Hypertensive encephalopathy in childhood. Diagnostic problems

Oppenheimer and Fischberg's vasoconstriction-hypothesis on the pathogenesis of hypertensive encephalopathy was subsequently supported by animal experiments. Later on the role of decompensation of the autoregulatory mechanism of the cerebral blood flow was revealed. The transient symptomatology comprises headache, seizures, focal cerebral symptoms (hemiplegia etc.), visual disturbances, mental disorders, papiledema etc. The age-dependency of the influence of edema is probably expressed by the predominance of seizures in childhood and the long duration of the symptoms in our third and fourth patient. The differentiation between hypertensive encephalopathy and a local complication of hypertension (hemorrhage) can be difficult, not at least because the first disturbance may be followed by the second (patient 3). Hypertension is not always present as initial symptom (patient 1 and 2). Hence a series of blood pressure readings is required in acute cerebral incidents in childhood. Steroid-treatment may lead, especially in patients suffering from a hypocomplementemic form of membranoproliferative glomerulonephritis, to a sudden rise of the blood pressure and subsequently to hypertensive encephalopathy (patients 2 and 3). Hypertensive encephalopathy is a neuropediatric emergency. The urgent treatment with dioxaside, fursemide and sodium nitroprusside is shortly reviewed.     

Postpneumonectomy syndrome: recognition and management

STUDY OBJECTIVE: Postpneumonectomy syndrome (PPS) results from extreme shift and rotation of the mediastinum after pneumonectomy producing symptomatic proximal airway obstruction and air trapping. Herein, we review our experience in the treatment of PPS. PATIENTS: Five patients with PPS were treated at our institution between 1991 and 1997. Four patients had previous right pneumonectomy; one patient had left pneumonectomy. Dyspnea was the presenting symptom in all five patients. The time interval to onset of symptoms and to surgical correction ranged from 6 months to 9 years (median: 6 months) and 9 months to 29 years (median, 21 months) after pneumonectomy, respectively. INTERVENTION: The clinical diagnosis of PPS was confirmed with chest radiograph, two-dimensional echocardiography, pulmonary function tests, CT scan, and awake fiberoptic bronchoscopy. Correction of PPS required reexploration of the pneumonectomy space followed by anterior pericardiorrhaphy and insertion of a saline solution-filled Silastic prosthesis (Dow Corning; Midland, MI) for the purpose of correcting the overshift of the mediastinum. There was no morbidity or mortality. RESULTS: All patients had relief of dyspnea. Corrective repositioning of the mediastinum was confirmed by chest radiograph, CT scan, and awake fiberoptic bronchoscopy. There was a mean increase in the cross-sectional diameter, as measured by CT scan, of the obstructed bronchus by 166.7% (range, 100 to 300%) in four patients. One patient had no change in the measured diameter. Postoperatively, the peak expiratory flow rate increased by a mean of 44.2% (range, 40 to 49%) in all five patients. CONCLUSION: The presence of PPS should be considered in all patients presenting with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum with a saline solution-filled prosthesis and anterior pericardiorrhaphy is easily performed and provides immediate and lasting symptomatic relief.     

Acute fluoride ingestion: recognition and management

Occasionally, the Oral Health Division of the Indiana State Department of Health receives inquiries regarding diagnosis and treatment of acute fluoride ingestion. Because a wide variety of fluoride preparations are available in the dental setting and over the counter, excessive ingestion of fluoride can occur if these products are not used properly. The following article is meant to be a quick and easy guide in the recognition and management of instances of acute fluoride ingestion.     

Onychomycosis: recognition, diagnosis, and management

A series of hydroxynaphthazarins has been synthesized. Some of them were found in in vivo experiments to be protectors of myocardium under ischemia-reperfusion and to reduce the infarction zone by 50% without any adverse effect. All compounds exhibit a moderate or small toxicity and are active in low doses.     

Cranial burst fracture in infants: acute recognition and management

In the past, the diagnosis of "growing skull fracture" or "diastatic fracture" has included a subset of injuries better referred to as "cranial burst fracture." Cranial burst fracture, typically associated with severe injury in infants less than 1 year of age, is a closed, widely diastatic skull fracture accompanied by acute cerebral extrusion outside the calvarium. We treated 11 such infants at the LeBonheur Children's Medical Center and 2 at the Children's National Medical Center from January 1986 through December 1994. Infants ranged in age from 1 to 17 months, with an average age of 5.7 months. All presented with marked scalp swelling and a Glasgow Coma Scale score of 10 or less. Twelve had a history consistent with severe injury (motor vehicle accident, 7, abuse 5). The cause of injury in one patient remains unproven. Surgery (reduction of herniated cerebral tissue, repair of large dural laceration, and cranioplasty) was usually performed within 10 days of injury, a time period long enough to assure hemodynamic stability and resolution of acute cerebral swelling, yet sufficiently brief to avoid the chronic changes (scarring, parasitization of scalp vessels by damaged cortex) associated with a "growing skull fracture." Prompt repair of cranial burst fracture may prevent ongoing brain injury such as has been neuropathologically demonstrated in patients with "growing skull fracture." Magnetic resonance imaging establishes the diagnosis of cranial burst fracture in equivocal cases, rendering unnecessary a "waiting period" to see if scalp swelling resolves. Our experience, together with information in the neuropathological and neurosurgical literature, suggests that cranial burst fracture is associated with severe trauma, requires expeditious treatment, and has been underdiagnosed in the past, leading to "growing skull fracture," a condition requiring more extensive surgery.     

Complications of laparoscopic pelvic surgery: recognition, management and prevention

Laparoscopic surgery has many advantages but it is not without complications. The complexity of the surgery significantly influences the complication rate. Laparoscopic surgeons ought to be aware of the possible complications and how they could be prevented, recognized without delay, and managed safely and efficiently. Important complications include injuries to the vessels, bowel and urinary tract. Incisional hernia ought to be reduced by careful closure of the fascia whenever a trocar > or =10 mm is used at the extraumbilical site. Gas embolism is a rare but potentially life threatening complication. Shoulder pain is a minor complication but is exceedingly common; it is less likely to occur if as much gas as possible is removed at the end of the operation while the patient is still in head down Trendelenburg position. Rare complications include pneumothorax, subcutaneous and pre-peritoneal emphysema, cardiac arrhythmia, nerve injury and venous thrombosis. Laparoscopic surgeons should also understand the principles of electrosurgery and how to avoid complications arising from the use of electrical energy including capacitative coupling, direct coupling and insulation failure.     

Female stress urinary incontinence due to intrinsic sphincteric deficiency: recognition and management

In a group of 10 subjects, nine schizophrenic patients and one healthy twin (seven men and three women, i.e. two monozygotic twin pairs: two patients and a healthy man and his sick twin brother, one dizygotic pair of two female patients, three male patients and one female patient without their appropriate twin siblings) Halstead-Reitan Neuropsychological Battery (HRNB) was used and partial neuropsychological tests (Wechsler Memory Scale, the Stroop Color-Word Test, Tonal Memory). The parameters of white matter density were evaluated by computed tomography. The fundamental findings include: In our small group numerous statistically significant correlations were found between neuropsychological tests and white matter density. 2. Higher density is associated with poorer neuropsychological efficiency. There are very similar correlations between neuropsychological variables and density parameters in different areas of the brain. 4. The majority of correlations of neuropsychological parameters is from the area of tactile and motor functions. 5. It is striking that there are statistically significant correlations of density with the simultaneous performance of both hands and the performance of the non-dominant hand but not with the performance of the dominant hand alone. 6. Some correlations pertain in addition to density also to the very controversial problem of the brain size of schizophrenic patients. In the investigated group an association between better neuropsychological performance and larger size of the brain was found. All findings will have to be tested in larger groups of patients and healthy subjects.     

Acute myocardial infarction: early recognition and management from the home healthcare nurses perspective

Acute myocardial infarction is the number one killer of men and women in the United States. Early recognition and treatment has been shown to decrease mortality and infarct size, and to improve left ventricular function. The home healthcare nurse is in a key position to perform a swift, pertinent assessment that can detect an acute myocardial infarction, provide the patient with the valuable information to decrease the time delay until thrombolytic therapy is initiated, participate in the rehabilitation post-myocardial infarction, and provide education and counseling for coronary heart disease risk reduction.     

Early infantile epileptic encephalopathy and glycine encephalopathy

INTRODUCTION: Early infantile epileptic encephalopathy (EIEE) with suppression burst activity in EEG (Ohtahara syndrome) is a rare type of epileptic encephalopathy in infancy and represents the earliest type of age-related symptomatic generalized epilepsy. The main etiologic factors associated to EIEE are cerebral dysgenesia and metabolopathies, principally nonketotic hyperglycinemia. CLINICAL CASE: We report a neonate with EIEE secondary to glycine encephalopathy, diagnosed by increased of LCR/plasma glycine index.     

Selective serotonin reuptake inhibitor discontinuation syndrome: Understanding, recognition, and management for psychologists.

Psychologists increasingly provide psychotherapeutic services to patients receiving concomitant pharmacotherapy. Ongoing experience with the relatively new selective serotonin reuptake inhibitors and other atypical antidepressants has revealed a discontinuation syndrome that emerges following abrupt or tapered withdrawal from these agents. The syndrome has both somatic and psychological characteristics, which tend to be mild and transient but can also be more distressing and become temporarily debilitating. Psychologists need to be aware of the potential for these events, as they are in an optimal position to collaborate with physicians and other prescribing clinicians to prevent or manage this syndrome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute necrotizing encephalopathy of childhood: a novel form of acute encephalopathy prevalent in Japan and Taiwan

Molecular genotyping for the major histocompatibility complex (MHC) class II loci, HLA-DRB1, -DQB1 and -DQA1, in 100 patients with relapsing/remitting multiple sclerosis (MS) demonstrated an association with the HLA-DR2, DQw6-associated alleles DRB1*1501, DQB1*0602 and DQA1*0102, thereby extending this finding among MS patients in several countries to an Australian population. Analysis by the relative predispositional effect (RPE) method provided no evidence for a second susceptibility allele at either DQA1 or DQB1. However, our data and that of others suggest a negative association with DQA1*0101. Associations were found with DQB1 alleles sharing sequence homology with DQB1*0602, with DQB1 alleles encoding leucine at residue 26 (Leu 26), with DQA1 alleles encoding glutamine at residue 34 (Gln 34) and with Leu 26 plus Gln 34 alleles, but each was shown by two-loci linkage analysis to be secondary to the DRB1*1501, DQB1*0602, DQA1*0102 association. The recently reported negative association with DQA1 alleles encoding phenylalanine at amino acid 25, leucine at amino acid 69 and arginine at amino acid 52 was not found in this study, although there was a trend towards reduced phenylalanine at amino acid 25. The determination at a molecular level of an explanation for the world-wide association with these alleles remains elusive despite major advances in MHC typing.     

Hypertensive crisis and nursing counseling

A hypertensive crisis is a serious complication that can happen to all patients with a history of hypertension. Unfortunately, it is a process that has not been much studied in the area of primary care. This study, using a sample of 700 hypertensive patients over a six year period, has the objective of trying to establish the incidence of crisis annually, the period of the most frequent attacks, and the effects the nursing consultations had upon these parameters. Nursing interventions included preventative methods such as trying to reduce the time between episodes by reinforcing good health habits through educational methods.     

Wernicke's encephalopathy and dialysis: report of two cases

Wernicke encephalopathy is considered a complication of dialytic therapy, but there are few reports of this complication. We report a 57 years old man and a 45 years old woman, with grade IV renal failure, who after acute peritoneodialysis and chronic hemodialysis respectively, had a confusional syndrome that responded to the administration of thiamine. CT scans in both patients discarded abnormal blood collections or new cerebrovascular episodes. The man bad two previous cerebrovascular episodes, a severe anemia that was corrected, angina and an episode of arrhythmia during the dialytic procedure previous to the confusional episode. The woman had an acute uremic syndrome and a concomitant urinary tract infection during the confusional episode. Wernicke encephalopathy must be suspected in patients in dialysis with confusional episodes.