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PubMedDate not supplied

[Digestive system neoplasms originating from the autonomic nervous system. Diagnostic, therapeutic and prognostic issues].

The gastrointestinal autonomic nerve tumors (GAN tumor) are uncommon stromal tumors of the intestinal tract and retroperitoneum. The distinction of GAN tumors from other gastrointestinal stromal tumors is based on electron microscopic findings. However further study of additional cases is needed to fully characterize both their gross and microscopic features and to further characterize the natural history of such tumors. In the present study we report two cases of GAN tumor that arose from the stomach and small intestinal with different prognostic evolution in two patients of 73 and 65 years old. They were both treated by surgery, but only one case was successful. In addition patient 1 aged 73, died 11 months after surgical treatment with liver metastases on CT. scan. Patient 2, is clinically well five years after surgical treatment.

Aged↗
PubMed1987

[TeBG and thyrotoxicosis in the hot thyroid nodule].

The binding capacity of serum TeBG (testosterone-estradiol binding globulin), the plasma concentrations of thyroid hormones and the TSH response to TRF (200 micrograms i.v.) have been measured in female patients with a solitary autonomously functioning thyroid nodule (n = 26) or with a cold thyroid nodule (n = 20). It was found that TeBG was higher than the upper limit for normal (1.77 micrograms/dl) in the patients (n = 10) with increased serum concentrations of thyroid hormones and in 5 patients among 16 with normal thyroid hormone levels. After surgical removal of the nodule, the increased TeBG levels fell down within the normal, while the response of TSH to TRF which was suppressed before surgery, was recovered. In patients with a cold nodule, the administration of dl-Thyroxine (200-300 micrograms/daily) suppressed the response of TSH to TRF and increased slightly TeBG from 0.97 +/- 0.08 to 1.29 +/- 0.10 micrograms/dl (p less than 0.05) with a value higher than 1.77 micrograms/dl in 5. These data suggested that the pituitary secretion of TSH and the liver production of TeBG have a different threshold of sensitivity to thyroid hormones action. It is proposed that the measure of TeBG is a tool for the diagnosis of thyrotoxicosis in patients with autonomous thyroid nodules.

Adenoma↗
PubMed1996

Surgery for supraventricular tachycardia.

1995 is the fifth anniversary of the advent of catheter ablation for the treatment of supraventricular tachycardia. Surgery has established the principles of the interventional approaches: 1) identification of the mechanism; 2) localization of the site of the mechanism; 3) identification of the anatomical arrhythmogenic substrate and its localization using preoperative and intraoperative electrophysiological cardiac mapping; 4) ablation of the arrhythmogenic substrate using "surgical" dissection or excision or various forms of energy to neutralize the substrate: cryoablation, laser, etc. Surgical approaches also established the EP interventions as the first line of therapy because they are curative. Currently, surgery for supraventricular tachycardia is essentially confined to atrial fibrillation, and after attempted catheter ablation for the Wolff-Parkinson-White syndrome. Atrial fibrillation is a complex arrhythmia, commonly associated with structural heart disease. To understand atrial fibrillation, a number of premises should be reviewed: atrial functional anatomy, atrial pathology, atrial fibrillation mechanism (s) and clinical presentation. The role of atrial fibrillation in terms of symptoms, morbidity and mortality is not clear because it is difficult to determine if atrial fibrillation is a symptom, a marker, an autonomous disease albeit it is in most cases an aggravating factor. Surgical rationales for atrial fibrillation are based on three concepts: exclusion, fragmentation and channelling. The Corridor operation was the first used direct surgical approach. The Maze operation and other techniques (fragmentation, spiral) have been reported. All surgical techniques have been reported with good results in terms of sinus node function and exercise tolerance, and to various degrees, in terms of atrial contraction. Currently, there is a trend to combine direct atrial fibrillation surgery with surgery for mitral valve albeit beneficial effects are not documented.

Atrial Fibrillation↗
PubMed1988

Pericallosal aneurysms.

The authors report a series of 19 patients with one (17 cases) or two (2 cases) pericallosal aneurysms referred during the past 10 years. Of the 19 patients, 18 had a ruptured pericallosal aneurysm and one was asymptomatic. On admission two were graded I, four graded II, six graded III, and six graded IV. Of the latter group two patients died from rebleeding, and the asymptomatic patient would not undergo surgery. The 16 operated patients underwent surgery after a delay ranging from 6 to 90 days after hemorrhage (25 days on average). The delayed surgery allowed the patients to be operated on in better neurological status: seven were graded I or Ia, six graded II, three graded III, and none graded IV. The results were excellent (with resumption of their previous activity) in 11 cases (69%), good (autonomous but with a slight deficit) in 4 cases (25%), and bad in 1 case (6%). There was no operative mortality or morbidity.

Adult↗
PubMed1995

Management of the hot thyroid nodule.

BACKGROUND: Solitary hyperfunctioning nodules of the thyroid gland are usually viewed as benign. They may present with autonomous euthyroidism but are of concern for potential progression to hyperthyroidism. Various methods of treatment are worthy of consideration. PATIENTS AND METHODS: Forty-five patients with solitary hot thyroid nodules verified by radioisotope scintiscanning were selected for treatment. Thirty-one underwent surgery, usually partial thyroidectomy. Eight euthyroid patients received no treatment, 5 underwent therapy with radioactive iodine (RAI), and 1 received thyroid suppression treatment. The cases were assessed retrospectively. RESULTS: Thyroidectomy patients had no morbidity, were well, and showed 1 Hürthle cell tumor and 5 coincidental small malignancies associated with benign hot nodules, including a contralateral cancer. Untreated patients showed continuance of good health, but nodules persisted and 1 Graves' orbititis occurred. The RAI-treated patients had persistent nodularity, improved function, and 1 case of hyperparathyroidism. Thyroid feeding only caused iatrogenic toxicity and was discontinued. CONCLUSIONS: There are various techniques for managing the hot nodule. Nonsurgical methods may be effective, but can result in persistent nodularity and iatrogenic sequelae. Excision had no morbidity in this series and was effective in providing immediate relief of problems present and potential.

Adenocarcinoma↗
PubMed2004

Evidence-based practice - an incomplete model of the relationship between theory and professional work.

RATIONALE, AIMS AND OBJECTIVES: Current day realities of diminishing resources, reductions in spending and organizational change within health care systems have resulted in an increased emphasis on a multidisciplinary team approach to quality patient care. The movement of nursing towards more autonomous practice combined with the current trend towards 'evidence-based practice' in health care demands increased accountability in clinical decision making. This paper focuses on one aspect of nurses' clinical decision making within the demands of evidence-based practice and cardiac surgery. In this field recent advances, combined with increasing demands on health care institutions, have promoted early extubation of post-operative cardiac patients. While this remains a medical role in many institutions, an increasing number of intensive care units now consider it as a nursing role. METHOD: This paper explores the realities of nurses' clinical decision making through a discussion of current practice in the extubation of patients following cardiac surgery. In addition, it considers the implications of current practice for both nurse education and the continued development of clinical nursing practice. CONCLUSION: The findings indicate that evidence-based practice appears to be an incomplete model of the relationship between theory and professional work.

Decision Making↗
PubMed2006

Combination of minimally invasive thyroid surgery and local anesthesia associated to iopanoic acid for patients with amiodarone-induced thyrotoxicosis and severe cardiac disorders: a pilot study.

BACKGROUND AND AIMS: Amiodarone-induced thyrotoxicosis is a life-threatening condition. A prompt control of thyrotoxicosis is obtained by thyroidectomy. Preparation with iopanoic acid proved to be very effective in reducing cardiovascular complications. Nevertheless, general anesthesia and extensive surgery may affect negatively patients also after adequate preparation. Safety and efficacy of minimally invasive video-assisted thyroidectomy performed under regional anesthesia (bilateral modified deep cervical block) in patients with amiodarone-induced thyrotoxicosis was evaluated. PATIENTS AND METHODS: Eight patients with amiodarone-induced thyrotoxicosis (three with type I and five with type II), mean age 66.2 years, were prepared with iopanoic acid. There were five men and three women. Three patients had dilatative cardiomyopathy, three had heart failure secondary to severe myocardial infarction, and two had refractory unstable rhythm disorders. RESULTS: Minimally invasive video-assisted thyroidectomy was performed under regional anesthesia. Mean operative time was 55.5 min. During surgery, lung and heart function remained well and no surgical complications occurred. After surgery, all patients remained on amiodarone therapy and two patients were subsequently removed from the checklist for heart transplantation. CONCLUSION: Minimally invasive video-assisted thyroidectomy under regional anesthesia can be proposed as resolution of amiodarone-induced thyrotoxicosis in high risk patients with severe cardiac disorders, after preparation with iopanoic acid.

Aged↗
PubMed1997

Neurogenic bowel dysfunction after spinal cord injury: clinical evaluation and rehabilitative management.

Neurogenic bowel dysfunction (NBD) is one of many impairments that result from spinal cord injury (SCI). The experience of persons with SCI reveals that the risk and occurrence of fecal incontinence and difficulty with evacuation are particularly significant life-limiting problems. This review relates the anatomy and physiology of colon function to the specific pathophysiology that detracts from the quality of life of persons after SCI. There are two patterns of NBD after SCI: the upper motor neuron bowel, which results from a spinal cord lesion above the sacral level, and the lower motor neuron bowel, which results from a lesion to the sacral spinal cord, roots, or peripheral nerve innervation of the colon. Rehabilitation evaluation consists of a comprehensive history and examination to define impairments, disabilities, and handicaps pertinent to NBD. Rehabilitation goals include continence of stool, simple willful independent defecation, and prevention of gastrointestinal complications. Intervention consists of derivation and implementation of an individualized person-centered bowel program, which may include diet, oral/rectal medications, equipment, and scheduling of bowel care. Bowel care is a procedure devised to initiate defecation and accomplish fecal evacuation. Digital-rectal stimulation is a technique utilized during bowel care to open the anal sphincter and facilitate reflex peristalsis. Recent advances in rehabilitation practices, equipment, pharmacology, and surgery have offered patients new bowel program alternatives. Interdisciplinary development of solutions for problems of NBD are evolving rapidly.

Aging↗
PubMed2001

Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery.

OBJECTIVE: To synthesize the findings of the randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: The authors performed a systematic search of the literature to identify all articles pertaining to regional anesthesia during cataract surgery on adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting the anesthesia approaches was graded by consensus as good, fair, poor, or insufficient. MAIN OUTCOME MEASURES: Evidence supporting the effectiveness of different forms of regional anesthesia. RESULTS: There was good evidence that retrobulbar and peribulbar blocks provide equivalent akinesia and pain control during cataract surgery. Additionally, sub-Tenon's blocks were at least as effective as retrobulbar and peribulbar blocks. There was good evidence that retrobulbar block provides better pain control during surgery than topical anesthesia, and there was fair evidence that peribulbar block provides better pain control than topical anesthesia. CONCLUSIONS: This synthesis of the literature demonstrates that currently used approaches to anesthesia management provide adequate pain control for successful cataract surgery, but there is some variation in the effectiveness of the most commonly used techniques. Data are needed on patient preferences to determine the optimal strategies for anesthesia management during cataract surgery.

Anesthesia, Local↗
PubMed1995

The effect of a combination of rectal diclofenac and caudal bupivacaine on postoperative analgesia in children.

Both caudal anaesthesia and non-steroidal anti-inflammatory drugs have been used in the management of postoperative pain in children. The aim of the present study was to evaluate the combination of caudal analgesia and rectally administered diclofenac in the treatment of pain following minor surgery in children. Thirty-nine, ASA grade 1 or 2, children undergoing inguinal or penoscrotal surgery were randomly assigned to receive either a caudal block using 0.125% bupivacaine with adrenaline or a similar caudal block in combination with rectally administered diclofenac 1 mg.kg-1. Children given a caudal block alone were more likely to need analgesia in the first 24 h postoperatively. It would appear that the combination of a caudal block and rectal diclofenac in children undergoing minor lower abdominal surgery reduces the need for subsequent analgesia.

Administration, Rectal↗
PubMedDate not supplied

[Urinary alterations in multiple sclerosis].

INTRODUCTION: The neurourological disorders of the lower urinary tract occur during the course of multiple sclerosis. Their expression as irritative, obstructive or mixed symptoms, in accordance with the standardized terminology of the International Continence Society, varies in each patient and also during the course of the illness of each patient. These vesicourinary disorders reduce the quality of life and their complications worsen the prognosis for survival if they are not suitably treated. DEVELOPMENT AND CONCLUSIONS: We review the anatomical and physiological basis integrating and coordinating vesical sphincter function; the dynamics of micturition with its phases of filling and emptying, their coordination with the sphincters through the different centres and circuits of the nervous system; the physiopathology, in relation to the localization of the plaques of demyelination, of incontinence due to detrusor hyperreflexia, hyperreflexia with dyssynergia, hyperreflexia of the detrusor with hypoactivity of the detrusor during the emptying phase and finally due to areflexia. The symptomatology and clinical features vary from 60% to 80% in the different series of cases, depending on the time of evolution and degree to which the patients are affected, with a predominance of irritative rather than obstructive symptoms. The treatment, which requires precise classification of the disorders, is with anticholinergic drugs or alpha 1 blocking and myorelaxant drugs, surgery, neurostimulators, rehabilitation, catheterism, the use of absorbent and collectors, other techniques and therapies which are being developed, without forgetting measures to prevent complications.

Autonomic Dysreflexia↗
PubMed1977

Physiological considerations important for the management of vasospasm.

The physiological mechanisms of known importance in the control of cerebral blood flow (CBF) and smooth muscle contraction and relaxation are reviewed. The pathophysiology of vasospasm following subarachnoid hemorrhage (SAH) is correlated with an alteration of these mechanisms. It is emphasized that smooth muscle relaxation is an energy-dependent process and that vasodilators require a functional smooth muscle membrane that may be severely impaired in ischemia or subarachnoid hemorrhage. The temporal profile of ischemia from spasm is correlated with the pathophysiology of altered metabolism of smooth muscle. The relevance of this complication to the timing of aneurysm surgery in 337 cases operated by one surgeon is considered along with various drug regimens suggested for its management.

Albuterol↗
PubMed2006

Advanced techniques in medical thoracoscopy.

For expert pulmonologists, advanced procedures in medical thoracoscopy are the nonroutine and more complex applications of the method. The main current indications are the treatment of infected pleural space, forceps lung biopsy and sympathectomy. In parapneumonic effusions and empyema, medical thoracoscopy is as a drainage procedure, intermediate between tube thoracostomy and video-assisted thoracoscopic surgery (VATS), which is efficient, significantly lower in cost and avoids surgical thoracoscopy under general anaesthesia. It is essential that it is performed early in the course of the disease and is particularly advisable for frail patients at high surgical risk. The efficacy of forceps lung biopsy has been demonstrated in diffuse lung diseases, whereas results in localised lung diseases and chest-wall lesions have been less positive. However, VATS is currently the preferred approach for these indications. The technique still maintains its efficacy for visceral pleura and peripheral lung biopsy, in particular in the presence of pleural effusion and lung disorders. At the present time, thoracoscopic sympathectomy is minimally invasive and is an accepted intervention for patients with a variety of autonomous nervous system disturbances. Essential hyperhidrosis patients, and well-selected patients with other disorders, can be helped with this procedure, which can also be performed by interventional pulmonologists.

Biopsy↗
PubMed1993

The validity and reproducibility of the skin vasomotor test--studies in normal subjects, after spinal anaesthesia, and in diabetes mellitus.

Skin sympathetic vasomotor control can be examined in the extremities by the skin vasomotor test. In this test the change in skin blood flow and skin temperature in the hand and foot in response to a cold stimulus is utilized as an index of distal sympathetic nerve fibre integrity. This is of importance in conditions such as diabetes mellitus as peripheral autonomic neuropathy is associated with orthostatic hypotension and diabetic foot complications. The validity and reproducibility of the test as a marker of distal sympathetic nerve function has been studied. The test was performed in nine healthy control subjects and in nine subjects (undergoing minor surgery) after a sympathetic nerve conduction block (L2-L3) was achieved in the lower extremities by spinal analgesia. Changes in skin temperature (p < 0.001) and skin blood flow (p < 0.005) in responses to cooling were significantly larger in the control group than in the group with spinal analgesia. Repeated skin temperature measurements on 42 occasions (test-retest period of 4 weeks) in eight healthy and 34 diabetic subjects indicated a reliability coefficient of 80%. We conclude, therefore, that the skin vasomotor test provides a valid and reproducible quantitative assessment of skin sympathetic nerve function in upper and lower extremities.

Adult↗
PubMed1999

Femoral nerve block and ketorolac in patients undergoing anterior cruciate ligament reconstruction.

PURPOSE: The primary objective was to evaluate the analgesic effectiveness of femoral nerve block and ketorolac following ACL reconstruction. The secondary objective was to examine their effects on recovery milestones. METHODS: Prior to standard general anesthesia, 90 patients were randomized into three groups of preoperative treatment: 1) femoral nerve block (15 mL bupivacaine 0.5%) and 1 mL normal saline i.v. (FNB group); 2) placebo femoral nerve block (15 mL normal saline) and 30 mg (1 mL) ketorolac i.v. (KT group); 3) placebo femoral nerve block (15 mL normal saline) and 1 mL normal saline i.v. (PL group). Postoperatively, pain was assessed by visual analogue score, demand and consumption of morphine via patient-controlled analgesia pump. The times for patients to tolerate oral fluid, food, sit up, ambulate and void were also noted. RESULTS: Morphine consumption within one hour, three hours and until POD 1 in the FNB group was lower than the PL group (7 +/- 6, 11 +/- 9, 27 +/- 23 mg vs 13 +/- 5, 20 +/- 9, 49 +/- 28 mg respectively), whereas only that within one hour in the KT group was lower than the PL group. Pain score was lower in FNB and KT groups in the first postoperative hour than in the PL group (P < 0.05). There were no differences among the three groups in the times to meet recovery milestone and discharge criteria. CONCLUSION: Femoral nerve block provides superior analgesia than placebo for ACL reconstruction but was insufficient to facilitate early recovery.

Adolescent↗
PubMedDate not supplied

Urinary incontinence after bilateral parasacral sciatic-nerve block: report of two cases.

OBJECTIVE: The authors describe the occurrence of urinary incontinence after bilateral parasacral sciatic-nerve blocks. CASE REPORT: Two female patients scheduled for bilateral hallux valgus corrective surgery under bilateral parasacral sciatic-nerve block developed urinary incontinence manifested by 3 episodes of enuresis in the first 5 hours after surgery. Physical examination revealed bilateral perineal and gluteal anesthesia and no bladder distention in both patients. Ten hours after block placement, both patients had recovered perineal sensibility and were able to control micturition. CONCLUSION: Given the anatomic relations between the sacral plexus and the autonomic and somatic afferent and efferent innervation of the bladder and urethra, the urinary incontinence observed in our 2 patients could be explained by loss of afferent activity by spread of the local-anesthetic solution to pelvic nerves, loss of the efferent innervation of the posterior urethral sphincter by spread of the local-anesthetic solution to the urethral branches of the hypogastric plexus, and loss of external urethral sphincter tonus by block of the pudendal nerves. Anesthesiologists should consider the possibility of occurrence of urinary incontinence when performing bilateral parasacral sciatic-nerve blocks.

Adult↗