectomy--sonographic diagnosis

In a 36-year-old woman, 10 years after laminectomy, a tentative diagnosis of arteriovenous shunt between the right iliac artery and vein, a rare complication of this procedure, was made on the basis of ultrasonographic findings. The signs consisted of dilatation of the iliac vein and of the inferior vena cava, a vascular bruit and tactile fremitus in the abdomen. In addition, cardiac enlargement and slight tricuspid and mitral incompetence in the absence of cardiac insufficiency were noted. After angiographic verification of the diagnosis the anomaly was corrected surgically.     

Dissociative tendencies and dissociative disorders.

Although dissociative disorders are relatively rare, dissociative experiences are rather common in everyday life. Dissociative tendencies appear to be modestly related to other dimensions of personality, such as hypnotizability, absorption, fantasy proneness, and some facets of openness to experience. These dispositional variables may constitute diatheses, or risk factors, for dissociative psychopathology, but more complex models relating personality to psychopathology may be more appropriate. The dissociative disorders raise fundamental questions about the nature of self and identity and the role of consciousness and autobiographical memory in the continuity of personality. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ventilatory support following burns and smoke-inhalation injury

The first major improvement in the treatment of burn injury came with the recognition of the importance of fluid resuscitation to prevent shock and renal failure. Subsequently, the use of topical antibiotics to control burn-wound infection and prevent invasive burn-wound sepsis led to the next significant reduction in morbidity and mortality of burn patients. Although progress has been made in the treatment of inhalation injury, the pathophysiology of the injury is still incompletely defined. A better understanding of pathogenic mechanisms will lead to the development of therapeutic agents and treatment regimens that will modulate the cascades of humoral mediators of organ dysfunction and reduce the morbidity and mortality associated with inhalation injury. The recognition of ventilator-induced lung injury has led to adoption of alternative ventilatory techniques such as high-frequency percussive ventilation, which has been shown to substantially reduce the morbidity associated with inhalation injury.     

Inhibitory control following perinatal brain injury.

Evidence from developmental, lesion, and neuroimaging studies indicates that the prefrontal cortex plays a major role in executive abilities, including inhibitory control. Proficient executive performance, however, relies not only on the integrity of the prefrontal cortex but also on its interactions with other brain regions. In the current study, the authors focused on the effect that early damage to the white matter tracts interconnecting prefrontal and other brain regions has on inhibitory control. Data were collected from 13 children with bilateral spastic cerebral palsy and from a control group of 20 children with no history of neurologic compromise. Converging evidence from 3 separate paradigms is presented that strongly suggests these children experience impairments in inhibitory control. Findings are discussed within the context of current cognitive and neuroanatomical models of inhibition. (PsycINFO Database Record (c) 2010 APA, all rights reserved)