Post-operative pyrexia in an orthopaedic unit

The causes of post operative pyrexia in an orthopaedic unit was studied prospectively in 520 patients who underwent surgery. Two hundred patients (38.4%) developed postoperative pyrexia as defined by having recorded high temperatures of over 38 degrees C on two occasions within 24 hours (excluding the first 24 hours post-operatively). The commonest causes of post-operative pyrexia were wound infection in 70 (13.4%), respiratory tract infections in 40 (7.6%) and malaria in 30 (5.7%) patients, while other causes were urinary tract infection in 20 (3.8%), thrombophlebitis in 15 (2.8%) and deep vein thrombosis in 15 (2.8%) of the patients; while ten (1.9%) patients had pyrexia of undetermined cause despite exhaustive clinical and laboratory workup. The other associated conditions in patients who developed pyrexia were diabetes mellitus in 20 (3.8%), HIV seropositivity and malignancy in 30 (5.7%) and six (1.1%) patients, respectively.     

Cutaneous lymphoma with extensive periarticular involvement in a horse

Two months after colic surgery, subcutaneous masses were found on the ventral and lateral portions of the thorax of a 3-year-old Hanoverian-cross filly. Six months later, the filly was admitted for evaluation of severe lameness. Arthrocentesis of the tarsocrural joint yielded clotted sanguineous material; however, unusual multinucleated giant cells were seen. Radiography of the right tarsus revealed soft tissue opacity and degenerative joint disease. The filly was euthanatized to prevent further suffering. At necropsy, multiple soft-tissue masses were located throughout the fascial planes of the tarsi and in the subcutis of the ventral and lateral portions of the thorax. Neoplasms consisted primarily of a large number of mature well-differentiated T lymphocytes. On the basis of these findings, the diagnosis was cutaneous lymphoma with unusual involvement of periarticular tissues. Severe degenerative joint disease in the right tarsus did not appear to be associated with the tumors.     

Acuity perimetry and the sampling theory of visual resolution

In fura-2-labelled human platelets, the thiol oxidising agent diamide decreases the intracellular calcium response to thrombin and serotonin without affecting the basal calcium levels. The effect of diamide on the thrombin response could be prevented by pre-treatment with dithiothreitol (DTT) and reduced when DTT was added 60 s after diamide. The effects of diamide and hydrogen peroxide on the thrombin response were additive. Hydrogen peroxide also produced a calcium response per se, but this response was not affected by diamide. Hydrogen peroxide increased rat brain phosphoinositide hydrolysis and reduced the response to carbachol and noradrenaline, whereas diamide was without effect. The binding of [3H]inositol-1,4,5-trisphosphate to human platelet membranes was inhibited by diamide but not by hydrogen peroxide. Thus diamide affects the phosphoinositide signal transduction pathway in a qualitatively different manner from that found with hydrogen peroxide. It is suggested that oxidative stress may contribute to the disturbances in the phosphoinositide transduction pathway that are found in Alzheimer's disease.     

Brain metastases as the only manifestation of an undetected primary tumor

BACKGROUND: The prognosis of patients with brain metastasis as the only manifestation of an undetected primary tumor generally is considered to be poor. Therefore, most treatment is palliative. The authors reviewed the clinical outcomes and treatment results of patients presenting with brain metastasis from an undetected primary tumor at The University of Texas M. D. Anderson Cancer Center. METHODS: Between 1977-1996, 220 patients were referred to the study department for the treatment of brain metastasis from an undetected primary tumor. The patients' records were reviewed to identify those for whom brain metastasis was the only manifestation of the primary tumor. The majority of patients were excluded from the current analysis because extracranial metastasis also were present. Thirty-nine patients qualified for this retrospective review. The level of neurosurgical excision varied, but all patients received radiotherapy. Tumor control in the brain and survival were analyzed by various tumor-related and treatment-related factors. RESULTS: In 31 patients, the brain metastasis were adenocarcinomas, whereas the remaining patients had tumors of various other histologies. In 12 patients, the primary tumor eventually was found, most commonly in the lung. The median survival time for all patients was 13.4 months. Overall survival rates (OS) at 1, 3, and 5 years were 56%, 19%, and 15%, respectively. Intracranial disease control was 72% at 5 years. Patients who received gross total resection (GTR) and radiotherapy had significantly better OS than patients who received radiotherapy alone. The OS of patients whose primary tumor was identified was similar to that of patients in whom the primary tumor remained occult. CONCLUSIONS: Brain metastasis as the only manifestation of an unknown primary tumor is a distinct clinical entity. The prognosis for patients with this presentation is better than that of patients with brain metastasis in general. Although the majority of patients die of extracranial disease, a few will achieve long term survival. Treatment to the brain is effective in controlling local disease; aggressive treatment with GTR and radiotherapy is recommended.     

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a disease characterized by the growth of wart-like neoplasms anywhere along the aerodigestive tract. The etiologic agent is the human papillomavirus, of which 90 subtypes have been described. The age distribution of those affected appears to be a bimodal curve, with the first peak around 5 years of age and the second occurring in adults in the third decade of life. The mainstay of treatment is surgical resection to maintain an adequate airway; patients often require multiple surgeries. The epidemiology, pathogenesis, clinical features, and treatment options are discussed. Current evidence regarding prognosis and the multifactorial nature of pathogenesis are also reviewed.     

Impact of dynamic 3D transoesophageal echocardiography in the assessment of atrial septal defects and occlusion by the double-umbrella device (CardioSEAL)

Previous research has supported theoretical claims that dichotomous thinking may be a risk factor for suicide. However, the concept of dichotomous thinking is vague, and thus far, no measures of it have been developed. This study developed a coding scheme useful on Thematic Aperception Test (TAT; Murray, 1943) protocols and applicable to other verbal productions to refine the concept of dichotomous thinking and to assess its utility as a predictor of suicidality. Suicidal patients had a significantly elevated rate of a narrowly defined type of dichotomous thinking involving diametric or polarized possibilities. However, suicidal and nonsuicidal patients did not differ on weaker forms of dichotomous thinking involving nonexclusive or nonbinary alternatives. Suicidal patients produced shorter TAT stories than nonsuicidal patients, supporting other findings in the literature that suicidal patients tend to be cognitively and affectively "shut down." Traditionally designated "suicide cards" also yielded shorter stories but did not elicit higher rates of dichotomous thinking.     

Systemic venous collateral development after the bidirectional cavopulmonary anastomosis. Prevalence and predictors

OBJECTIVES: To determine the prevalence of systemic venous collaterals after the bidirectional cavopulmonary anastomosis and the factors associated with their development. BACKGROUND: Systemic venous collaterals have been found after cavopulmonary anastomosis. Methods. Cardiac catheterization was performed in 103 patients before and after a bidirectional cavopulmonary anastomosis. RESULTS: After surgery, 51 venous collaterals were identified in 32 patients (31%). Collateral development was associated with an abnormal superior vena caval connection (56% incidence vs. 26% with a single right superior vena cava, p = 0.01) and postoperative factors including pulmonary artery distortion (53% incidence vs. 22% without distortion, p = 0.002); increased superior vena caval mean pressure (14 +/- 5 mm Hg versus 11 +/- 4 mm Hg with no collaterals, p = 0.0002); increased pulmonary artery mean pressure (13 +/- 4 mm Hg vs. 11 +/- 4 mm Hg with no collaterals, p = 0.02); lower right atrial mean pressure (5 +/- 2 mm Hg vs. 6 +/- 3 mm Hg with no collaterals, p = 0.04); and increased mean gradient between superior vena cava and right atrium (8 +/- 3 mm Hg vs. 5 +/- 4 mm Hg with no collaterals, p = 0.0002). Using multiple logistic regression, only this last factor was independently associated with collateral development with an odds ratio per 1 mm Hg of 1.33 (95% CI 1.12-1.58, p = 0.001) for their presence. CONCLUSIONS: Systemic venous collaterals occur frequently after a bidirectional cavopulmonary anastomosis and are found postoperatively when a significant pressure gradient occurs between cava and right atrium.     

The predictive value of intraoperative somatosensory evoked potential monitoring: review of 244 procedures

INTRODUCTION: There is some controversy regarding the value of intraoperative neurophysiological monitoring in predicting postoperative neurological deficits. We discuss our experience with the use of intraoperative somatosensory evoked potentials (SSEPs) during surgery of cranial base tumors. METHODS: We retrospectively reviewed all of the procedures that had been performed for the resection of cranial base tumors from July 29, 1993, through March 16, 1995. One hundred ninety-three consecutive patients had undergone a total of 244 procedures. SSEP waveforms were classified as follows: Type I, no change; Type II, change that reverts to baseline; Type III, change that does not revert to baseline; and Type IV, complete flattening of the SSEP waveform without improvement. Two patients had no waveforms from the beginning of the case (Type V) and were excluded from further analysis. New immediate postoperative neurological deficits were recorded. RESULTS: There were 64 male and 129 female patients, with a mean age of 46.6 years. One hundred seventy-seven patients had Type I SSEP waveforms, 13 of whom had postoperative deficits (7%). Fifty-six patients had Type II SSEPs, and nine (16%) of them had postoperative neurological deficits. Six patients had Type III SSEPs, and three had Type IV SSEPs, all of whom (100%) had postoperative deficits. There was a correlation between SSEP type and the results of the postoperative neurological examinations. The positive predictive value is 100%, and the negative predictive value is 90%. Although a change in the waveform that did not revert to baseline (Types III and IV) always predicted a postoperative deficit, a normal waveform did not always rule out postoperative deficits. Pathological abnormality, vessel encasement, vessel narrowing, degree of cavernous sinus involvement, brain stem edema, middle fossa location, final amount of resection, age, and tumor size correlated with a high predictive value of SSEP monitoring on univariate analysis (P < 0.05). None of these variables correlated significantly on multivariate analysis (P > 0.05), although brain stem edema was close (P = 0.0571). CONCLUSION: Intraoperative SSEPs have a high positive predictive value during surgery for cranial base tumors, but they do not detect all postoperative deficits.     

Effect of hypertonic saline solution and dextran on ventricular blood flow and heart-lung interaction after hemorrhagic shock

BACKGROUND: Hypertonic saline solutions may have beneficial hemodynamic effects in the resuscitation of hemorrhagic shock. The effects on cardiac function and potential interaction with lung function are controversial and served as the basis for this study. METHODS: Domestic swine were resuscitated from hemorrhagic shock with equivalent sodium loads of lactated Ringer's solution (LR) or 7.5% NaCl plus 10% dextran (HSD). Hemodynamic data were obtained at baseline, shock, and after resuscitation. Right ventricular ejection fraction and left ventricular change in pressure with respect to time (dP/dt) were used to index contractility. Regional myocardial blood flow was determined with microspheres. Lung water was determined gravimetrically. RESULTS: There were no differences in the ability to restore hemodynamic parameters with equivalent sodium loads of LR and HSD resuscitation. Right ventricular ejection fraction and left ventricular change in pressure with respect to time were only transiently affected by shock and resuscitation. Regional myocardial blood flow was increased above baseline values after HSD. The total resuscitation volumes were 1958 +/- 750 mL and 140 +/- 31 mL with LR and HSD, respectively. CONCLUSIONS: Although LR and HSD were equally effective in the early resuscitation of hemorrhagic shock, this occurred at the expense of significantly greater volume requirements for resuscitation with LR. This may contribute to cardiac dysfunction in this setting. Enhanced regional myocardial blood flow after HSD resuscitation may be beneficial against ongoing myocardial stress.