Signs of massive intraoperative pulmonary embolism with extensive invasive monitoring

Single-fiber electromyography (SFEMG) is useful in the evaluation of disorders of neuromuscular transmission and the assessment of motor unit morphology. Standard EMG techniques are used routinely in the evaluation of laryngeal dysfunction, but the feasibility of laryngeal SFEMG has not been established. We, therefore, performed laryngeal SFEMG in 10 normal individuals to demonstrate the feasibility of the technique and generate preliminary normative data. We also studied 2 patients with amyotrophic lateral sclerosis and 1 patient previously treated with botulinum toxin for comparative purposes.     

A severe outbreak of bovine mastitis assoicated with Mycoplasma bovigenitalium and Acholeplasma laidlawii

An outbreak of clinical mastitis is described in which 75 cows of a herd of 200 Friesian cows were affected in one or more quarters over a period of three months. Sixty animals failed to return to normal despite various intramammary and systemic antibiotic treatments. Heifers, dry cows and lactating animals were affected. The milk of 15 out of 53 animals tested yielded mixed cultures of Mycoplasma bovigenitalium and Acholeplasma laidlawii. Thirteen of 34 sera showed evidence of antibodies to A laidlawii.     

Multicenter study of noninvasive monitoring systems as alternatives to invasive monitoring of acutely ill emergency patients

Responses in dry matter intake (DMI) and acidbase balance to three sources of anionic salts (dietary cation-anion difference = -63 to -40 meq/kg of dry matter), an acidified fermentation by-product, MgSO4.7H2O + NH4Cl, and MgSO4.7H2O + CaCl2.2H2O + CaSO4, were evaluated relative to the responses of cows fed a control diet (dietary cationanion difference = 203 meq/kg of dry matter) that did not contain anionic salts. Diets were fed for 1-wk periods to eight nonlactating Holsteins assigned to two replicated 4 x 4 Latin squares. Daily DMI increased as time of access to the diet increased up to d 5; mean DMI over d 5 to 7 was reduced by dietary anionic salts. Diets containing anionic salts induced a mild metabolic acidosis that was completely compensated by nonrespiratory mechanisms (decreased blood bicarbonate and base excess; pCO2 and pH values were unaffected). Urinary pH values and bicarbonate excretion were reduced, and urinary NH4+ and titratable acidity excretion were increased, for cows fed diets containing anionic salts. Strong ion difference in urine was decreased by dietary anionic salts because of the relatively greater excretions of Cl- and S2- versus Na+ and K+ by cows fed these diets. Dietary anionic salts decreased mean ruminal pH by 0.12 units, possibly because of the reduced strong ion difference of ruminal fluid. Dietary anionic salts increased mean ruminal NH3 concentration by 2.2 mM, probably because of the higher nonprotein N content of these diets. The strong negative relationship (r2 = 0.95) between urinary pH and net acid excretion by cows fed the diets containing anionic salts suggested that urinary pH measurement might be a useful tool to assess the degree of metabolic acidosis that was imposed by dietary anionic salts.     

Continuous, less invasive, hemodynamic monitoring in intensive care after cardiac surgery

The aim of radioimmunotherapy in treating solid tumors is to target tumor sites while sparing normal tissues. This can best be achieved by using a monoclonal antibody (MAb) with high tumor uptake and rapid clearance. Because MAbs are basic, positively charged proteins, and mammalian cells are negatively charged, the electrostatic interactions between the two can create higher levels of background binding resulting in low tumor to normal organ ratios. To overcome this effect, investigators have attempted to improve MAb clearance by using various methods such as secondary agents as well as chemical and charge modifications of the MAb itself. The use of a second agent to remove the MAb involves using a biotinylated MAb followed by treatments with a molecule like avidin. Charge modification can be accomplished by conjugating a chemical moiety with a positive, negative or neutral charge to residues exposed on the surface of MAbs. Experimental results demonstrate that the lowering of the isoelectric point by this method correlates with a decreased clearance time and improved tumor targeting. Altering the pharmacokinetic characteristics of intact MAbs with charge modification can improve their clearance times to rates similar to those of MAb fragments. Several groups have reported on the effects of chemical modification using molecules such as dextran, PEG, lactose and biotin. Some of these modified MAbs retain the antigen binding specificity of the parent molecule and have improved clearance characteristics from blood and other organs. Hence, these methods can be used to improve both the diagnostic and therapeutic potential of MAbs by improving the signal to noise ratio and the absolute tumor accretion of MAb, respectively.     

Detection of antibodies to Candida albicans germ tubes for diagnosis and therapeutic monitoring of invasive candidiasis in patients with hematologic malignancies

We prospectively investigated the ability of detection of antibodies to Candida albicans germ tubes (CAGT) to diagnose invasive candidiasis in 95 consecutive admissions of 73 patients with hematologic disorders undergoing intensive chemotherapy. The episodes were divided into three groups according to clinical and microbiological diagnosis. Group 1 comprised eight admissions of eight patients with invasive candidiasis. Group 2 comprised 42 admissions of 34 patients without evidence of invasive candidiasis. Group 3 comprised the remaining 45 admissions of 37 patients with febrile episodes which were not diagnosed by microbiological culture. Antibodies to CAGT were detected in 87.5% of group 1 patients. Detection of antibodies to CAGT in patients with Candida fungemia was delayed somewhat relative to the time the blood culture was positive, but antibodies to CAGT were detected earlier than a diagnosis was made in patients with deep-tissue candidiasis. Sera from 2 admissions in group 2 and 12 admissions in group 3 revealed antibodies to CAGT. At a titer of > or = 1:20, detection of antibodies to CAGT had a sensitivity of 87.5%, specificity of 95.2%, positive predictive value of 77.8%, and negative predictive value of 97.6%. Antibodies to CAGT were usually detected before beginning of empiric antifungal therapy. Titers of antibodies to CAGT were maintained in most patients who died but declined and eventually disappeared in the patients who survived. Since antibodies to CAGT were detected in all patients with tissue-proven invasive candidiasis but negative by blood culture, detection of antibodies to CAGT complemented blood cultures for diagnosis and therapeutic monitoring of patients with hematologic malignancies and invasive candidiasis.     

Pulmonary tuberculosis associated with invasive pseudallescheriasis

A 54-year-old woman with pulmonary tuberculosis developed pneumonia caused by Scedosporium apiospermum, the asexual stage of the fungus Pseudallescheria boydii. Mycobacterium tuberculosis and P boydii were cultured in BAL fluid. The patient cleaned swimming pools in a spa health resort and was highly exposed to fungal conidia. She was successfully treated with antituberculosis drugs, miconazole nitrate and ketoconazole, leading to remission of her pulmonary infection. Invasive pulmonary pseudallescheriasis associated with tuberculosis is an unusual finding, especially in an immunocompetent individual.     

Complications with heparin-lock needles. A prospective evaluation

The survival of forty-seven patients with cancer of the rectum treated by electrocoagulation is compared with thirty-seven patients treated by abdominoperineal resection. The one to ten year survival for the electrocoagulationgroup was 48 per cent and the one to eight year survival for the abdominoperineal resection group was 46 per cent. We believe that electrocoagulation when selectively applied has a place in the management of cancer of the rectum.     

Complications associated with harvesting autogenous iliac bone graft

The harvesting of an autogenous iliac bone graft is a frequently performed orthopedic procedure. Although often regarded as the simple or routine part of bone graft requiring surgery, complications are not necessarily uncommon. Documented donor-site complications include nerve, arterial, or urethral injury; chronic donor-site pain; cosmetic deformity; herniation of abdominal contents; sacroiliac joint instability; pelvic fractures; gait disturbances; hematoma; infection; peritoneal perforation; and hip subluxation. Most of these complications are avoidable when the surgeon is aware of their possibility and is familiar with the involved anatomy and preferred surgical approaches.     

Use of invasive cardiovascular monitoring in patients with burns greater than 30 per cent body surface area: a survey of 251 centres

A survey of the use of invasive cardiovascular monitoring in patients with burns greater than 30 per cent body surface area was performed. Questionnaires were sent to a total of 251 burns units in the UK, USA, Canada, Australia and New Zealand. The overall response rate was 68 per cent. Most centres reported that they managed less than 20 of these patients each year. Fifty-five per cent of centres used central venous pressure monitoring in more than half of their patients. In contrast, only 8 per cent of burn units used pulmonary artery catheters in over half of their patients. Few centres described the use of predetermined goals to direct therapy associated with PA catheter insertion.     

Temporal physiologic patterns of shock and circulatory dysfunction based on early descriptions by invasive and noninvasive monitoring

In the past, most investigators failed to consider time relationships in their studies of circulatory problems. Because of this, data obtained in middle- or late-stage shock during organ failure are often presented as being characteristic of specific shock syndromes. Even "early" studies are not physiologically early, but instead have often come to mean early after ICU admission or early after life-threatening hypotensive events. The hypotensive episode represents decompensation of protective circulatory mechanisms, not the beginning of circulatory dysfunction. Early monitoring demonstrates that circulatory changes do not start with hypotension, but with the precipitating event, i.e., hemorrhage, trauma, surgery, or sepsis. When monitoring is started after hypotension, the first half of the problem is missed. It is, therefore, appropriate to focus on the earliest period of circulatory dysfunction with noninvasive methods to evaluate pathophysiology, to predict outcome, and to propose therapeutic protocols to improve outcome. Invasive monitoring is generally accepted as the "gold standard" for critically ill patients. The pulmonary artery flotation catheter has translated information to the bedside previously only available in cardiac catheterization laboratories, forever changing the way we treat ICU patients. Newer high-tech hardware and software innovations in the impedance method give more accurate and reliable cardiac index (CI) measurements that now satisfactorily agree with thermodilution in most clinical conditions. Minor disparities are more than made up for by the continuous online display of data. This impedance device, combined with pulse oximetry and transcutaneous oximetry, provides a feasible, noninvasive hemodynamic monitoring system that can be applied in a manner similar to electrocardiogram electrodes in the emergency department, operating room, ICU, hospital floors, and doctor's offices. More importantly, noninvasive monitoring provides a continuous, online, real-time display of hemodynamic data needed to titrate therapy rapidly and expeditiously. This is a major advantage, since therapy is more effective if given prophylactically or early and then titrated to optimal goals. Noninvasive monitoring provides a powerful method for objective evaluation of early, rapidly changing circulatory dynamics beginning with the precipitating event. This gives a new and different view of circulatory failure, exceeding the boundaries of our old concepts of shock based on blood pressure, subjective symptoms, and imprecise signs. Data of survivors revealed increased cardiac function (CI and oxygen delivery) shortly after surgery, trauma, and sepsis; this response is needed to meet the increased metabolic demands defined by the increased oxygen consumption. Nonsurvivors have limited responses to the added metabolic demands of external stressors. Therapy should augment naturally occurring compensations, but it must be given promptly within appropriate time limits.     

Complications of internal fixation of maxillofacial fractures with microplates

PURPOSE: The aim of this retrospective study was to evaluate the complications of open reduction and internal fixation of maxillofacial fractures with microplates. PATIENTS AND METHODS: In 44 patients with maxillofacial trauma, fractures of the maxillofacial skeleton were treated by open reduction and internal fixation using a 1.0-mm and 1.5-mm microsystem. Simultaneously occurring fractures of the mandible or frontozygomatic suture were treated with a 2.0-mm miniplate system. Perioperative and postoperative complications were traced using patient charts, operation reports, and radiographs. The average follow-up was 46.8 months (range, 31 to 54 months). RESULTS: A total of 124 1.0-mm microplates and 546 1.0-mm microscrews, and 17 1.5-mm microplates and 75 1.5-mm microscrews, was used. The perioperative complication rate was 1.2% for the 1.0-mm screws (use of four emergency screws, breakage of one screw in the dense frontozygomatic suture area, and an insertion of a screw in a premolar root). The postoperative complication rate was 0.8% for the 1.0-mm screws (screw dislocation without clinical implication). No complications were observed with the 1.5-mm system. Plate-related infection did not occur. All fractures healed well. Three patients asked for plate removal because of a vague, persisting pain in the treated area. After removal, only one patient was free of pain. A loose 1.5-mm screw was found in this patient. CONCLUSION: The overall complication rate for microsystems was 2.0%. Both microsystems proved to be a reliable modality to fix fractures of the maxillofacial skeleton. Complications can be considered incidental and of neglectable clinical significance.     

Complications of Keller bunionectomy and Keller with Swanson hemi-implant

The authors compare results of hallux valgus correction by the Keller bunionectomy and by the Swanson hemi-implant. The Keller bunionectomy, which is simple to perform and usually gives a satisfactory cosmetic result, is still commonly used although many authors believe that implant arthroplasty is now the procedure of choice. The primary cause of complications seen after the Keller bunionectomy is lack of stability, whereas the largest cause of failure in implant arthroplasty is probably infection.     

Complications of rhytidectomy

In a recent study of rhytidectomy patients, the most common complications were hematoma, inflammation, crusting, hypertrophic scars, hair loss, and changes in ear lobe appearance. The nurse's role in early detection and prevention cannot be overlooked. This article will review these complications and less common ones, emphasizing the known etiologies, signs and symptoms, and the nurse's role in assessment and intervention.     

Complications of blepharoplasty

Although blepharoplasty is a technically straightforward procedure, many postoperative complications may occur. Some of the untoward effects may be only a transient nuisance for the patient, such as mild ocular dryness, whereas other sequelae can lead to severe visual loss. An extensive review of the prevention, diagnosis, and management of complications associated with blepharoplasty is presented.