Correction of long term joint contractures of the hand by distraction. A case report

Joint contractures are a common complication of hand trauma. The conventional treatment consists of arthrolysis, tenolysis and occasionally arthrodesis. Frequently, this does not achieve a good result, particularly when there has been a long delay in presentation. Progressive lengthening of a joint by distraction (joint distraction) allows the release of joint contractures even in cases of failure of traditional methods. We present a case of a delayed (20 years) work related traumatic flexion deformity of the PIP joint of the left index and middle fingers. This was the result of a complete division of both flexor tendons of both fingers. The range of movements, both active and passive, was limited to 90/100 degrees in the index finger and 95/100 degrees in the middle finger. Following joint distraction using our lengthening device (Antãotrade mark, Portugal) the patient was able to achieve an active and passive range of movements of 10/100 degrees for the PIP joint of the index finger and 40/100 degrees of the middle. This clinical case shows the simplicity and application of our technique for the correction of joint contractures.

Motor cortex excitability in focal epilepsies not including the primary motor area--a TMS study

It is unclear whether focal epilepsies chronically influence the processing of cortex distant to the epileptogenic zone. Therefore, motor cortex excitability was analysed in patients with temporal and extratemporal epilepsies whose epileptogenic zones did not include the primary motor area. Single and paired-pulse transcranial magnetic stimulation (TMS) was applied to the primary motor cortex in 20 healthy controls and 23 patients with focal epilepsy (39.4 +/- 13.2 years; 12 left, 11 right; 14 temporal, nine extratemporal: six frontal, three parieto-occipital) ipsi- and contralateral to the epileptogenic zone. In all patients, the epileptogenic zone did not include the primary motor cortex. The resting motor threshold (RMT), the cortical silent period (CSP), the intracortical inhibition [ICI; combined interstimulus intervals (ISI) 2 and 3 ms] and the intracortical facilitation (ICF; combined ISI 10 and 15 ms) were determined. The measures obtained ipsilateral to the epileptogenic zone were compared with those elicited in contralateral hemispheres and, in exploratory analyses, with controls using non-parametric tests, including Hodges-Lehmann estimates of median differences (HLE) with 95% confidence intervals (CI). In the patient group, the CSP elicited in the ipsilateral motor cortex (median 162.3 ms) was shortened compared with the contralateral CSP (median 174.6 ms; HLE 15.9 ms; CI 6.2, 27.0 ms; P = 0.002). This interhemispheric difference was more pronounced in extratemporal epilepsies (HLE 23.4 ms; CI -3.2, 67.6 ms) compared with temporal epilepsies (HLE 14.3 ms; CI 4.7, 26.2 ms). Patients with parieto-occipital epilepsies showed the greatest interhemispheric differences in CSP (HLE 33.5 ms) and patients with mesial temporal epilepsies the smallest (HLE 9.9 ms). No significant differences were found between ipsi- and contralateral RMT, ICI or ICF. In analyses of subgroups, the CSP was shorter in epileptic hemispheres of patients with extratemporal epilepsies (141.4 ms) than in controls (173.4 ms; HLE 40.0 ms; CI 3.2, 83.4 ms; P = 0.029). ICF was increased in epileptic hemispheres of extratemporal epilepsies (147.6%) compared with temporal epilepsies (114.6%; HLE 33.0%; CI 4.1, 68.3%; P = 0.038). The results suggest that focal epilepsies influence chronically distant cortex, leading to decreased inhibition and increased facilitation in the ipsilateral motor cortex even when the epileptogenic zone is apart from it. This alteration may be due to synaptic reorganization and appears to be more pronounced in extratemporal and neocortical temporal than in mesial temporal epilepsies. This may have diagnostic implications.

Burn patients in Portugal: analysis of 14,797 cases during 1993-1999

The incidence and cause of burns in Portugal are unknown. The present study seeks to collect these data as a basis for future studies in prevention and development of treatment regimes. The data used in this work was obtained from the registries existing in The Direcção Geral de Saúde (General Health Administration) and relates to burn patients admitted to 91 Portuguese hospitals--that serve all the territory--during the period of 1993-1999. All patients selected had at least one diagnosis of burn (ICD-9: 94.###) among all the diagnoses motivating an admission. A total of 14,797 burn patients were obtained. Among all the patients admitted to hospitals, 8731 (59.0%) were male and 6066 (41.0%) were female, with a male/female ratio of 1.44:1. The mean length of in-hospital stay was 15.5+/-21.0 days. Throughout this period, 553 (3.7%) patients died in Portuguese hospitals as a result of burn injury. There were no significant differences in the number of deaths in each year, P=0.45, in contrast to the decrease of burn mortality rates reported in other studies. It is likely that the reason for this situation is the lack of investment in the last years in this area and the delay in opening new Burn Centres.

Early extubation does not increase complication rates after coronary artery bypass graft surgery with cardiopulmonary bypass

BACKGROUND

With the evolution of anesthesia and surgical procedures, fast track extubation has gained an increased interest, mainly based on the possibility of reducing health costs seemingly without compromising patient care.

AIM

To compare two groups of patients submitted to a non-fast track extubation and a fast track extubation protocol after coronary artery bypass graft surgery with cardiopulmonary bypass, regarding their times of ventilation and intubation and their complication rates in the postoperative period.

METHODS

During the year of 1998, 323 sequential patients scheduled for isolated coronary artery bypass graft surgery with cardiopulmonary bypass were enrolled in the study. Fifty-nine patients were excluded due to preoperative use of emergent mechanical and/or inotropic hemodynamic support, low body mass index (< or =18-20 kg/m(2)), reoperations for acute surgical complications, off-pump coronary artery bypass graft surgery, severe respiratory disease, recent myocardial infarction (< or =7 days) and absence of relevant data. Previous myocardial infarction (> or =7 days), prophylactic intraaortic balloon pump and use of postoperative vasoactive drugs were not exclusion criteria. We compared 76 patients sequentially submitted to anesthesia by one of the authors with a fast track extubation protocol and 188 patients sequentially submitted to anesthesia by others in the same period and using a conventional anesthetic protocol.

RESULTS

Demographic data, previous medical and cardiac history, preoperative medication and operative data were all similar between the two groups. The mean ventilation and intubation times were significantly shorter in the fast track extubation group than in the non-fast track extubation patients (30 min vs. 7 h and 50 min vs. 8 h, respectively). Forty-two percent of patients in the fast track extubation group were extubated on arrival at the intensive care unit. Morbidity and mortality were similar in both groups.

CONCLUSIONS

The study shows that a very fast track extubation protocol may be safely implemented in patients submitted to coronary artery bypass graft surgery with cardiopulmonary bypass.

An outbreak of legionnaires' disease in a municipality in northern Portugal

Eleven cases of legionnaires' disease, all patients living in the same municipality, were admitted to a district hospital in northern Portugal. Preliminary investigations suggested an association with the events of the annual festivities in that municipality. Legionella pneumophila was not isolated from any of the suspected sources, but evidence from a case control study suggested that an aerosol produced by a decorative fountain in the main square during the night of a rock concert was the likely vehicle of infection. The prevalence of smoking was higher among cases than controls.

An outbreak of legionnaires’ disease in a municipality in northern Portugal

Eleven cases of legionnaires´ disease, all patients living in the same municipality, were admitted to a district hospital in northern Portugal. Preliminary investigations suggested an association with the events of the annual festivities in that municipality. Legionella pneumophila was not isolated from any of the suspected sources, but evidence from a case control study suggested that an aerosol produced by a decorative fountain in the main square during the night of a rock concert was the likely vehicle of infection. The prevalence of smoking was higher among cases than controls.

Consumers' self-care algorithms for the common cold: implications for health education interventions

Two hundred ninety-seven young adults enumerated a self-care plan with at least seven behaviors for the management of a cold with a fever. They summarized satisfaction with their self-care activities and the role of self-care after a lecture on self-care in managing the common cold. Half of the participants relied solely on self-care, and the other half said they would seek medical attention. Having a fever directed two thirds of the sample in their decision making concerning treatment. Five percent would change their self-care behaviors as a consequence of the instruction. Methodological and theoretical implications for self-care interventions are discussed.

An outbreak of legionnaires disease in a municipality in northern Portugal

Eleven cases of legionnaires disease, all patients living in the same municipality, were admitted to a district hospital in northern Portugal. Preliminary investigations suggested an association with the events of the annual festivities in that municipality. Legionella pneumophila was not isolated from any of the suspected sources, but evidence from a case control study suggested that an aerosol produced by a decorative fountain in the main square during the night of a rock concert was the likely vehicle of infection. The prevalence of smoking was higher among cases than controls.

[Progressive myositis ossificans. Stone man]

Myositis ossificans progressiva (MOP) is a rare hereditary connective tissue disease, genetically inherited as an autossomal dominant trait with complete penetrance but variable expression. The onset usually takes place during childhood and progressive involvement of the spinal cord and proximal extremities leads to immobilization and articular dysfunction. We present a case of a 29-year-old woman with the typical features of MOP and review the pathogenesis, clinical manifestations and treatment options of this rare disease.

A case of multiple sclerosis triggered by organic solvents

The neurotoxicity of organic solvents has long been recognized. Some are used as anesthetic agents, others in various industries. Their acute effect has been well documented since the nineteenth century, but more recently they have become notorious as the cause of addiction to glue sniffing. They may alter the immune system by causing lymphopenia, impairing phagocytosis and decreasing the level of serum complement, as well as altering the impermeability of the blood-brain barrier and leading to the appearance of white matter lesions in the brain. The following case study explores the possible role of organic solvents in the pathogenesis of multiple sclerosis.

The distally based island superficial sural artery flap: clinical experience with 36 flaps

The principles of neurocutaneous flaps, first described by Masquelet in 1992, represented a new concept in skin vascularization. The distally based superficial sural artery flap is an example of this kind of flap, which is supplied by the vascular axis that accompanies the sural nerve. The authors treated 36 patients with 36 distally based superficial sural artery flaps. All flaps survived, but six of them exhibited partial necrosis. No patient experienced anesthesia of the lateral side of the foot or neuroma at the donor site 12 months after surgery. The authors confirmed that this flap is very useful for soft-tissue reconstruction of the distal third of the leg and foot. Additionally they conclude that the principal advantages are that the blood supply is reliable, execution is easy and fast, the operation can be performed under regional anesthesia, the flap has a large arc of rotation, direct closure of the donor area is possible for small flaps, major arteries or nerves are not sacrificed, and excellent durability is achieved, even on weight-bearing areas. The major drawback is the donor site scar.

[Dural fistulas of the anterior cranial fossa]

Dural arterio-venous shunts (DAVS) of the anterior cranial fossa are quite rare. There are only a few cases reported in the literature. The authors present 5 cases of dural arterio-venous shunts (DAVS) of the anterior cranial fossa, allowing more data for later reviews of this rare and aggressive localisation of DAVS. The clinical set, imaging findings (with emphasis in diagnostic angiography), treatment and outcome in these 5 patients are described. Haemorrhage was the presenting form in 4 patients; the other case presented was investigated for headache. There were bilateral symmetric feeders in two patients, unilateral feeders in another two and unilateral predominant feeders in one; contribution of the external carotid artery, when present, was always minimal. Venous drainage included one or combinations of these: superior sagittal sinus, sylvian veins and cavernous sinus. Three patients had venous aneurysms in anterior cranial fossa; of these, two presented with haemorrhage, but the third one of them has been asymptomatic for 7 years. Three patients were treated by surgical exclusion of the shunt and became clinical and angiographicaly normal. According to the literature, our cases confirm the highly aggressive behaviour of these DAVS. Surgical treatment is an efficacious method of therapy and should be done as soon as possible. Embolization can be attempted but is technically difficult and eventually too expensive.

Fibrodysplasia ossificans progressiva: report of two cases

Fibrodysplasia Ossificans Progressiva (FOP) is a rare hereditary connective tissue disease, genetically inherited as an autosomal dominant trait with complete penetrance but variable expressivity. Onset is typically in childhood and progressive involvement of the spine and proximal extremities leads to immobility and articular dysfunction. We present two cases with the typical features of FOP and a review of the pathogenesis, clinical manifestations and treatment options of this rare disease.

Predictors of college students' alcohol consumption: implications for student education

Understanding why young adults consume alcohol the way they do can lead to more effective educational programming for promotion of students' personal health and safety. The authors examined the predictive role of expectations about alcohol, perceived peer norms of consumption, awareness of rules, and individual self-efficacy in conjunction with demographic variables for male and female college students' weekly alcohol consumption. The sample of 4,960 students analyzed here is 10 to 20 times larger and more nationally representative than the samples used in similar studies. The authors used a general linear model; 41% of the men's variance and 33% of the women's variance in self-reported weekly alcohol consumption were explained by the set of predictors. In descending order of variance accounted for in male and female students' self-reported weekly alcohol consumption, perceived gender-specific norms of consumption, expectations about the effects of alcohol, and the importance of drinking in high school were significant predictors for both men and women. The salience of psychological variables for young adults' consumption of alcohol underscores the importance of recognizing individual predictors of behavior in the broader ecological context in which those behaviors are performed.

Traumatic rupture of angiomyolipoma: a case report

OBJECTIVE

To describe a case of traumatic rupture of renal angiomyolipoma (AML).

METHODS

The images and clinical data of the present case are presented.

RESULTS

A rare case with exuberant clinical presentation of a perirenal hematoma resulting from traumatic rupture of renal AML is presented with a brief review of the role of ultrasound (US) and body-CT in the diagnosis of this pathology and its complications.

CONCLUSIONS

Whenever there is a collection detected by US in the various anatomic renal spaces, in a patient with flank pain and low hemoglobin shortly after abdominal trauma, it is advisable to perform abdominal CT and search for a hematoma. Small amounts of fat, detected by US and body-CT, may lead to the diagnosis of an underlying AML that can rupture, even in the case minor forces are applied to the kidney.