BASILAR ARTERY DISEASE—Clinical Manifestations

Patients with basilar artery disease show their first symptoms by characteristic ischemic attacks. If the attending physician correctly diagnoses the condition and initiates anticoagulant therapy before a catastrophic episode occurs, there is reason to believe that the disease may be arrested temporarily.     

LYMPHOBLASTOMAS IN CHILDHOOD—Cutaneous Manifestations

The lymphoblastomas occurring in childhood are divided for purposes of discussion into lymphocytoma cutis, mycosis fungoides, lymphosarcoma, Hodgkin''s disease, and leukemia. The cutaneous lesions may be either specific (as a result of the infiltration of the skin with specific cells of the conditions) or toxic (non-specific). With the possible exception of mycosis fungoides, the cutaneous manifestations are not diagnostic. The final diagnosis depends upon microscopic examination of the specific tissue involved and the coordination of the clinical and microscopic findings.     

CEREBRAL ATROPHY — Clinical Manifestations in Adults

A study was made of the cases of 200 patients with demonstrated cerebral atrophy. In patients under 70 years of age cerebral atrophy was twice as common in men as women. Over 70 years the ratio was reversed. The incidence of cerebral atrophy was relatively high in the age group 35 to 50.Convulsions were present in more than a third of the 200 patients. Neurological abnormalities were present in 51 per cent of the entire series. Significant personality deviations were observed in 31 per cent. Although the electroencephalogram was abnormal in many patients, it appeared to be of little aid in the diagnosis of the cerebral atrophy. The spinal fluid did not seem to be consistently altered in any significant or diagnostic manner.Most of the patients in the 35 to 50 year age group did not have the symptoms characteristic of Alzheimer''s disease, and in only a few cases did the symptoms resemble those of other recognized disease entities.     

Abdominal Aortic Aneurysms—Unusual Clinical Manifestations

Misleading symptoms were responsible for failure to make the diagnosis of symptomatic abdominal aortic aneurysm in 15 patients. The presenting complaints appeared to be specific for other diseases, such as genitourinary disease, diverticulitis, intra-abdominal neoplasm and functional large intestinal disorders. A correct diagnosis was ultimately made in 12 patients and aneurysmectomy was performed. In three patients, who died of ruptured aneurysm, the diagnosis was not made until postmortem examination.An awareness of the atypical symptoms of aneurysms, careful physical examination and appropriate x-ray studies will lead to the diagnosis of symptomatic aortic aneurysms. Early resection will result in a lower mortality rate.     

Rubella Syndrome—Cardiovascular Manifestations and Surgical Therapy in Infants

Of nine patients under five months of age with cardiovascular manifestations of the rubella syndrome, six had patent ductus arteriosus. Three of these six also had pulmonary artery stenosis. One infant had bilateral isolated pulmonary artery stenosis. The significant clinical findings leading to the diagnosis of pulmonary artery stenosis were axillary murmurs in the presence of right ventricular hypertrophy. Demonstration of a gradient across the stenosis at the time of catheterization, together with cineangiography, established the diagnosis. In two cases ventricular septal defect was the only cardiac anomaly.Six babies under five months of age had interruption of a patent ductus arteriosus because of uncontrollable congestive heart failure or failure to thrive. Although growth failure was not necessarily due to heart disease, all were developing satisfactorily following operation.Diagnosis and therapy of the cardiac complications of the rubella syndrome is possible in the first few months of life. Early recognition of cardiac defects in the young infant with the rubella syndrome permits aggressive medical management and in selected instances surgical therapy.     

RHEUMATOID ARTHRITIS—Diagnosis in Peripheral Joint Affliction

The diagnosis of rheumatoid arthritis in a typical case depends upon a history of pain and swelling of various joints throughout the body. In the first stages the disease usually involves only the small joints of the hands and feet, but sooner or later it spreads to the larger joints. This may be accompanied by fibrosis of one or more joints, causing disability ranging from disuse of one joint up to total incapacity. Diagnosis in early or atypical cases is often impossible until the patient has been under observation a long time. It is important that diagnosis be made as early as possible, in order that appropriate therapy may be started and ankylosis and disability of the joints prevented.Since laboratory procedures and roentgen films do not show early changes, emphasis is placed on the history and physical examination for diagnosis.     

Fragmentation of Care Threatens Patient Safety in Peripheral Vascular Catheter Management in Acute Care– A Qualitative Study

Background

The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.

Methods

Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.

Results

Four key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.

Conclusion

Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.     

Vascular Anastomosis—Sutures,Staples or Glue?

Different vascular suturing techniques were assessed in the experimental laboratory. Staples made of tantulum wire were employed for vascular anastomoses in normal dogs'' arteries and veins and in atherosclerotic rabbits'' aortas. The staples were driven with the NRC Vascular Suturing Instrument. In a similar series of experiments a plastic bonding agent (Eastman 910) was used. The anastomosed vessels were found to be patent and few complications were encountered. However, it is unlikely that the conventional suture technique with the currently available materials will be replaced by these methods except under special circumstances. Clinical application of the stapling method is envisaged in the anastomosis of small vessels and in situations when speed is essential, whereas the bonding agent promises to be useful as an ancillary method in combination with sutures or staples.     

Gangliosides and Glycosphingolipids of Peripheral Nervous System Myelins—a Minireview

A summary is provided of the available data on the composition of gangliosides and glycosphingolipids in the peripheral nervous system (PNS) including myelins and their antigenic properties. The composition of gangliosides and glycosphingolipids in the PNS is very different from that in the central nervous system (CNS), both quantitatively and qualitatively. One major difference is the abundance of neolacto-series gangliosides in the PNS, with the backbone structure Gal 1-4GlcNAcl-3Gal l-4Glcl-lCer. Their abundance contrasts with the abundance of ganglio-series gangliosides in the CNS. The neolacto-series gangliosides are localized mainly in the myelins of the PNS. In addition to gangliosides, other acidic and neutral glycosphingolipids in the neolacto-series are also characteristic of the myelins of the PNS. The ceramide (fatty acid and sphingosine base) compositions of gangliosides in the PNS are different from those in the CNS gangliosides, having greater percentages of long-chain fatty acids and dehydrosphingosines than found in the CNS gangliosides.     

VASOPRESSOR AGENTS—Influence of Acidosis on Cardiac and Vascular Responsiveness

Clinical observations have indicated that patients who are in shock and who have coexisting acidosis respond relatively poorly to sympathomimetic amines. In experiments with dogs, it was found that, in the presence of acidosis, the pressor action of epinephrine, norepinephrine and metaraminol was considerably reduced. The effect on cardiac rhythm was also considerably lessened after the pH value of the blood had been lowered.In view of these observations in animals, six human patients with profound shock and acidosis were studied. All had a considerably lessened pressor response to vasopressor agents; then, after elevation of the blood pH by intravenous infusion of a 1-molar solution of sodium lactate, responsiveness was restored.These observations emphasize the desirability of close observation of the acid-base status, and early treatment of acidosis, as an important aspect in the management of patients with shock.