Citations

Cluster headache is a stereotypic, primary headache disorder that is marked by repeated short-lasting attacks of severe, unilateral head pain and associated autonomic symptoms. Cluster headache is probably due to an abnormality in the circadian hypothalamic generator with subsequent trigeminovascular activation. We have reviewed the clinical manifestations, pathophysiology, gender differences, and treatment options in cluster headache.

The clinical syndrome of hypertension, headache, palpitation, diaphoresis, flushing, and emotional lability is classically associated with pheochromocytoma. Two patients are presented with this constellation of symptoms in whom investigations for pheochromocytoma were unrevealing. Headache was the presenting and most prominent complaint, with daily episodes of short-lasting, intermittent, and paroxysmal attacks. Each paroxysm of headache was associated with a dramatic increase in systolic and diastolic blood pressure. After failure to control the labile fluctuations in blood pressure and headache with several classes of anti-hypertensive medications used in combination, a prompt and persistent response occurred after the administration of clonidine. The pathophysiology of this syndrome and the mechanism of clonidine action are reviewed in the context of a possible failure of the baroreceptor reflex.

Abstract Background The ability to deliver nutrition enterally after operation has been a significant advance in managing patients after major intra-abdominal operations. Methods The experience of a single surgeon at a tertiary referral hospital over a 10-year period with insertion and use of 500 consecutive needle catheter jejunostomies (NCJs) was reviewed critically from prospectively collected data. Results The NCJ was used to deliver nutrition in 93 per cent, fluid and electrolytes in 95 per cent, and various medications in the postoperative period in the majority of patients. There were three major complications: small bowel obstruction and pneumatosis intestinalis in one and two patients respectively. Minor complications included diarrhoea (15 per cent), abdominal distension (15 per cent), abdominal cramps (3 per cent), subcutaneous infection at the insertion site (1 per cent) and catheter occlusion precluding use (1 per cent). In 16 patients, the NCJ was replaced percutaneously with a larger-bore catheter for more prolonged enteral feeding at home after discharge. Conclusion Through the experience gained, indications are offered for the placement of NCJs and cautions are provided concerning appropriate use of an NCJ to provide nutritional support, fluid and electrolyte replacement or maintenance, and safe enteral administration of medication. Overall, an NCJ appears to allow safer, cheaper and equally effective delivery of nutrition compared with total parenteral nutrition after major intra-abdominal operations.

Abstract Background Perineal wounds, created at the time of extended resection for locally advanced malignancy and following chemoradiation, are at risk of serious complications. Methods To determine whether immediate myocutaneous flap closure prevents complications, 57 patients treated with multimodality therapy and proctectomy (35 perineal wounds) or sacrectomy (22 posterior wounds) were studied. Patients were categorized according to whether they underwent primary skin and pelvic closure (group 1; n = 20); primary skin and omental pelvic closure (group 2; n = 24); or immediate myocutaneous flap closure (group 3; n = 13). Results Groups were similar with respect to age and sex; however, group 1 had more primary tumours and required less radical surgery and chemoirradiation than groups 2 and 3. Groups 1 and 2 experienced more complications overall (eight of 20, nine of 24 and three of 13 patients in groups 1, 2 and 3 respectively), more acute wound complications (seven of 20, nine of 24 and two of 13), delayed wound healing (three of 20, six of 24 and one of 13) and more reoperations for perineal wound problems (five of 20, seven of 24 and zero of 13). Patients in group 2 had a significantly longer hospital stay than those in group 1. Flap closure (group 3) did not increase the length of stay. The routine use of primary flap closure reduced overall wound complications (eight of 31 versus ten of 26 patients) and length of hospitalization (13 versus 17 days). Conclusion Complete wound healing was achieved in all patients; however, immediate myocutaneous flap closure reduced the need for readmission and reoperation.

Abstract Aim The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch–anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. Methods Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. Results Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981–1985 to 3 per cent in 1991–1994 (P=0·02). After mean follow-up of 6·5 (range 2–15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and night-time incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of ‘clinical’ pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. Conclusion These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.

Abstract Background Long-term functional outcome after operative treatment of necrotizing pancreatitis (NP) has not been studied extensively. Methods Pancreatic function, performance status, recurrence of symptoms and other related problems were analysed in 44 consecutive patients successfully discharged from hospital after operative necrosectomy (1983–1995) and followed up completely for a mean of 5 years. Results Clinical pancreatic insufficiency developed in half the patients. Diabetes mellitus (11 patients), steatorrhoea (six) or both (five) were associated with a mean estimate of 52, 66 and 67 per cent parenchymal necrosis respectively. Normal pancreatic function was associated with 27 per cent parenchymal necrosis (P < 0·05). Diabetes worsened while steatorrhoea tended to improve over time. Abdominal pain and pancreatitis recurred in six and two patients respectively. Performance status worsened in four patients because of recurrent pancreatitis and severe steatorrhoea. Poor long-term performance was associated with a higher Acute Physiology And Chronic Health Evaluation II score on admission (mean 14 versus 9). Conclusion NP has prominent effects on long-term pancreatic exocrine and endocrine function in half the patients, but most preserve a good overall functional status. The development of pancreatic insufficiency varies with the extent of pancreatic parenchymal necrosis.

Background— Recent studies have identified cardiomyocytes of extracardiac origin in transplanted human hearts, but the exact origin of these myocyte progenitors is currently unknown. Methods and Results— Hearts of female subjects (n=4) who had undergone sex-mismatched bone marrow transplantation (BMT) were recovered at autopsy and analyzed for the presence of Y chromosome–positive cardiomyocytes. Four female gender-matched BMT subjects served as controls. Fluorescence in situ hybridization (FISH) for the Y chromosome was performed on paraffin-embedded sections to identify cells of bone marrow origin with concomitant immunofluorescent labeling for α-sarcomeric actin to identify cardiomyocytes. A total of 160 000 cardiomyocyte nuclei were analyzed approximating 20 000 nuclei per patient. The mean percentage of Y chromosome–positive cardiomyocytes in patients with sex-mismatched BMT was 0.23±0.06%. Not a single Y chromosome–positive cardiomyocyte was identified in any of the control patients. Immunofluorescent costaining for laminin and chromosomal ploidy analysis with FISH showed no evidence of either pseudonuclei or cell fusion in any of the chimeric cardiac myocytes identified. Conclusions— These data establish for the first time human bone marrow as a source of extracardiac progenitor cells capable of de novo cardiomyocyte formation.

Reduced shoulder endurance in rotator cuff tear patients has been observed clinically. A simple and inexpensive shoulder endurance test protocol was developed. This study reports the test-retest reliability of the protocol. Twenty healthy volunteers without a history of shoulder pathology participated in the study. Each subject was tested twice, each on a separate day. Test-retest correlation coefficients of the arm endurance times were 0.59 and 0.60 for the dominant and nondominant sides, respectively. The protocol appears promising for assessing shoulder function.

Thumb motion and stability were examined after sequential division of support ligaments of the trapeziometacarpal (TMC) to simulate the pathologic condition of ligament laxity. The motion obtained with passive circumduction was measured with a magnetic tracking system. The lengths of the TMC joint ligaments were approximated by measuring the distance between origin and insertion of each ligament. The change in this apparent interorigin distance of the ligaments was measured before and after ligament sectioning. The anterior oblique ligament (AOL) and the ulnar collateral ligament (UCL) had the greatest effect on TMC joint stability during circumduction of the thumb. Division of the first intermetacarpal ligament (IML) did not produce a change in apparent length of other ligaments. We conclude that small changes in ligament length affect thumb stability and alter the path of circumduction. Neither the IML or posterior oblique ligaments were major stabilizers of the TMC joint during circumduction, prehensile grasp, or tip pinch. Reconstruction of the AOL and UCL ligaments should be considered for treatment of the initial stages of TMC instability.